Treatment of Urinary Tract Infections

Treatment of Urinary Tract Infections Endre Ludwig 1 Classification of urinary tract infections Symptomatic infections Uncomplicated UTI (mainly in women)  acute cystitis  acute urethra syndrome (urethritis)  recurrent cystitis 2 Acute pyelonephritis in women Complicated UTI Acute and chronic prostatitis Asymptomatic bacteriuria 3 Acute uncomplicated UTIs in women Definition  acute lower urinary tract infection without any sort of complicating factors Predisposing factors  use of diaphragma/spermicide  delayed postcoital micturition 4 Clinical signs  dysuria, frequency, urgency, suprapubic tenderness, slight fever Pathogens  (predictable species and sensitivity) E. coli 80 % Staphylococcus saprophyticus 5-15 % other Enterobacteriaceae (Proteus, Klebsiella spp.) 5 note:  S. saprophyticus disappeares in menopause  Chlamydia trachomatis, Ureaplasma urealyticum may cause urethritis 6 Diagnosis  leukocyturia (more than 10 in unspunned urine)   clinical signs bacteriuria 7 note: culture is only recommended (?) in case of – suspected upper UTI – recurrent cystitis – therapeutic failure exclude: – STD – vaginal infections – complicating factors (urological examinations) 8 Thepary  cotrimoxazole, trimethoprim (depending on the local resistance data) or fluoroquinolones for 3 days  aminopenicillins (beta-lactamase inhibitor combinations depending on the local resistance rate), or 1st or 2nd generation cephalosporins for at least 5 days 9 Thepary   nitrofurantoin for 5-7 days fosfomycin trometalol note: short course therapy is not recommended in – diabetic patients – pregnancy 10 Possible reasons of failure  postmenopausal age, diaphragma/spermicide use  non-E. coli infection (S. saprophyticus, C. trachomatis)  false diagnoses (complicated UTI) 11 Recurrent UTI in women more than two episodes within a half year (mainly in genetically predisposed women) mostly in close relationship with sexual intercourse note: exclude complicated infections 12 Therapy  6-12 month continuous low-dose antibiotic prevention (cotrimoxazole, trimethoprim, norfloxacin)  self-treatment – at first sign of UTI – after sexual intercourse – use of vaginal oestrogene cream in postmenopausal women 13 Acute uncomplicated UTI in men Pathogen  uroviolent E. coli (P. adhesins, O, K, and H serogroups) note: exclude gonococcal and nongonococcal urethritis 14 Pathomechanism  sexual intercourse Clinical signs:  dysuria, frequency, suprapubic pain Therapy  10-14 day antimicrobial therapy note: exclude complicating factors 15 Acute uncomplicated (nonobstuctive) pyelonephritis in women Pathogens:  E. coli 85-90 %  other Enterobacteriaceae spp. Clinical signs  dysuria  flank pain  fever  general symptomes 16 Dignosis   clinical signs leukocyturia  bacteriuria (urine culture is recommended) 17 Therapy  10-14 day antimicrobial treatment (beta-lactams, fluoroquinolones according to susceptibility testing) note: hospitalisation and/or parenteral (switch) therapy depending on the particular situation 18 Complicated UTI Definition: urinary tract infection in an individual with functional or structural abnormalities of the genitourinary tract or in the presence of metabolic and other predisposing illnesses 19 Complicating factors  obstruction (urolithiasis, tumors, urostatic hypertrophy, uretic and urethral structures, congenital abnormalities, bladder diverticuli, renal cysts, pelvicalyceal junction obstruction) 20 Complicating factors (2)  foreign bodies (indwelling catheter, ureteric stent, nephrostomie tubes) metabolic and other diseases (diabetes mellitus, renal failure, post renal transplantation, medullary sponge kidney)  21 Complicating factors (3)  functional abnormalities (neurogenic bladder, vesicoureteral reflux) other (urinary intrumentation and urological surgery, ileal conduits and other urinary diversions)  Nicolle (Drugs 1997 53, 583-592) 22 Pathogens E. coli (45-50 %) Pseudomonas aeruginosa (5-20 %) other Enterobacteriaceae (10-30 %) Enterococcus spp. (5-20 %) Candida spp. (5 % or higher in diabetics and in patients with indwelling catheter) 23 Diagnosis  clinical signes of infection (typically recurent symptomes)  leukocyturia  bacteriuria (funguria)  presence of complicating factors 24 Therapy  duration: in general 7-14 days (as short as possible to supress acute clinical symptomes), in case of infection stones 4-6 weeks  antibiotic according to susceptibility testing  recommended antimicrobials: fluoroquinolones, beta-lactams, aminoglycosides 25 Outcome of therapy  no final cure is to expected without the correction of complicating factor expected cure rate at 6-9 days postherapy: 65 % at 4-6 weeks less than 40 %  26 Outcome of therapy (2)  because of the frequent recurrency or relapse, long-term prophylactic or suppressive therapy are needed in few cases in patients non responding to a therapy of average duration, longer treatment, 2-6 weeks should be attempted 27  Asymptomatic bacteriuria Definition: significant bacteriuria (100.000/ml) in two consecutive urine samples) without clinical symptomes. The absence of leukocyturia questions the presence of infections 28 Pathogens  Gram-negative bacilli (Enterobacteriaceae, Pseudomonas spp.) Enterococcus spp.  29 Treatment  as a rule, antimicrobial therapy is not recommended, and contraindicated in patients with permanent indwelling catheter 30 Treatment (2)  treatment is recommended in – children – pregnant women – patients before or after the surgical correction of the structural abnormalities – patients before implantation surgery – immunocompromised patients 31 Duration of therapy: not well established, 7-10 days in general Recommended antimicrobials: according to susceptibility tests 32