Questions:

Problem Identification:

1. A. What clinical and laboratory features are consistent with the

diagnosis of an acute uncomplicated lower UTI in this patient?
 Elderly patients frequently do not experience specific urinary symptoms,
but they will present with altered mental status, change in eating habits,
or gastrointestinal (GI) symptoms.
 A standard urinalysis should be obtained in the initial assessment of a
patient.
 Microscopic examination of the urine should be performed by preparation
of a Gram stain of unspun or centrifuged urine. The presence of at least
one organism per oil-immersion field in a properly collected uncentrifuged
specimen correlates with greater than 100,000 colony-forming units
(CFU)/mL (105 CFU/mL) (>108 CFU/L) of urine.
 The presence of pyuria (>10 white blood cells/mm3 [10 × 106 /L]) in a
symptomatic patient correlates with significant bacteriuria.
 The nitrite test can be used to detect the presence of nitrate-reducing
bacteria in the urine (eg, E. coli). The leukocyte esterase test is a rapid
dipstick test to detect pyuria.
 The most reliable method of diagnosing UTIs is by quantitative urine
culture. PatientsPatients with infection usually have more than 105
bacteria/mL [108/L] of urine, although as many as one third of women
with symptomatic infection have less than 105 bacteria/mL [108/L].
 B. How does one differentiate cystitis from urethritis (caused by
Chlamydia trachomatis, Neisseria gonorrhoea, or herpex simplex virus)
or vaginitis (due to Candida or Trichomonas species)?

 Infection of the bladder (cystitis). This type of UTI is usually caused by

Escherichia coli (E. coli), a type of bacteria commonly found in the
gastrointestinal (GI) tract. However, sometimes other bacteria are responsible.

Sexual intercourse may lead to cystitis, but you don't have to be sexually active
to develop it. All women are at risk of cystitis because of their anatomy —
specifically, the short distance from the urethra to the anus and the urethral
opening to the bladder.

 Infection of the urethra (urethritis). This type of UTI can occur when GI

bacteria spread from the anus to the urethra. Also, because the female urethra
is close to the vagina, sexually transmitted infections, such as herpes,
gonorrhea, chlamydia and mycoplasma, can cause urethritis.

C. Should urine culture be obtained in this patient experiencing her

second episode of cystitis?

 If you continue to get bladder infections, you may require further testing. Tests
for these conditions may include imaging tests such as a computed tomography
(CT) scan, ultrasound, or cystoscopy (looking inside the bladder with a thin,
lighted telescope-like instrument).

D. What are the most likely pathogens and frequency of occurrence

causing this patient's infection?
  The most common cause of uncomplicated UTIs is E. coli, accounting for
more than 80% to 90% of community-acquired infections. Additional
causative organisms are Staphylococcus saprophyticus (coagulase-
negative staphylococcus), Klebsiella pneumoniae, Proteus spp.,
Pseudomonas aeruginosa, and Enterococcus spp.

E. What factors can increase the risk of developing a UTI?

1. Female anatomy. A woman has a shorter urethra than a man does, which
shortens the distance that bacteria must travel to reach the bladder.

2. Sexual activity. Sexually active women tend to have more UTIs than do

women who aren't sexually active. Having a new sexual partner also
increases your risk.

3. Certain types of birth control. Women who use diaphragms for birth

control may be at higher risk, as well as women who use spermicidal
agents.

4. Menopause. After menopause, a decline in circulating estrogen causes

changes in the urinary tract that make you more vulnerable to infection.

Other risk factors for UTIs include:

2. Urinary tract abnormalities. Babies born with urinary tract abnormalities

that don't allow urine to leave the body normally or cause urine to back
up in the urethra have an increased risk of UTIs.

3. Blockages in the urinary tract. Kidney stones or an enlarged prostate can

trap urine in the bladder and increase the risk of UTIs.

4. A suppressed immune system. Diabetes and other diseases that impair

the immune system — the body's defense against germs — can increase
the risk of UTIs.

5. Catheter use. People who can't urinate on their own and use a tube
(catheter) to urinate have an increased risk of UTIs. This may include
people who are hospitalized, people with neurological problems that make
it difficult to control their ability to urinate and people who are paralyzed.

6. A recent urinary procedure. Urinary surgery or an exam of your urinary

tract that involves medical instruments can both increase your risk of
developing a urinary tract infection.
 F. Create a list of this patient's drug-related problems.

 Certain types of birth control.

 Sexual activity.
 Female anatomy.

G. Since this is her second episode of an uncomplicated UTI, should she

receive prophylactic antibiotics to prevent further episode?

 In patients with more frequent symptomatic infections and no apparent

precipitating event, long-term prophylactic antimicrobial therapy may be
instituted. Prophylactic therapy has been found to reduce the frequency of
symptomatic infections in elderly men, women, and children. In women,
most studies show a reinfection rate of 2 to 3 per patient-year reduced to
0.1 to 0.2 per patient-year with treatment. Before prophylaxis is initiated,
patients should be treated conventionally with an appropriate agent.

Desired outcome

7. What are the goals of pharmacotherapy in this case?

- The goal of pharmacotherapy are to eradicate the infection, prevent
complications, and provide symptomatic relief to patients. Early treatment is
recommended to reduce the risk of progression to pyelonephritis. It is
important to identify antimicrobial resistance patterns when considering
empirical antimicrobial selection. Oral therapy with an empirically chosen
antibiotic that is effective against gram-negative aerobic coliform, such as
Escherichia coli , is the principal treatment intervention in the patients with
lower urinary tract infections.

Therapeutic alternatives

8. A. What are the desirable characteristics of an anti-infective selected

for the treatment of this uncomplicated UTI?
- The optimal characteristics of agents to treat uncomplicated urinary tract
infection must include activity against the major pathogens involved in these
infections as well as a low potential for development of bacterial resistance.
High urinary levels should be present for an adequate period to eliminate the
organisms. Side effects should be minimal with minimal effect on the
bacterial flora of the community.
B. What feasible pharmacotherapeutic alternatives are available for
empiric first line and second line of an uncomplicated UTIs?

Empirical first line agent

- Sulfamethoxazole or trimethoprim alone, has been first-line therapy for

uncomplicated UTI. These agents are effective as 3-day therapy, but adverse
reactions, particularly allergic reactions to sulfamethoxazole, sometimes occur
and are occasionally serious. For women infected with susceptible E coli, cure
rates 90% to 95% are achieved with 3 days therapy.

- Nitrofurantoin is a narrow-spectrum antimicrobial with no systemic activity. It is

indicated only for treatment of uncomplicated UTI caused by E coli and
Staphylococcus saprophyticus . It has been used for treating uncomplicated UTIs
for more than 50 years and has had continuing safety and efficacy.

- Fluoroquinolones including norfloxacin, ciprofloxacin, ofloxacin, levofloxacin,

gatifloxacin, are effective as 3-day therapy and are well tolerated.

Empirical second line agents

- Ceftriaxone, Active against most Enterobacteriaceae and can be used to

commence outpatient therapy followed by oral therapy. However, there is no
demonstrated long term post-antibiotic effect as noted with aminoglycosides.
- Gentamicin, An effective modality along when given IV or IM or given as a
first dose in outpatient treatment. In light of the proven post antibiotic effect
of aminoglycosides, this regimen may be preferable when combined
parenteral and oral outpatient treatment is used. Single dose therapy has not
been associated with adverse impact on the kidneys. All aminoglycosides are
associated with the risk of ototoxicity beginning with the first dose.
- Amoxicillin, Use for mild-to-moderate acute uncomplicated pyelonephritis
caused by Enterococcus or to complete a 14d course of therapy for same
which began with parenteral ampicillin. Employ only after susceptibility data
returns.

C. Which non-pharmacologic therapies may be useful in treating

uncomplicated UTIs? Conflicting evidence exists that certain behaviour
may decrease the risk of UTI.

- The prevention of high risk behaviours is the first step in managing females
with rUTI. There are many simple measures which can influence a person’s risk.

Fluid intake
 It is telling that perhaps one of the commonest advice given to women to
prevent rUTIs is to increase fluid intake. The concept being that if uni-
directional flow of urine and reduced retrograde migration of bacteria occurs,
then the risk of UTI will reduce. Studies have only provided conflicting results
with this intervention, and over hydration may result in worsening of some
overactive lower urinary tract symptoms in women.

Sexual hygiene

In one large case control study, a multivariate analysis revealed frequency of

sexual intercourse in young women is the strongest risk factor for UTIs.

Body mass index (BMI)

BMI was shown in a cross-sectional study to be associated with UTI. Women

with an elevated BMI of 30–34.9 were significantly more likely to suffer from
a UTI (OR 1.22; 95% CI: 1.15–1.28). However, other BMI classifications have
not shown statistical significance.

PVR
It is generally accepted that a PVR volume greater than 50–100 mL is an
independent risk factor for rUTIs in many populations, especially post
menopausal women and the elderly. There are several conservative measures
to reduce PVR with minimal risks, but with little proven evidence, include
frequency of urination, double voiding, forward pelvic tilting whilst voiding,
and pelvic floor exercises or relaxation techniques.

Patient Counseling
6. What information should be provided to the patient to enhance compliance, ensure
successful therapy and minimize adverse effects?
Educating patient through giving them relevant information regarding cystitis or UTI.
The role of medication in the treatment and eradication of the infection. Precautionary
measures to prevent occurrence and reoccurrences
Information about compliance to dosage and drug regimen and its importance
especially antibiotics to prevent reoccurrence. Frequent reoccurrence may lead to
prolonged use of antibiotics will result to antibiotic resistance. Incomplete dosage
therapy or a significant in part of short courses of antibiotics on the gut and vaginal
microbiota which can contribute to reoccurrence and antibiotic resistance.
Informations regarding the importance of preventive measures such as:
Drinking lots of fluid
this reach out bacteria from the bladder.water is the best choice.avoid caffeinated
drinks that may irritate the urinary bladder.
Change urination habits
Urinate whenever you have the urge, do not hold it as they can encourage bacterial
growth, holding pee can further increase the risk.
Urinate a soon after sexual activity to flash bacteria that may have been pushed into
the urethra
After using toilet, wipe from front to back to help bacteria away from the urethra
Explore birth control option
Some types of birth control might promote an overgrowth harmful bacteria. This
includes diaphragm, non lubricated condoms, spermicides and spermicide condom.
Avoid scented products
The vagina naturally contains more than 50 different microbes many of which of type of
bacteria called lactobacilli.This bacteria helps keep the vagina and the pH level
balance.Scented feminine products can disrupt this balance allowing harmful bacteria to
overgrow and will result to cystitis, bacterial vaginosis and yeast infection.
Take probiotics
Are live microorganisms that can increase good gut bacteria.They may also help
promote the growth of good bacteria in the urinary tract including fermented foods
such as yogurt , kefir, sauerkraut or tempeh. Taking probiotic supplements, and using
probiotic suppositories.
Consume cranberries
Are traditional home remedy for preventing UTI. The berry has compounds called
proanthocyanidine that prevent E.coli from adhering to tissues in the urinary tract.
It also thought that vit.C in cranberries may increase the activity of urine, which might
reduce overgrowth a bad bacteria.
Information about the prevention of cystitis can potentially reduce the use of an
antibiotics that may lead to resistance and further complications and adverse effects.

Source:
hptts::/www.healthline.com

Other assignment
7. List potential therapeutic methods to prevent cystitis in patients who experience moe
than 2 episodes a year (recurrent cystitis)

Antibiotics.
A three-day course of antibiotics is the usual treatment for each bout of cystitis.
Antibiotics commonly used include trimethoprim and nitrofurantoin
Continuous low-dose antibiotics Continuous low-dose antibiotic prophylaxis is effective
at preventing recurrent UTIs. One dose each night will usually reduce the numbers of
bouts of cystitis. A six month course of antibiotics is given.
You may still have bouts of cystitis if you take antibiotics regularly but the episodes
should be much less often. If a bout does occur, it is usually caused by a germ
(bacterium) which is resistant to the antibiotic you are taking regularly. A urine sample
is needed to check on which bacterium is causing any bout of cystitis. You may then
need a temporary change to a different antibiotic.

Postcoital antibiotics
Postcoital antibiotic prophylaxis is another effective measure to prevent UTIs in women
when sexual activity usually precedes UTI. Post-coital treatment involves taking a
course of antibiotics within 2 hours of intercourse allowing for decreased cost and
presumably side effects

Vaginal Estrogen
Vaginal oestrogen has been shown to reduce the number of bouts of cystitis in
postmenopausal women who get recurrent cystitis. However, it is not as effective as
taking antibiotics regularly. It is usually taken as an estradiol tablet that you insert into
your vagina at night twice a week or as a ring that releases estradiol continuously and
stays in the vagina for three months at a time. It can help even in postmenopausal
women who don't have any of the other vaginal symptoms.
Conservative measures
Patients may be counselled on modifiable predisposing factors for UTI, including sexual
activity and spermicide use.Voiding before or after coitus is also unlikely to be harmful
Lifestyle changes such as properly washing the vulvovaginal area and drinking plenty of
water are often suggested
Different approaches have been proposed including use of probiotic lactobacillus,
functional foods ( cranberries and their extracts ) and vaccines. Although promising,
existing data for prevention of UTI using lactobacillus are to date insufficient and await
further validation.

Sources:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3202002/#!po=1.08696

https://patient.info/womens-health/lower-urinary-tract-symptoms-in-women-
luts/recurrent-cystitis-in-women

https://www.karger.com/Article/Fulltext/488224
References:
https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_ABX_Guide/540458/all/P
yelonephritis__Acute__Uncomplicated
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5522788/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1531733/

https://www.medscape.com/answers/233101-3225/how-are-acute-urethritis-and-
cystitis-differentiated

Pharmacotherapy Handbook Ninth Edition