Urinary tract infections (PDF)

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					Facts Behind the Fact Card
Pharmacist CPE

Urinary tract infections
by Lynn Gould

         rinary tract infections
         (UTIs) are very common,
         affecting about 250,000
people in Australia each year.1
Many people go to a pharmacy
seeking medications to self-treat their
symptoms. UTIs are rarely serious
when they occur in otherwise healthy
adults, but they do have the potential
to cause permanent kidney damage
or life-threatening infection if they
are not treated promptly, especially in
people who have medical conditions
that may complicate the infection.2
Pharmacists can give advice about
the need for appropriate treatment
and about strategies to prevent and
manage the discomfort of UTIs.

Who is at risk                                      •   Women – up to the age of 50 years,             Other risk factors for UTI include:
for urinary tract                                       UTIs are about 50 times more common            • Pregnancy – pregnancy-related changes in
                                                        in women than in men; a woman’s                   the urinary tract, such as pressure on the
infections?3-7                                          urethral opening is near sources of bacteria      bladder and ureters from an expanding
•   Babies and children – among infants,                from the anus and vagina and a woman’s            uterus, contribute to urinary reflux.6
    boys are more likely to develop UTIs;               urethra is relatively short, allowing          • An obstruction blocking the passage of
    after infancy, UTIs are more common                 bacteria quick access to the bladder. In          urine, such as a tumour, kidney stone, or
    in girls. Uncircumcised infant boys and             men, antibacterial prostatic secretions           enlarged prostate.7
    young children with severe constipation             discourage pathogen growth. After 50           • Conditions that affect the bladder’s
    are more prone to UTIs. Developmental               years of age, the incidence of UTI is             nerve supply, such as multiple sclerosis
    abnormalities such as vesicoureteral reflux         almost as high in men as in women due             and spinal-cord injuries, or the immune
    (a bladder valve abnormality which allows           to the increased frequency of prostate            system, such as diabetes and HIV.
    a backflow of urine from the bladder to             disease.                                       • Catheterisation – even with optimal care,
    the ureter) and conditions that produce         •   Elderly people often have a number                catheter use for one month or longer will
    obstruction to the flow of urine are present        of risk factors for UTI, including                eventually result in bladder infection.
    in up to 50% of infants and in 20 to 30%            alterations in urinary tract structure         • Constipation has been shown to
    of school-aged children with a UTI. If              such as uterine prolapse and benign               contribute to bladder instability.
    the kidneys are infected this can result in         prostatic hyperplasia, and limited             • There is increasing evidence that genetic
    scarring, contributing to high blood pressure       functional status impairing mobility,             factors may influence susceptibility to
    and poor kidney function in adulthood.              hygiene, and toileting.                           recurrent UTI. It is thought that epithelial

6                                                                                                                       in
                                                                                                                             ation           April 2006
Facts Behind the Fact Card – Urinary tract infections
                                                                                                      Practice Points
    cells from susceptible women may                The symptoms of cystitis include5,9
    possess specific types or greater numbers
                                                                                                      Practice Point 
                                                    •   Dysuria (painful, burning urination)
    of receptors to which E. coli can bind,         •   Urinary frequency and urgency
    thereby facilitating colonisation.                                                                The role of lactobacilli in
                                                    •   Nocturia
                                                    •   Suprapubic or back pain
                                                                                                      protecting against UTIs6,22,-2
Types of UTI                                       •   Cloudy, unpleasant smelling or bloody         Lactobacilli are a normal component of the
                                                                                                      periurethral flora. They produce hydrogen
Urinary tract infections may be acute,                                                                peroxide and lactic acid which are toxic to
                                                    A person whose bladder is malfunctioning          uropathogens and provide the periurethral area
recurrent or chronic, simple or complicated.
                                                    because of nerve damage or who has a              and vagina with a pH that inhibits bacterial
Lower UTIs are urethritis (infection of the         permanent catheter may have asymptomatic          growth and blocks potential sites of attachment.
urethra) and cystitis (infection of the bladder).   cystitis until the infection progresses to        Women who are exposed to the spermicide
Upper UTIs are ureteritis (infection of the         pyelonephritis                                    nonoxynol-9 are at increased risk of UTI, possibly
                                                                                                      due to the reduction of lactobacilli by the
ureters) and pyelonephritis (infections of the      Urethritis – generally causes dysuria without     antibacterial spermicide. Antibiotic use potentially
kidneys).                                           symptoms of suprapubic pain or urinary            increases UTI risk by the same mechanism.
                                                    frequency. In men, urethritis usually begins
                                                                                                      The replenishment of urogenital microflora
Causes,3,,7,8                                     with a discharge containing yellowish-green
                                                    pus when N. gonorrhoeae is involved or clear
                                                                                                      with probiotics taken orally in capsules, drinks
                                                                                                      or yogurt, or applied via vaginal douche, is
Urine is normally sterile. A UTI occurs             mucus when other organisms are involved.5,10      gaining popularity. Results from studies using a
when a micro-organism enters the urinary                                                              combination of L. rhamnosus GR-1 and
system, usually via the urethra or, rarely,         Pyelonephritis – symptoms often begin             L. fermentum B-54 (recently replaced by RC-14)
from the bloodstream. The most common               suddenly with chills, fever, pain and             indicate that the recurrence rate of UTI can be
                                                    tenderness in the lower back, nausea and          significantly reduced using one or two capsules
infecting organism is E. coli, which may                                                              vaginally per week for one year, with no side
be spread through contamination from the            vomiting, Symptoms of cystitis may also be
                                                                                                      effects or yeast infections. Although these results
gastrointestinal tract. Other causative bacteria    present. In chronic pyelonephritis the pain       are promising, further large clinical studies are
include Staphylococcus saprophyticus, Neisseria     may be vague, and fever may be intermittent       needed to define the role of lactobacillus as a
                                                    or not occur at all. Chronic pyelonephritis       probiotic in the prevention of UTI.
gonorrhoeae, and Proteus, Klebsiella and
Enterococcus species. An increasing number          occurs only in people who have major
of bladder infections in men and women              underlying abnormalities, such as a urinary
have been linked to two sexually transmitted        tract obstruction, large kidney stones or
                                                    urinary reflux.5                                  Practice Point 2
organisms – Chlamydia trachomatis and
mycoplasma. Infection via the bloodstream is        Babies, children and elderly people may
usually due to relatively virulent organisms,       not have typical symptoms of a UTI. Their
such as Salmonella and Staph. aureus.               symptoms may include: 5,9,11-13                   It has been shown that cranberries prevent
                                                                                                      bacteria (particularly E. coli) from adhering to
The Herpes simplex virus type two may cause         •   Neonates – fever or hypothermia, poor         epithelial cells lining the wall of the bladder. There
urethritis, and certain fungi or yeasts can             feeding, jaundice                             is evidence from two RCTs that cranberry juice
                                                    •   Infants – vomiting, diarrhoea, fever, poor    may decrease the number of symptomatic UTIs
cause a UTI. The most common fungal
                                                                                                      over a 12-month period in women, but there is
agent is Candida, which frequently infects              feeding, failure to thrive
                                                                                                      as yet no clear evidence for other groups such as
people who are catheterised or who have an          •   Children – irritability, loss of appetite,    children, men and the elderly. The dosages used
impaired immune system. Rarely, other types             diarrhoea, change in urination pattern,       in the trials varied from 300ml daily to 250ml
of fungi, such as Blastomyces or Coccidioides,          persistent fever (an infant or young child    three times a day and the optimum dosage and
                                                        with an unexplained fever for more than       concentration of cranberry juice remains to be
may infect the urinary tract.5                                                                        scientifically determined. Adverse effects included
                                                        three days should have a urine specimen
An infection is usually prevented from                                                                nausea, gastric reflux and diarrhoea. There have
                                                        tested for infection)                         been reports of serious side effects and death
moving up through the urinary tract by the          •   Elderly people – fever or hypothermia,        in older patients taking cranberry concurrently
flow of urine flushing out organisms and by             poor appetite, lethargy, changes in           with warfarin; however currently there is no
closure of the ureteral sphincters. However,            mental status – e.g., confusion, agitation.   reliable evidence documenting this effect. The
any physical obstruction to the urine flow, or                                                        large number of dropouts/withdrawals from trials
                                                                                                      indicates that drinking large amounts of cranberry
the reflux of urine from the bladder into the
ureters, increases the likelihood of a UTI.1,3,5
                                                    Diagnosis                                         juice over long periods of time may not be
                                                                                                      acceptable. Tablets or capsules have been used
                                                    It is important for a person who suspects         at doses up to 10g daily for prevention and may
                                                    they have a UTI to see a doctor for diagnosis.    be more acceptable. Further properly designed
Symptoms                                            Early treatment will lead to quicker recovery     trials of the various cranberry dosage forms are
The clinical symptoms of UTIs do not                and, if the infection is in the kidney,           needed before definitive recommendations can
                                                                                                      be made.
always correlate with the site of infection or      permanent damage can occur if it is left
with the degree of bacteriuria.9                    untreated.1

     ation         April 2006                                                                                                                        7
                                                       Facts Behind the Fact Card – Urinary tract infections

Practice Points
                                                          Table . When urine culture is necessary6
Practice Point 3
                                                          When symptoms of infection are present in
Management and                                            •    children                         • patients with an indwelling catheter
prevention of UTIs,3,2,20,2-27                         •    men                              • patients with a known genito-urinary abnormality

Strategies which may help to reduce the                   •    elderly patients                 • immunocompromised or diabetic patients
discomfort of UTIs include:                               •    pregnant women
•   An analgesic such as paracetamol may be
    taken to relieve the pain associated with a           Or where there are/is
    UTI.                                                  •    three or more episodes           • relapse or treatment failure
•   A warm bath or a hot water bottle or
                                                               per year
    heating pad on the suprapubic area or
    lower back may help to ease the pain.
•   Drink plenty of water to help ‘flush out’
    the urinary system (the evidence for this
    is unclear and some people believe that
    it may do little to clear bacteria from an         The two main diagnostic tests for UTI are          prostatic hyperplasia, or neurogenic bladder
    inflamed bladder while the pain of frequent        urinalysis and urine culture.                      weakness) can lead to more complicated
    urination may be distressing).                                                                        UTIs, with persistent infection, recurrent
•   Avoid coffee, alcohol and spicy foods,             Urinalysis is used to provide quick
                                                                                                          infections or treatment failure. The
    which irritate the bladder.                        information to support the diagnosis of a
•   Smokers should stop smoking as smoking
                                                                                                          underlying problem must be corrected or
                                                       UTI. It may be done at the doctor’s surgery
    irritates the bladder.                                                                                the patient is at risk of kidney damage.3
                                                       using a dipstick to test a sample of urine for
•   Urinary alkalinisers such as Ural,                                                                    Other potential causes of complicated UTIs
                                                       the presence of leukocyte esterase (released
    Citravescent and Citralite, may be used                                                               are catheterisation and resistant bacteria.10
    to reduce symptoms of dysuria and/or               from white blood cells secondary to
    frequency; however, there is evidence that         bacterial invasion) and nitrites (produced         The clinical manifestations of complicated
    casts doubt on the effectiveness of this           by the bacterial breakdown of dietary              UTIs range from cystitis to urosepsis with
    strategy. They should not be used with             nitrate).                                          septic shock.10 Factors associated with poor
    quinolone antibiotics (e.g., ciprofloxacin,                                                           outcome or death from complicated UTI
    norfloxacin) as crystalluria may occur.            Urine culture is the only absolute way to          include old age, general disability, kidney
    Alkalinisation of the urine may reduce the         make a diagnosis of UTI. A ‘clean-catch’
    effect of tetracyclines, lithium and salicylates                                                      stones, recent hospitalisation, diabetes,
                                                       midstream urine specimen (collected from           sickle cell disease, cancer and chronic renal
    and increase the effect of amphetamines
    and pseudoephedrine. Concomitant                   the middle portion of the flow of urine after      disease.12
    use with antacids may result in systemic           the external genitalia have been carefully
    alkalosis, hypernatraemia or aluminium                                                                A gonorrheal infection of the urethra that is
                                                       cleaned) is cultured and studied under a
    toxicity and use with laxatives may have                                                              inadequately treated can cause a narrowing
                                                       microscope to identify pathogenic bacteria.
    an additive effect. They should be used                                                               of the urethra, which increases the risk
    with caution in patients with cardiac failure,
                                                       In patients who cannot produce a clean-
                                                                                                          of developing cystitis or pyelonephritis.
    hypertension and renal impairment. Long-           catch urine specimen, alternative methods
                                                                                                          Untreated gonorrhea occasionally leads to
    term use may result in hypernatraemia and          to obtain an uncontaminated specimen               an abscess around the urethra which can
    alkalosis.                                         include suprapubic aspiration (SPA) and            produce urethral diverticula, which can also
Strategies which may help to prevent UTIs              transurethral catheterisation.5,9,12,14,15         become infected. If the abscess perforates the
include:                                                                                                  skin, urine may flow through a newly created
                                                       Imaging tests may sometime be necessary,
•   Drink plenty of fluids.                                                                               abnormal connection (urethral fistula).5
                                                       especially in children younger than five
•   Avoid delaying urinating and ensure the
    bladder is as empty as possible.                   years of age, in men at any age, and in
•   Women should wipe from the front to the            women with frequently recurring infections                  Prevention of cystitis
    back after urinating.                              (three or more per year), in order to detect
•   Empty the bladder immediately after sexual         any underlying problems in the urinary
•   Wash hands well after going to the toilet.
                                                       tract. These tests include ultrasound,
•   Wear cotton underwear and do not wear              intravenous pyelography (IVP) – a series of                                            Bowel
    tight fitting trousers or tights.                  x-rays using a contrast dye – and CT scans,
Non-English speaking patients can find                 which give a detailed three-dimensional
information in several languages on the                picture of the urinary tract.5,9,12
following website:                                                                                                  Wiping from back                                                                                                      to front after a
publications/5460.html                                 Complications                                                                        bowel movement
                                                                                                                                            may force germs
                                                       Underlying conditions that impair the                                                into urethra
                                                       normal urinary flow (such as kidney stones,

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                                                                                                                               ation           April 2006
    Facts Behind the Fact Card – Urinary tract infections

                                                                                                    Practice Points
                               Male urinary tract
                                                                                                    Practice Point 

                                                                                                    Recurrent UTIs7,8,26,28,29
                                                              Renal pelvis                          Recurrent UTI may result from an abnormality
                                                                                                    of the urinary tract. In men, chronic prostatitis
                                                                                                    is the most common cause of recurrent UTI,
                                                                                                    while changes related to decreased oestrogen
                                                                                                    levels are thought to contribute to recurrent UTI
                                                                                                    in post-menopausal women. In elderly women,
                                                              Ureter                                recurrent infection may be due to poor urethral
                                                                                                    function, incontinence, atrophic changes,
                                                                                                    diabetes or vaginal colonisation by bowel flora.

                                                              Urinary bladder                       In patients with recurrent symptomatic UTIs
                                                                                                    (three or more infections per year) antibiotic
                                                                                                    prophylaxis of three months or longer is
                                                              Urethra                               recommended. Recommended antibiotics for
                                                                                                    prophylaxis are:
                                                                                                    •    nitrofurantoin 50 mg at night or, in
                                                                                                         women, within two hours of sexual
                                                                                                         intercourse; or
                                                                                                    •    cephalexin 250 mg at night; or
                                                                                                    •    trimethoprim 150 mg at night.
                                                                                                    Night-time dosing is recommended to maximise
Treatment2,7,8                                 or immunosuppression. For an episode of           urinary concentrations. A systematic review
                                                  recurrent urinary tract infection, treatment      of studies in women concluded that infection
The usual treatment for both simple                                                                 rates quickly return to their previous level on
                                                  should be continued for 10 days; selected
and complicated UTIs is antibiotics.                                                                withdrawal of antibiotics. There is not enough
                                                  patients may be permitted to self-initiate
Recommended antibiotic regimens vary                                                                evidence to conclusively support the use
                                                  treatment. Single-dose therapy is not as          of hexamine hippurate (Hiprex) for urinary
according to the individual patient and the
                                                  reliable as multiple dose therapy in preventing   prophylaxis.
site, duration and severity of infection.
                                                  relapse. However, in remote communities
                                                                                                    Two trials of topical oestrogen in
In acute cystitis, recommended oral               treatment with nitrofurantoin 200mg orally as     postmenopausal women showed a significant
antibiotics are:                                  a single dose has been found useful.              reduction in the incidence of UTIs. However, a
•     trimethoprim 300mg (child – 6mg/kg)                                                           more recent trial of oestriol vaginal pessaries
                                                  Mild cases of acute pyelonephritis may be         found that the preventive effect was inferior to
      once daily; or                              treated orally with:                              prophylaxis with nitrofurantoin. There is no good
•     cephalexin 500mg (child - 12.5mg/kg)                                                          evidence to support prescribing oral oestrogens
                                                  •    cephalexin 500mg (child – 12.5mg/kg)
      12 hourly; or                                                                                 for this purpose.
                                                       six hourly; or
•     amoxycillin + clavulanate 500+125mg
                                                  • amoxycillin + clavulanate 875+125mg
      (child – 12.5+3.1mg/kg) 12 hourly or
                                                       (child – 22.5+3.2mg/kg) 12 hourly; or
•     nitrofurantoin 50mg six hourly (not
                                                  • trimethoprim 300mg (child – 6mg/kg)
      recommended for children).
Children may also be prescribed trimethoprim       If resistance to all the above drugs is proven
+sulphamethoxazole 4+20mg/kg 12 hourly.           or the causative organism is Pseudomonas
If resistance to all the above drugs is proven,   aeruginosa, ciprofloxacin 500mg 12 hourly
a suitable alternative is norfloxacin 400mg       may be used (ciprofloxacin should, as far as          Relevant fact cards
12 hourly for three days. Fluoroquinolones        possible, be avoided in children).
should not be used as first-line drugs as they                                                          Below is a list of fact cards
                                                   Treatment should be continued for a total of         relevant to the topic of this
are the only orally active drugs available for                                                          month’s inPHARMation. PSC
                                                  10 days. A follow-up urine culture after the
infections due to multiresistant bacteria.                                                              suggests pharmacists and their
                                                  conclusion of therapy is advised.
                                                                                                        staff familiarise themselves with
Duration of treatment varies from three to                                                              these cards and use them while
                                                  Severe cases of acute pyelonephritis with
five days for a non-pregnant woman or child                                                             counselling customers.
                                                  vomiting or suspected sepsis should initially
to 10 days for a pregnant woman and 14 days                                                             • Urinary Tract Infection
                                                  be treated parenterally and oral therapy              • Bladder and Urine Control
for a man. Elderly women should be treated
                                                  substituted as soon as possible, guided by            • Menopause
for a minimum of seven days if the infection
                                                  antibiotic sensitivity results:                       • Prostate Problems
is acquired in a hospital or aged care facility                                                         • Antibiotics
                                                  amoxy/ampicillin 1g (child – 25mg/kg) IV six
or is associated with incontinence, diabetes
                                                  hourly plus gentamycin 4-6mg/kg (child <10

     ation        April 2006                                                                                                                    9
                                                     Facts Behind the Fact Card – Urinary tract infections
Practice Points
Practice Point                                      years – 7.5mg/kg ; >=10 years – 6mg/kg) IV         or difficulty breathing should immediately be
                                                     daily (adjust dose for renal function).            reported to the doctor. Pulmonary function
                                                                                                        should be monitored at least six-monthly
UTIs and pregnancy,6,7,32                          Where the use of an aminoglycoside is
                                                                                                        during long-term treatment. 17,19,20,21
                                                     undesirable – e.g., in the elderly or pregnant,
UTI in pregnant women is a significant risk factor   in the presence of significant renal failure or    Trimethoprim causes potassium
for low-birthweight infants and prematurity.
                                                     following a previous adverse reaction – use, as    retention which may potentially result in
Asymptomatic bacteriuria occurs in 5% to 9%
of both non-pregnant and pregnant women.             a single drug, cefotaxime 1g (child – 50mg/        hyperkalaemia, especially with high doses,
If left untreated in pregnancy, progression to       kg) IV eight hourly or ceftriaxone 1g (child       concomitant use of other potassium-sparing
symptomatic UTI including acute cystitis and         – 50mg/kg) IV daily.                               drugs, or in renal impairment. It may
pyelonephritis occurs four times more frequently                                                        potentiate the effects of warfarin, digoxin
than in non-pregnant women. Therefore, a urine       Treatment should be continued for 10 to 14
                                                                                                        and phenytoin, and concomitant use with
culture should be obtained from all women            days, the greater part of which may be oral
early in pregnancy, even in the absence of UTI                                                          other folate inhibitors such as methotrexate
                                                     or in an established outpatient IV antibiotic
symptoms.                                                                                               increases the risk of megaloblastic anaemia.
                                                     therapy program. A follow-up urine culture
Treatment of asymptomatic bacteriuria with                                                              During prolonged use, patients should have
                                                     at the conclusion of therapy is advised.
a course of antibiotics reduces the risk of                                                             their complete blood picture and folate status
developing symptomatic UTI by 80-90%.                The presence of Candida in the urine is            regularly monitored.20,21
Recommended drug regimens are:                       common, particularly in association with
                                                     indwelling urinary catheters, and does
•    cephalexin 500mg 12 hourly (category A); or
                                                     not necessarily indicate a UTI. Antifungal
•    nitrofurantoin 50mg six hourly (category A                                                         1.   Urinary tract infections, Better Health Channel;
     – see below); or                                therapy is not usually indicated. If candiduria (accessed 13 Feb 2006).
•    amoxicillin + clavulanate 500 + 125mg 12        occurs in association with an upper UTI,           2.   Urinary Tract Infections in Teens and Adults,
     hourly (category B1).                           systemic treatment with antifungal drugs is             WebMD;
Treatment should be continued for 10 days, after                                                             asp (accessed 13 Feb 2006).
which the urine culture should be repeated.                                                             3.   Urinary tract infection in adults, MedicineNet;
                                                     Nitrofurantoin should not be taken with a     
Trimethoprim is not recommended in pregnancy                                                                 (accessed 13 Feb 2006).
due to lack of safety data and the potential         urinary alkaliniser because alkalinising drugs
                                                                                                        4.   Urinary tract infections, ACP Medicine;
risks associated with folic acid antagonism.         increase its rate of excretion, thus potentially (accessed
Fluoroquinolones should be avoided because           reducing its antibacterial effect.                      13 Feb 2006).
of possible adverse effects on foetal cartilage
                                                                                                        5.   Urinary tract infections, Merck Manual Home
development. Nitrofurantoin should be                Macrodantin is a macrocrystalline form                  Edition;
avoided after the 36th week of gestation due         of nitrofurantoin. It is less likely to cause           ch272i.html (accessed 13 Feb 2006).
to the potential risk of producing haemolytic        nausea, vomiting and diarrhoea, which              6.   Clinical update: Urinary Tract Infection: Providing
anaemia in an infant with glucose-6-phosphate                                                                the Best Care; Medscape, 24 June 2003
dehydrogenase deficiency.
                                                     are the most common adverse effects of
                                                     nitrofurantoin. To further minimise these
Prophylaxis for pregnant women should be                                                                7.   Understanding UTIs – The Basics, WebMDHealth;
considered in patients who have had acute
                                                     effects it should be taken with food or milk.  (accessed
pyelonephritis during pregnancy, patients            Rare but serious adverse effects include:               14 Feb 2006).
with recurrent bacteriuria during pregnancy                                                             8.   Urinary Tract Infections, the Merck Manual of
                                                     • Polyneuropathy leading to degeneration                Diagnosis and Therapy; (accessed
and patients who had recurrent UTI requiring
prophylaxis before pregnancy.                        of motor and sensory nerves and muscle                  14 Feb 2006).
                                                     atrophy. This is more likely to occur in           9.   Gupta K, Stamm W, Urinary Tract Infection; ACP
Recommended drugs are:                                                                                       Medicine Sept 2004
                                                     patients with renal impairment (patients on             484580?src=search
•    nitrofurantoin 50mg at night or within two      long-term therapy should have their renal
     hours of sexual intercourse or                                                                     10. Orenstein R, Wong ES, Urinary Tract Infections in
•    cephalexin 250mg at night.                      function monitored regularly), diabetes,               Adults; American Family Physician Vol. 59 No. 5,
                                                     electrolyte imbalance, anaemia or vitamin              March 1999

                                                     B deficiency. If a patient on nitrofurantoin       11. Hellerstein S, Urinary Tract Infection; eMedicine
                                                     experiences any numbness or tingling, they             15 Feb 2006).
     Relevant shelf talkers                          should see their doctor.                           12. Di Leo Thomas LA et al, Urinary Tract Infections
                                                                                                            Overview, eMedicine
     Below is a list of shelf talkers relevant       • Hepatotoxicity which may manifest as                 fulltext/24812.htm (accessed 13 Feb 2006)
     to the topic of this month’s                    hepatitis, cholestatic jaundice or hepatic         13. Midthun SJ, Criteria for Urinary Tract Infection
     inPHARMation. PSC suggests                      necrosis. Patients on long-term therapy                in the Elderly: Variables That Challenge Nursing
     pharmacists and their staff                                                                            Assessment; Urologic Nursing, 25 June 2004
     familiarise themselves with these               should have their liver function monitored
     shelf talkers and use them while                every month for the first three months, and
                                                                                                        14. Dulczak S, Kirk J, Overview of the Evaluation,
     counselling customers.                          then every three months.                               Diagnosis, & Management of UTIs in Infants and
     •   Paracetamol                                                                                        Children; Urol Nurs 2005;25(3):185-192.
                                                     • Pulmonary hypersensitivity, which may      
     •   Cranberry
     •   Laxatives                                   cause permanent pulmonary damage or even           15. Mosby’s Dictionary of Medicine, Nursing & Health
                                                     death. Symptoms such as cough, chest pain              Professions, Australia & New Zealand edition, 2006.

0                                                                                                                          in
                                                                                                                                 ation                April 2006
 Facts Behind the Fact Card – Urinary tract infections

16. NPS Prescribing Practice Review 30: Antibiotics in      24. Andreu A, Lactobacillus as a probiotic for preventing
    primary care, June 2005                      urogenital infections.                                       clsysrev/articles/CD003265/frame.html
17. eTherapeutic Guidelines; Antibiotic, 2003                   Reviews in Medical Microbiology. 15(1):1-6, January     29. NPS News 40, June 2005
18. Australian Medicines Handbook Drug Choice                                                                           30. Jepson RG, Mihaljevic L, Craig J. Cranberries for
    Companion: Aged Care, 2003                              25. PRODIGY Guidance - Urology, UK Dept. of Health;             preventing urinary tract infections. The Cochrane
                                                                April 2002 (revised July 2005).          Database of Systematic Reviews, Issue 2, April 2004
19. Goodman & Gilman’s The Pharmacological Basis of             (accessed 22 Feb 2006).
    Therapeutics 11th edition, 2006.                                                                                    31. Braun L, Herbs & Natural Supplements - An
                                                            26. Clinical Information Sheet 14, North West Melbourne         evidence-based guide, 2005
20. E- MIMS 2006                                                Division of General Practice
21. Australian Medicines Handbook 2006.                         pages/after_hours/GPRAC-CIS-14.html (accessed 21        32. Drugs and Pregnancy, Pharmacy Dept., The Royal
                                                                Feb 2006)                                                   Women’s Hospital Melbourne, 2001
22. Reid G, Bruce A W, Urogenital infections in women:
    can probiotics help? Postgraduate Medical Journal       27. Cystitis, NSW Multicultural Health Communication
    2003;79:428-432                Service
    content/full/79/934/428                                     affairs/mhcs/publications/5460.html (accessed 1 March
23. Reid G, The Rationale for Probiotics in Female              2006).
    Urogenital Healthcare; Medscape General                 28. Methenamine hippurate for preventing urinary tract
    Medicine, 2004;6(1):e38                   infections. The Cochrane Database of Systematic
    viewarticle/470468_                                         Reviews 2006, Issue 1

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                             Select one correct answer from each of the following questions.                                                  (via the Navigate
Answers due 3 May 2006

Please answer the following multiple choice questions using the information in Facts Behind the Fact Card
and Practice Points. This activity is recognised under the PSA CPD & PI Program. ONE credit point will
be awarded to pharmacists with five out of six answers correct.
To receive your credit remove the answer card provided. Complete the contact details section and your
answers and fax the card to 02 6285 2869.

.   Urinary tract infections:                              b) Pregnant women should routinely have a urine             b) Nitrofurantoin is the antibiotic of choice for
a)   do not commonly occur in post-menopausal                  culture to test for the presence of asymptomatic            cystitis in children.
     women;                                                    bacteriuria.                                             c) In IV therapy for severe pyelonephritis where
b)   usually originate in the kidneys, via the blood;       c) A pre-menopausal woman presenting with                      gentamycin is contraindicated, ceftriaxone may
c)   in elderly people may present with changes in             symptoms of cystitis should routinely have a                be used in combination with amoxycillin.
     mental status;                                            urine culture to confirm the diagnosis.                  d) Ciprofloxacin should be avoided during
d)   can be specifically diagnosed by urinalysis.           d) Imaging tests such as ultrasound are usually                pregnancy due to the possibility of damage to
                                                               recommended for post-menopausal women                       foetal cartilage.
2. In the treatment of UTI:                                    with symptoms of pyelonephritis.
a) Antibiotics are usually reserved for severe                                                                          6. Which of the following statements is FALSE?
   infections involving the kidneys.                        .    Which of the following statements is TRUE?            a) In men, chronic prostatitis is the most common
b) Cranberry juice is first-line treatment for              a)    The concomitant use of trimethoprim and                  cause of recurrent UTI.
   uncomplicated cystitis.                                        enalapril may increase the risk of hyperkalaemia.     b) Structural and functional abnormalities of the
c) Pregnant women should only be treated if they            b)    The therapeutic effect of nitrofurantoin may be          urinary tract are a significant cause of UTIs in
   have symptomatic UTI.                                          enhanced if it is taken with a urinary alkaliniser.      babies.
d) Fluoroquinolone antibiotics should not be used           c)    Circumcision may increase the risk of UTI in          c) The optimum dose of cranberry juice for UTI
   as first-line treatment.                                       infant boys.                                             prevention has been proven to be 250ml three
                                                            d)    The most common fungal agent implicated in               times a day.
3. In the diagnosis of UTI:                                       UTI is Blastomyces.                                   d) Patients on long-term nitrofurantoin therapy
a) Cystitis should be suspected if a pre-menopausal                                                                        should have their lung and liver function
   woman presents with a sudden fever and back              . With regard to antibiotic therapy in UTI:                   regularly monitored.
   pain.                                                    a) A mild case of pyelonephritis in a non-pregnant
                                                               woman should be treated for three to five days.

                                             Pharmacist CPE answers – Baby care (the first six months) (December 2005)
                                                                 1. c   2. b      3. d     4. c      5. a     6. d

     ation            April 2006                                                                                                                                               

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