Document Sample
					       TOPIC: UTI/Prostatitis
      SUBJECTIVE/OBJECTIVE                           ASSESSMENT                                         PLAN
OBJECTIVE EVIDENCE CURRENT MEDS                                                     FURTHER TESTS        (TOXIC &        EDUCATION

UTI                          Etio:               Need to treat; need to prevent progression of UTI from urethra =>         Note: In immunocomp,      Goals: Improve QOL,      PE:
Uncompromised UTI –          80-90% e.coli,      bladder => kidney => pyelonephritis; need to prevent high                 pregnant, and diabetic    prevent M/M, prevent     -finish abx as
otherwise healthy pt’s       staphsaprophyticu incidence of mortality in elderly and nosocomial cases.                     patients use 7-10d thx,   reoccurrence, prevent    directed, otherwise
                             s                                                                                             instead of 3d             progression to           infxn could come
Compromised UTI –            (remainder:                                                                                                             pyelonephritis, decrease back or spread to the
                             klebsilla, proteus,
Incr severity, incr risk of tx                                                                                        Non Drug Recc                  discomfort               kidneys
failure                      enterococcus)                                                                            -Hydration                                              -drink plenty of water
                                                 Thx Opt:                                                             -frequent voiding           Monitor:                    -urinate as needed
Cystitis = lower tract UTI   risk factors:       ~common tx~                                                          -post coital voiding        S/sx of UTI                 -post coital voiding
                             female>male,        TMP/SMX: tx’s e.coli, p. mirabilis, klebsiella pneumoniae, staph     -cranberry juice            Urine analysis/culture      -cranberry juice
                             elderly>young,      saprophyticus                                                        -d/c diaphragm use (if                                  -wipe back to front
                             obstruction,        +DOC in simple outpt                                                 applicable)                                             -d/c diaphragm use
S:                           instrumentation, -c/x in sulfa allergy, photosensitivity                                 -abstain from sexual        SE - TMP/SMX                -abstain from sexual
-Pain during                 pregnancy,          CL- renal                                                            intercourse                 sulfa allergy, GI           intercourse
urination/dysuria            DM,                                                                                      -whip from front to back    intolerance , rash, sob,    -report any urinary
-Increased frequency,        Diaphragm use, FQ/Ciprofloxacin: tx’s enterobacter, TMP/SMX resistant e.coli                                         anapylaxis, SJS,            sx/s
urgency                      Lack of             +tx’s bact resistant to TMP/SMX (resistance common on west           Dose – TMP/SMX              anaplastic anemia,          -educated pt on role
-Tenderness/pain             circumcision,       coast)                                                               1 DS tab q12h, 3d (up to    photosensitivity            of prophylaxis (if
(suprapubic)                 Sexual              -CNS stimulation in children <18yo, cyp1A2 inhibitor,                14d in complicated cases)                               app)
-Decreased outflow           intercourse,        photosensitivity, n/v/anorexia, tendonitis, fever/chills, urine crystal                          SE - Ciprofloxacin          PE - TMP/SMX
-Reddish urine               UTI hx              formation                                                                                        GI intolerance , rash, sob, -Use sunblock/hat
                                                                                                                                                  anapylaxis,                 -Drink lots of water
O:                             nosocomial,         Nitrofuration: tx’s enterobacter, many GNR (not pseudomonas, or Dose – Ciprofloxacin           photosensitivity,           -notify MD of rash or
-Pos. bact (urine) culture: catheters (usu:        serratia), TMP/SMX resistant e.coli                                250mg-500mg q12h, 3d (up n/v/anorexia, tendonitis, trouble breathing
(>10^2 org/ml)                 pseudomonas,        +well tolerated                                                    to 10d in complicated       fever/chills, urine crystal -take wf if GI
-gram stain                    providencia,        -short t/12 requires 7d thx, Pulmonary rxn, numbness/tingling in   cases)                      formation                   intolerance
-Pyuria: Pos. WBC count        morganella)         extremities                                                                                                                -may discolor urine
(10WBC/mm^3) by esterase                                                                                                                          SE - Nitrofurantoin         (orange-brown)
test                           risk factors for Fosfomycin: tx: most urinary pathogens, enterococcus faecalis         Dose – Nitrofurantoin       Pulmonary rxn,              -do not take w/
-hematuria (r/i cystitis)      compromised         (not pseudomonas)                                                  Macrodantin: 50mg-100mg numbness/tingling in            antacids
                               UTI: men,           +long t1/2 allows single 3gram dose                                q6h, 7d                     extremities                 -stains soft contacts
                               children, pregnant, -early recurrence; can’t use in men (not studied), children, women Macrobid: 100mg bid, 7d                                 yellow
R/O:                           structural/hormona with sx >6d; pregnant, diabetic or immunocomp require 7d thx        (SR form)                   SE - Fosfomycin             -shake susp well
Acute Pyelonephritis (Fever l abnorm in urinary hydration                                                                                         Rash                        PE - Ciprofloxacin
chills, Flank pain); acute     tract, impaired     urinary acidification                                                                                                      -TMP/SMX PE
cystitis; vulvo-vaginitis      host response,      urinary analgesic                                                  Dose – Fosfomycin                                       (except discolor
(trichomonas, yeast, herpes metabolic/hormon                                                                          Female: 3gm in 4oz of water                             urine and soft
simplex, bact vaginosis);      e abnormalities, ~other tx~(not common)                                                Male: 3gm QD for 3d in                                  contact stain
STD; trauma, allergy, irritant                     Amox: tx’s enterococcus facaleis                                   complicated UTI             PE – Fosfomycin             warnings)
                                                   Cephalosporin (1st-3rd) cefixime, cefpodoxime proxetil,                                        -avoid antacids             -take 2hrs after
                                                   cefprozil: tx’s e. coli, p. mirabilis, k. pneumoniae                                           -if S/Sx do not improve     meals
                                                   -cefixime has poor gram+ activitiy; cephelexin does not eradicate                              w/i 3d contact MD           -sml meals, po care,
                                                   e.coli fr/ vag/fecal areas                                                                                                 chew gum if n/v
                                                   +long t1/2 allows short course thx                                                                                         -notify md if
                                                   Ampicillin or Vanco + AMG:                                                                                                 tendon/joint pain
                                                   Tx’s Enterococcus facaleis                                                                                                 PE - Nitrofurantoin
                                                                                                                                                                              -may darken urine
                                                                                                                                                                              -take wf
                                                                                                                                                                              -susp can be mixed
                                                                                                                                                                              -notify md of sob,
                                                                                                                                                                              cough, tingling, cp
                                                                                                                                                                              -avoid etoh

Recurrent UTIs                Etio/risk factors: Need to treat; need to prevent progression of UTI from urethra =>   (See above)           Goals: Improve QOL,       (See above)
                              (See above UTI’s) bladder => kidney => pyelonephritis; need to prevent high                                  prevent M/M, prevent
S:                            untreated or       incidence of mortality in elderly and nosocomial cases.                                   reoccurrence, prevent
-Pain during                  undertreated UTI                                                                                             progression to
urination/dysuria                                ~Prophylactic Abx~                                                                        pyelonephritis
-Increased frequency,                            TMP/SMX: ½ SS tab po QHS or TIW                                (See above)                (See above)               (See above)
urgency                                          TMP: 100mg po QHS                                              (See above)                (See above)               (See above)
-Tenderness/pain                                 Nitrofurantoin: 50-100mg po QHS                                (See above)                (See above)               (See above)
(suprapubic)                                     Intravaginal Estriol:                                          Dose – Estriol             SE – Estriol              PE – Estriol
-Decreased outflow                               + repopulates normal comensals in vagina to maintain low pH and0.5mg cream each night for Spotting, DVT/PE, n/v,    -continue use to
-Reddish urine                                   prevent e.coli binding                                         14d, then biw              depression, ha, change in prevent reoccurrence
                                                 -only use in postmenopausal women                                                         libido                    of UTI
O: UTI’s occur in clusters                                                                                                                                           -wear a pantyliner
-Pos. bact (urine) culture:                     (regular bladder emptying) <=controversial whether really helps                                                      after applying
(>10^2 org/ml)                                  postcoital voiding                                                                                                   medicine
-gram stain                                     d/c diaphragm (if applicable)                                                                                        -insert applicator
-Pyuria: Pos. WBC count                         abstention from sexual intercourse                                                                                   high into vagina
(10WBC/mm^3) by esterase                        cranberry juice                                                                                                      -annual exams
test                                                                                                                                                                 important
-hematuria (r/i cystitis)                       ~Intermittent self administration of Abx~                                                                            -small frequent
-3+ episodes w/i 6mos                           +recurrent UTIs are usually symptomatic, self diagnosis is                                                           meals avoid n/v
                                                accurate, cost effective, less abx toxicitiy
                                                -infections are not being prevented

                                                ~postcoital abx~
                                                + works in pts whose infxns related to intercourse
                                                TMP/SMX: ½ SS tab within 2 hours after intercourse                   (See above)           (See above)              (See above)
                                                Nitrofurantoin: 50mg within 2 hours after intercourse                (See above)           (See above)              (See above)
                                                (or any prophylactic abx regimen listed above)

UTIs in men                       Etio:                 Need to treat; need to prevent progression of UTI from urethra => TX 7-10d (10-14d                          Goals: Improve QOL,           (See above)
                                  75% GN, proteus,      bladder => kidney => pyelonephritis; need to prevent high         preferred)                                prevent M/M, prevent
S:                                prvidencia, e.coli;   incidence of mortality in elderly and nosocomial cases.                                                     reoccurrence, prevent
-Pain during                      enterococcus is                                                                         If recurrent (most likely due             progression to
urination/dysuria                 most common GP                                                                          to kidney or prostate infxn)              pyelonephritis or
-Increased frequency,             (bacteriology is                                                                        then tx 4-6wks                            prostatitis
urgency                           less predicatable     TMP/SMX: tx’s e.coli, p. mirabilis, klebsiella pneumoniae, staph
-Tenderness/pain                  in men)               saprophyticus                                                     (See above)                               (See above)                   (See above)
(suprapubic)                                            +DOC in simple outpt
-Decreased outflow                                      same as for women except TX 7-10d (10-14d preferred)
-Reddish urine                 Risk Factors:
                               (See above, with
O: -Pos. bact (urine) culture: exception of             FQ/Ciprofloxacin: tx’s enterobacter, TMP/SMX resistant e.coli
(>10^3 org/ml)                 female specific          same as for women except TX 7-10d (10-14d preferred)                                                        (See above)
-gram stain                    risk factors; ie:                                                                                     (See above)                                                  (See above)
-Pyuria: Pos. WBC count        diaphragm use)
(10WBC/mm^3) by esterase
-hematuria (r/i cystitis)

***voided urine are LESS
likely to be contaminated
than in women.***
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*******************************   Etio:                 *****                                                                        ***                             *****************************
*                                 Recurrent or          Need to treat; need to prevent progression of pyelonephritis and                                             *                             (See above)
Pyelonephritis                    untreated UTI’s       kidney damage; need to prevent high incidence of mortality in                                                                              PE - Ampicillin
(Upper tract UTI involving        spread into upper elderly and nosocomial cases.                                                    Dosage Ampicillin               SE - Ampicillin               -take on empty
kidneys)                          urinary tract =>                                                                                   500mg po QID, 7D                Stomach upset                 stomach, 2hrs before
                                  kidneys               Ampicillin: if GPC (enterococcus)                                                                                                          or 4 hrs after meals
S:                                                      500mg po QID, 7D                                                                                                                           -use BUM if on Ocs
-flank pain                       Risk Factors:                                                                                                                      SE - Ciprofloxacin
-flank tenderness                 (See above “UTI’s) FQ/Ciprofloxacin: use if GNR                                                    Dosage Ciprofloxacin            GI intolerance , rash, sob, PE - Ciprofloxacin
-fever/chills                     also recurrent and +tx’s bact resistant to TMP/SMX (resistance common on west                      500mg po BID, 7D                anapylaxis,                   -TMP/SMX PE
-loin pain                        untreated UTIs        coast)                                                                                                       photosensitivity,             (except discolor
-n/v                                                    -CNS stimulation in children <18yo, cyp1A2 inhibitor,                                                        n/v/anorexia, tendonitis, urine and soft
-hematuria                                              photosensitivity, n/v/anorexia, tendonitis, fever/chills, urine crystal                                      fever/chills, urine crystal contact stain
O:                                                      formation                                                                                                    formation                     warnings)
-pos bact (urine) culture                                                                                                                                                                          -take 2hrs after
-Gram stain                                                                                                                                                                                        meals
-kidney inflammation                                                                                                                                                                               -sml meals, po care,
-pyuria                                                                                                                                                                                            chew gum if n/v
                                                                                                                                                                                                   -notify md if
                                                                                                                                                                                                   tendon/joint pain

Acute Prostatitis               Etio:                Need to treat to prevent progression to chronic prostatitis and            4wk thx                         Goals: Prevent            (See above)
(prostatitis type I)            80% e.coli,          prostate damage due to inflammation and infection.                                                         development of chronic
                                (klebsiella,                                                                                                                    prostatitis; improve QOL,
S:                              enterobacter,        (all below abx achieve penetration and high levels in prostatic                                            decrease M/M
-chills                         proteus,             secretions)
-pain upon                      enterococci also
defication/urination            causative)           TMP/SMX: tx’s e.coli, p. mirabilis, klebsiella pneumoniae, staph           Dose – TMP/SMX                  (See above)                   (See above)
                                                     saprophyticus                                                              1 DS tab q12h, 28days
O:                              Risk Factors:        +DOC in simple outpt
-fever                          (See above, with     -c/x in sulfa allergy, photosensitivity
-Pos. bact (urine) culture      exception of         CL- renal
-inflammed prostate             female specific
-tender, warm prostate          risk factors; ie:    Clindamycin                                                                Dose- Clindamycin       SE – Clindamycin                      PE – Clindamycin
                                diaphragm use);      -c. difficile overgrowth                                                   150mg-450mg/dose q6-8h; Pseudomembranous                      -report severe
R/O:                            -40yo+ males                                                                                    max 1.8g/day; 28 days   colitis; diarrhea                     diarrhea
N. Gonorrhoeae in men           -recurrent UTIs      Doxycycline                                                                                                                              -take each dose with
<35yo                                                -only 50% penetration                                                      Dose- Doxycycline               SE – Doxycycline              full glass of water
                                                     CL: renal                                                                  100mg qd; 28 days               Photosensitivity, GI          -finish all medication
***prostatic massage can                                                                                                                                        intolerance                   -do not skip doses
ppt bactermia… avoid                                 Erythromycin                                                               Dose- Erythromycin
prostate test =>                                     -hepatotoxicity                                                            250mg – 500mg 16-12h; 28 SE – Erythromycin                     PE – Doxycycline
contraindicated to exam and                                                                                                     days                     Diarrhea, hepatotoxicity              -avoid sunlight
milk for prostatic fluid of                                                                                                                                                                    -finish all medication
WBC***                                                FQ/Ciprofloxacin                                                           (See above) x28d                (See above)                   -do not skip doses
                                                                                                                                                                                               -take with food
******************************* ********************* ************************************************************************** ******************************* ***************************** -avoid milk
Chronic Prostatitis             Etio:                 Need to treat to prevent continual prostatitis and prostate damage                                                                       products/antacids
(prostatitis type II)           80% e.coli,           due to inflammation and infection.
                                (klebsiella,                                                                                                                                                   SE – Erythromycin
S:                              enterobacter,         (need abx that can penetrate the non-inflammed epith of prostate)                                                                        -avoid milk/antacids
-recurrent UTI’s                proteus,              (All dosages the same as above, except 2-3mos duration of                                                                                -avoid EtoH
                                enterococci also thx)                                                                                                                                          -report diarrhea
O:                              causative)            TMP/SMX
-NO inflammation                                      FQ/Ciprofloxacin
-Pos. bact (urine) culture      Risk Factors:         Doxycycline
-Pos. WBC count                 (See above, with -only 50% coverage
-enlarged, “boggy” prostate exception of
                                female specific       Prostatectomy
                                risk factors; ie:     +suggested in pts with acute recurrent episodes
                                diaphragm use); -
                                50yo+ males, -
                                recurrent UTIs

Chronic Non-Bacterial         Etio              Tetracycline (See above)x28d                                                       4wk thx                                                        Cure is unusal
Prostatitis (prostatitis type Unclear; possibly                                                                                    (See above)                       (See above)                  (See above)
III)                          chlamydia         Thermal Thx
                              trachomatis,      +relieves pain
S:                            mycoplasma
-pain/inflammation            hominis,
-genitourinary and voiding trichomonas
discomfort                    vaginalis,
O:                            urealyticum or
-Neg. bact (urine) culture    viral
-Pos. WBC count
-highly variable prostate     Risk Factors:
exam results                  30-50yo male

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***                             ********************* ******                                                                       *                                 **                            **
Chronic Pelvic Pain             *                     Alpha blocking agents                                                        Dose – Prazosin                   SE – Prazosin                 PE – Prazosin
Syndrome                        Etio                  +maybe helpful                                                               initial: 1mg/dose bid-tid         Hypotension                   -Rise from
                                Unclear; possibly -not formally studied as a treatment                                             maint: 3-15mg/day bid-qid         Dizziness                     sitting/lying position
S:                              neuromuscular         ie: prazosin                                                                 max 20mg/day                      Drowsiness                    slowly
-pain                           dysfunction of                                                                                                                                                     -take first dose at
-increased urgency              bladder               muscle relaxants                                                             Dose – carsiopradol                                             bedtime
-dysuria                                              +maybe helpful                                                               350mg TID-QID                     SE – carsiopradol             -report painful,
-decreased force of stream Risk Factors:              -not formally studied as treatment                                                                             Drowsiness                    persistent erection
-voiding problems               30-40yo male          ie: carsiopradol                                                                                               Flushing                      -avoid alcohol
-Neg. bact (urine) culture                                                                                                                                                                        PE – carsiopradol
-Pos. WBC count                                                                                                                                                                                   -dizziness
                                                                                                                                                                                                  -avoid CNS
                                                                                                                                                                                                  -avoid alcohol

Catheter Associated UTI’s Etio:           treat only if symptoms are present; colonization is common          Not applicable   Not applicable   Not applicable
S:                                        Systemic Abx (see above, abx used to treat UTIs) – only
-pain                     Risk Factors:   transiently decrease bacteriuria and may select for resistant
-increased urgency        catheter        organisms
                                          ~Catheter irrigation~
O:                                        polymixin-neosporin irrigation
-pos. bact culture                        -no effect on bacteriuria, most organisms that colonize are

                                          chlorhexidine and acetic acid irrigation
                                          + helps to prevent bacteriuria
                                          - not studied

                                          2% provodone-iodine solution
                                          +decreases bacteriuria from 28% => 4% in straight catheterization
                                          -it’s effect on indwelling catheters is unknown

                                          H2O2 disinfection of collection bag
                                          +/- conflicting results

                                          ~catheter placement/use~
                                          ***remove catheter as soon as feasible***
                                          +best way to prevent infection, 35%pts with bacteriuria
                                          spontaneously clear after removal, can be combined with single
                                          dose abx thx (ie: TMX/SMP DS one dose)

                                          suprapubic catheterization/intermittent catheterization
                                          + decreases incidence of bacteriuria, especially in those who
                                          require long term catheterization, can be combined with
                                          prophylactic abx

Asymptomatic Bacteriuria etio                      Thx NOT indicated in                                                      Not applicable                  Not applicable               Not applicable
                         persistent e.coli         -School aged children
S:                                                 -non-pregnant women
-none                    Risk Factors              -diabetics
                         Women > men               -elderly
O:                                                 -catheter pts undergoing exchange
-Pos culture
                                                   No compelling reason to treat, not associated with increased
                                                   mortality, increased incidence of pyelonephritis, or incontinence;
                                                   Single course thx will clear bacteriuria in 60% pt at 6mos
                                                   compared to 35% who receive no thx

                                                   Thx indicated in (see above “UTI” for regimens)
                                                   -preschool children
                                                   -pregnant women
                                                   -non elderly men (30-60yo)
                                                   -pts with abnormal urinary tracts
                                                   -pts undergoing invasive urologic procedures

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*                         *                     ******                                                                       *                               **                            *
Fungal UTI                etio                  usually don’t need to treat since candiduria and candidemia are
Uncommon outpt infxn;     candida vaginititis, uncommon; treat when urinary tract manipulation or surgery can
effects susceptible inpt  candida albicans; lead to candiduria and candidemia; also treat if pt is of extremely
S:                        candida galbrata compromised health or has bladder cancer
-Pain during              (rare)
urination/dysuria                               Fluconazole                                                                  Dose – Fluconazole              SE - Fluconazole             PE – Fosfomycin
-Increased frequency,     Risk Factors          +tx’s candida                                                                200mg po qd, 7d                 Hepatotoxicity; monitor      -take with food
urgency                   -women > men          -DDI, hepatotoxicity                                                                                         LFTs; GI                     -complete entire
-Tenderness/pain          -intercourse with                                                                                                                                               course of thx
-Decreased outflow        infected partner      (5FC                                                                                                                                      -use BUM if on OCs
-Reddish urine            -inpatient            50-75mg/kg/day in 4 divided doses
                          -prolonged            caspofungin (IV) or voriconazole
O:                        catheterization       tx’s c. galbrata) <= 5FC, Caspofungin (IV), and voriconazole were
-Pyuria: Pos. WBC count   -diabetes             not emphasized in class or in the syllabus… these will come up
(10WBC/mm^3) by esterase -steroid thx           later in the fungal lectures
test                      -abx thx
-hematuria (r/i cystitis)                       remove catheter
                                                alkalinize the urine
                                                ampho B catheter irrigation 50mg/l at 42ml/hr for one day
                                                -UCSF data suggests this is rarely effective if catheter remains in


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