Download Chapter 16 Cholinesterase Inhibitors

Chapter 88
Drug Therapy of Urinary
Tract Infections
Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.
Urinary Tract Infections (UTIs)


Most common infections
Sexually active young women


Elderly women in nursing homes


25%-35% develop at least one UTI a year
30%-50% have bacteria at any given time
UTIs less frequent in males

Occurrence likely associated with complications
(eg, septicemia, pyelonephritis)
Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.
2
Urinary Tract Infections (UTIs)


Complicated or uncomplicated UTIs
Upper (kidney)



Lower (bladder and urethra)



Acute pyelonephritis
Acute bacterial prostatitis
Acute cystitis
Acute urethral syndrome
Recurrent urinary tract infections
Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.
3
Organisms That Cause UTIs


80% of uncomplicated community-acquired
UTIs – Escherichia coli
Hospital-acquired UTIs frequently caused by
Klebsiella, Proteus, Enterobacter,
Pseudomonas, staphylococci, enterococci,
and E. coli
Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.
4
Drug Therapy of Urinary Tract
Infections

Trimethoprim/sulfamethoxazole – frequently
the treatment of choice for oral therapy of
urinary tract infections
Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.
5
Acute Cystitis

Symptoms




Dysuria, urinary urgency, urinary frequency,
suprapubic discomfort, pyuria, bacteriuria
(subclinical pyelonephritis)
Single-dose therapy
Short-course therapy (3 days)
Conventional therapy (7 days)
Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.
6
Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.
7
Acute Uncomplicated Pyelonephritis

Common in young children, elderly, women of
child-bearing age


Fever, chills, severe flank pain, dysuria, urinary
frequency, urinary urgency, pyuria, and usually
bacteriuria
E. coli – causative organism in 90% of
community-acquired infections


Mild pyelonephritis – moderate infection
(treatment at home with oral antibiotics)
Severe pyelonephritis – requires hospitalization
and IV antibiotics
Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.
8
Complicated UTI

Males and females with structural or
functional abnormality of urinary tract


Prostatic hypertrophy, renal calculi,
nephrocalcinosis, renal or bladder tumors, ureteric
stricture, or indwelling catheter
Symptoms range from mild to severe

May develop systemic illness manifesting as fever,
bacteremia, and septic shock
Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.
9
Recurrent UTI

Relapse



20% recolonization with the original infecting
organism
Suggests structural abnormality of urinary tract,
involvement of kidneys, or chronic bacterial
prostatitis
Reinfection


80% of recurrent UTIs in females
Usually involves lower urinary tract and may be
related to sexual intercourse
Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.
10
Acute Bacterial Prostatitis

Inflammation of the prostate caused by local
bacterial infection




High fever, chills, malaise, myalgia, localized pain,
dysuria, nocturia, urinary urgency, urinary
frequency, urinary retention
80% of cases caused by E. coli
Frequently associated with indwelling urethral
catheter, urethral instrumentation, transurethral
prostatic resection
Responds well to antimicrobial therapy
Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.
11
Urinary Tract Antiseptics




Nitrofurantoin (Furadantin, Macrodantin,
Macrobid)
Methenamine (Mandelamine, Hiprex, Urex)
Nalidixic acid (NegGram)
Cinoxacin (Cinobac)
Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.
12
Nitrofurantoin (Furadantin)




Bacteriostatic – low concentrations
Bactericidal – high concentrations
Uses – lower UTIs, prophylaxis, recurrent
lower UTIs
Adverse effects



Gastrointestinal effects
Pulmonary reactions
Hematologic effects
 Peripheral neuropathy
 Other
Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.
13
Methenamine (Mandelamine)


Decomposes into ammonia and
formaldehyde, which denature bacterial
proteins
Therapeutic uses


Chronic lower UTIs
(trimethoprim/sulfamethoxazole is preferred)
Adverse effects

Relatively safe and generally well tolerated
 Contraindicated for renal and liver failure
Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.
14
Methenamine (Mandelamine)

Drug interactions


Urinary alkalinizers
Sulfonamides
Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.
15
Nalidixic Acid (NegGram)





Relative of fluoroquinolones
Inhibits replication of bacterial DNA
Resistant bacteria often emerge during
treatment
Active against most gram-negative UT
pathogens
Approved only for UTIs
Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.
16
Nalidixic Acid (NegGram)

Adverse effects


Low incidence of severe effects
Most common





GI disturbances
Visual disturbances
Rash
Photosensitivity
Avoided by patients with history of convulsive
disorders
Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.
17
Nalidixic Acid (NegGram)

Drug interactions


Intensifies warfarin
Dosage may need to be decreased
Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.
18
Cinoxacin (Cinobac)




Close relative of nalidixic acid with the same
mechanism of action, antimicrobial spectrum,
and indications
Therapeutic levels achieved only in the urine
Adverse effects like those of nalidixic acid
Decrease dosage in patients with renal
impairment
Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.
19