A disease Presentation
URINARY TRACT INFECTION
PHARM. UCHEGBU PROMISE M.
10TH MAY 2023
TEAM MEMBERS
• PHARM LYDIA OMONIYI
• PHARM BILIKISU ABDUL
• PHARM GABRIEL NWATU
• PHARM OZOBI CHARLES CHIZOBAM
OUTLINE
• Introduction
• Epidemiology and Pathophysiology
• Classification and Risk factors/Symptoms
• Diagnosis and Complications
• Treatment and Management of UTI
• Case presentation
• Pharmaceutical Care evaluation
• Conclusion
• Reference
INTRODUCTION
Definition
Urinary Tract Infection are common infections that happen when
bacteria, often from the skin or rectum enter the urethra, and infect the
urinary tract (NCDC 2021)
•A urinary tract infection (UTI) is an infection in any part of the urinary
system- the kidneys, ureters, bladder and urethra. Most infections
involve the lower urinary tract ie the bladder and urethra.
EPIDEMIOLOGY
• UTIs in women are very common, approximately 25% to 40% of
women in the US aged 20-40 years have had UTI`s
• UTIs account for over 6 million patients visits to physicians per year
in the US
• Cystitis occurs in 0.3% to 1.3% of pregnancies
• Acute pyelonephritis occurs in 1% to 2% of pregnancies (Hsiao 2007)
• UTIs have been studied in Sweden and other parts of Europe. These
studies shows that 1 in 5 adult women experience a UTI at some point
• There are about 1.5 million cases yearly in Nigeria (UCTH 2021)
PATHOPHYSIOLOGY
• The bacteria that most often cause cystitis and pyelonephritis
are enteric usually gram-negative aerobic bacteria (most
often) Escherichia coli (75%-95% of cases), Klebsiella spp,
Proteus mirabilis, Pseudomonas aeruginosa and gram-
positive bacteria (less often) such as Staphylococcus
saprophyticus isolated in 5 to 10% of bacterial UTI’s,
Enterococcus faecalis.
PATHOPHYSIOLOGY CONTD.
•UNCOMPLICATED UTI’S
•Usually considered to be cystitis or pyelonephritis that occurs in
premenopausal adult women with no structural or functional
abnormality of the urinary tract and who are not pregnant and have no
significant comorbidity that could lead to more serious outcomes.
PATHOPHYSIOLOGY CONTD.
•COMPLICATED UTI’S
•Can involve either sex at any age. UTI’S is considered complicated if
The patient is a child or is pregnant
A structural or functional urinary tract abnormality and obstruction of
urine flow
A comorbidity that increases risk of acquiring infection or resistance
to treatment such as poorly controlled diabetes, chronic kidney
disease or immunosuppression
RISK FACTORS
•Factors resulting in compromise of normal host defenses to bacterial
colonization
Iatrogenic/drugs
1. In-dwelling catheter
2. Antibiotic use
3. Spermicides
Behavioral
1. Voiding dysfunction
2. Frequent or recent sexual intercourse
RISK FACTORS contd.
Anatomic/physiologic
1. Vesicoureteral reflux
2. Female sex
3. Pregnancy
SIGNS AND SYMPTOMS
DIAGNOSIS
URINALYSIS
Urine Microscopy and Urine Dipstick
• Identify the presence of WBC in urine – polyuria (> 10WBCs/ul)
• urine dipstick is readily more available
URINE CULTURE
MANAGEMENT OF UTI
• NON PHARMACOLOGICAL MANAGEMENT
Maintenance of proper hygiene
Advice patients to drink plenty of water
Citrus juices should be taken
Limit caffeine intake
PHARMACOTHERAPY
The gold standard for treating urinary tract infections is antibiotic
use. Oral treatment with an empirically chosen antibiotic that is
effective against gram negative coliform bacteria e.g E. coli
UNCOMPLICATED LOWER UTI OR
CYSTITIS
ANTIBIOTIC Dosage CONSIDERATION
Nitrofurantoin 100mg for5 days Avoid in CrCl < 30ml/min
Trimethoprim-sulfamethoxazole 960mg for3 days Increasing E. coli resistance
ALTERNATIVELY,
fosfomycin 1 dose May not be readily available
IV beta-lactam or Oral beta-lactam 3-7 days
Fluoroquinolones should be reserved for complicated cystitis when
other oral antibiotics are not feasible because of their propensity for
collateral damage (given for 3 days)
COMPLICATED LOWER UTI OR
CYSTITIS
ANTIBIOTIC DURATION CONSIDERATION
Nitrofurantion 7 days Avoid in CrCL< 30ml/min
Fosfomycin Q 48 hrs * 3-5 doses
Trimethoprin - 7 days Increasing E.coli resistance
sulfamethoxazole
IV beta-lactam, oral beta- 7 days
lactam or Aztreonam in severe
cephalosporin allergy
Delayed response to therapy may warrant 10-14 days therapy
Fluoroquinolones should be reserved for complicated cystitis when other oral antibiotics
are not feasible because of their propensity for collateral damage (given for 3 days)
PYLONEPHRITIS
ANTIBIOTIC DURATION
Trimethoprim- 7-14 days
sulfamethoxazole
Fluoroquinolones 5-7days
Beta lactams 7 days IV beta lactam therapy
followed by oral trimethoprim
–sulfamethoxazole therapy 7-
14 days
Nitrofurantoin and Fosfomycin should not be used for
pyelonephritis, upper urinary tract infection or patients with
bacteremia.
Oral beta lactams are associated with lower efficacy and
higher relapse rates compared to trimethoprim-
sulfamethoxazole and fluoroquinolones (IV can be used initially
followed by oral beta lactams)
PHARMACOTHERAPY IN PREGNANCY
DRUGS TREATMENT REGIMEN SIDE EFFECT
Pyelonephritis Ceftriaxone 1g IV q24hr Polyuria, GI disturbance
Cefotaxime 1-2g IV q8h
cystitis Nitrofurantoin 100mg PO bd for 7 days Diarrhea
Bacteriuria Amoxicillin 500mg PO tds for 7 days Diarrhea, vomiting,
Augumentin 1g PO bd for 7days nausea, headache
Cephalexin 250mg PO qds for 7days GI disturbance
Fosfomycin
3g PO stat in water
Nausea
ANTIBIOTICS CONTRAINDICATED IN
TREATMENT OF UTI IN PREGNANCY
Tetracycline (adverse effect on fetal bones and teeth and congenital
defects)
Trimethoprim in first trimester (facial defects and cardiac
abnormalities)
Nitrofurantoin is considered safe to use but not during delivery or
near term i.e >36 weeks due to possibility of hemolytic anemia in
new born as a result of their immature erythrocytic enzyme system
Chloramphenicol (gray baby syndrome)
• Sulphonamide in the third trimester (hemolytic anemia in mothers
with G6pd deficiency, jauntice)
PHARMACIST ROLE
Emphasize the need for proper hygiene by patients
Advise patient on the need to adhere strictly to their antibiotics in
order to prevent resistance
Look out for actual and potential drug therapy problems with
treatment plan and make necessary interventions if the need arises.
Ensure adequate sensitizations on ways of contacting a urinary tract
infection and how to identify symptoms.
Encourage fluid intake by patient especially water
ADDITIONAL INFORMATION
• A CASE PRESENTATION ON URINARY TRACT INFECTION
CASE PRESENTATION
• Demographic data
–Patient name : N Y
–Sex : Female
–Age : 43 years
–Ward: GOPD
–Religion : Islam
–Occupation: Business
–Marital status: Married
–Date of visit; May 1 2024
• Presenting complain
• Pain on micturition
• Mild generalized headache for 1 week
• Fever for 1 week
• Nocturia and right flank pain
• Acid dyspepsia
Patient history
• Past medical history
– Not a hypertensive or Diabetic patients
• Family history
– 5th of 5 children
– Married with 4 children
• Social history
– Non smoker
– Non alcoholic
Review of systems
CVS
– BP 150/100mmHg (110-130mmHg)
– PR 78bpm (60-80bpm)
– RR 20cpm (16-20cpm)
– HS S1 S2
Abdomen
– Renal angle tenderness
Laboratory investigations
• Urine mcs……….. Prescribed but not done
• FBS ……………. 4.4mm/mol (3.9_ 6.1 mmol/l)
• MP……………… positive
• WBC …………… 12100 (4000 to 11000cells/ml)
• Differential counts
• N………………. 75 (45-70%)
• L………………….35 (20-45%)
• E………………….4 (1-6%)
• B………………….0 (less than 1%)
• M………………….15 (2-10%)
TEST RESULT
COLOUR AMBER
APPEARANCE CLEAR
PH 7.0
UROBILINOGEN NORMAL
GLUCOSE NEGATIVE
PROTEIN NEGATIVE
BLOOD NEGATIVE
NITRITE NEGATIVE
KETONE NEGATIVE
BILIRUBIN NEGATIVE
ASCOBIC ACID NEGATIVE
LEUCOCYTES POSITIVE
• Diagnosis
UTI (PYLONEPHRITIS) KIV MALARIA
• Plan
i. Tabs Levofloxacin 500mg bd for 5days
ii. Tabs ACT for 3days
iii. Tabs Aceclofenac 1 bd for 5days
iv. Tabs omeprazole 20mg bd for 7days
NEXT VISIT: 6TH MAY 2024
• Plan; continue antibiotic treatment for additional 5days
PATIENT COUNSELLING
• Patients should wipe from front to back after urinating or after a
bowel movement
• Drinking enough fluid especially water is really helpful
• Women prone to UTIs should avoid using birth control methods such
as contraceptive diaphragm and spermicidal jell
• Avoid caffeinated drinks
CONCLUSION
Early treatment with antibiotic has significantly reduced the
complication associated
Urine culture and sensitivity remains gold standard of diagnosing UTI
Need for sensitization on ways to prevent UTI’s
REFERENCES
Koffuor GA, Boye A, Siakwa PM, asymptomatic urinary tract
infection in women attending antenatal clinic in cape coast,Ghana. E3
journal of Medical research 2012; 1(6)
Gupta K, Stamm WE. Pathogenesis and management of recurrent
urinary tract infections in women. World J Urol. 1990;17(6):415-420
Medscape Article on Urinary tract infection
Nicolle, et al. infectious diseases society of America guidelines for
the diagnosis and treatment of bacteriuria in adult. Clin infect Dis
2005;40:643-54
