rxPassport Pharmacy Newsletter
 
April 2015
 
 
Uncomplicated UTIs – The Community Pharmacist’s Role
 
Meet Your Patient
 
Margaery (19 yo) has come into the pharmacy to ask for help.
 
You gather the following information:
 
She is urinating 5-8 times a day
 
She feels a burning/painful sensation every time she urinates and just yesterday, she noticed some blood in her urine
 
She has never experienced this before
 
She has not been sexually active and has no vaginal discharge
She asks if cranberry juice or probiotics will help
 
Urinary tract infections (UTIs)
 
UTI refers to a symptomatic bacterial infection within the urinary tract. It represents a wide variety of syndromes, including urethritis, cystitis, prostatitis, and pyelonephritis. Collectively, they are the most common bacterial infections in females of child-bearing age (15-45 yrs)1. About 60% of females will experience a UTI within their lifetime, with approximately 25% having a recurrence within 1 year2.
 
Did you know?
 
Asymptomatic bacteriuria is very common, and treatment is indicated in patients who are immunocompromised, pregnant, and those with prior urological operation4
 
 
Classification of UTIs3
 
UTIs are also characterized as either: 3
 
Uncomplicated* infections occur in:
 
o Individuals without structural or functional abnormalities of the urinary tract that interfere with normal flow
 
Complicated infections occur as a result of:
 
o A compromised immune system
 
o Predisposing lesion of the urinary tract
 
o Congenital distortion of the urinary tract
 
o Nephrolithiasis
 
o Benign prostatic hyperplasia
 
o Neurologic deficits - that interfere with normal flow
 
 
*UTIs in males are generally not classified as uncomplicated because these infections are rare in the absence of complicating factors
 
Host Defenses4-7
*Click to enlarge
 
Remember
 
Under normal conditions, the urinary tract is sterile due to host defense mechanisms against bacterial colonization, with the exception of the distal urethra
Risk Factors3
 
Diabetes
 
Female gender
 
Sexual intercourse and spermicide use
 
Pregnancy
Indwelling urinary catheters and urinary tract instruments
Recent antibiotic use
Vesicoureteral reflux (retrograde flow of urine from the bladder back up to the kidneys through the ureters)
Incomplete voiding and residual urine
 
Can be due to obstruction (e.g. stones, large prostate, tumor) or neuromuscular disease (e.g. stroke, diabetes)
Did you know?
 
UTIs are more common in women because of the proximity of the urethra to the anus, and a shorter urethra than men, and thus a shorter distance bacteria must travel to reach a woman’s bladder
Pathogenesis in Women4
 
Infection begins with colonization of the vagina by fecal flora, followed by ascension via the urethra into the bladder. Pyelonephritis can develop when the pathogens ascend further to the kidneys via the ureters, or via bacteremia.
 
Microbiology8,9
 
In community acquired uncomplicated UTI, the vast majority of infections are due to E. coli (75-95% of cases)
 
Local antimicrobial susceptibility patterns should be considered in empiric therapy
 
Clinical Presentation and Assessment3
 
Signs and Symptoms:
 

*Click to enlarge
 
Symptoms of pyelonephritis can occur ± symptoms of cystitis
Clinical Practice Tip
 
If a woman presents with any of the sign or symptoms listed in cystitis, there is a 50% chance that she may have cystitis, and over a 90% chance in those who present with painful urination and increased frequency in the absence of vaginal discharge or irritation10
 
Pharmacologic Treatment11
 

*Click to enlarge
 
So which is the best choice?
 
The choice of agents should not only take into account efficacy, but also safety, patient allergy/tolerability, local resistance patterns, availability, cost and compliance. Resistance to many of these antibiotics is increasing and the determination of local resistance patterns is imperative to successful treatment of UTIs.
 
Non-Pharmacologic Treatments
 
Drink plenty of water to help flush the urinary tract
 
Never delay the urge to urinate
 
Wipe from the front to the back
 
Wash genital areas before and after intercourse
 
Avoid feminine sprays and douches
 
Wear cotton underwear to allow moisture to evaporate
 
Managing Margaery’s Symptoms
 
Tell her that based on her signs and symptoms, it is very highly likely that she is experiencing a bladder infection
 
Educate her on what may have caused her acute uncomplicated cystitis and reinforce non-pharmacologic measures to prevent (re)infection of the urinary tract
 
Let her know that cranberry juice and probiotics may or may not help
 
 
Clinical Controversy – Role of Cranberry Juice and Probiotics
 
Cranberry Juice may have potential clinical benefits however, the consistency of results are varied, as are the types of cranberry products tested, leading to inconclusive evidence to support its recommendation12,13
 
Lactobacilli are the dominant bacteria of the vaginal flora and possess antimicrobial properties that help to regulate other urogenital microbiota. UTIs lead to a shift in the local flora, thus lactobacilli-containing probiotics have been proposed to treat and prevent UTIs by restoring the vaginal flora. However, there is limited evidence to support its recommendation14.
 
Chris
 
By Christopher Low, PharmD Student
 
With appreciation to Mike Boivin
 
In this issue
 
Urinary tract infections (UTIs)
 
Pathogenesis in Women
 
Clinical Presentation and Assessment
 
So which is the best choice?
 
Clinical Controversy – Role of Cranberry Juice and Probiotics
 
Resources
 
References
 
Pharmacy Student Blog
 
Resources
 
IDSA Guidelines
 
References
 
1. Warren JW, Abrutyn E, Hebel JR, et al. Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis. Clin Infect Dis 1999;29:745–758
 
2. Naber KG, Cho YH, Matsumoto T, et al. Immunoactive prophylaxis of recurrent urinary tract infections: a meta-analysis. Int J Antimicrob Agents 2009;33:111–119
 
3. Gupta, K., Hooton, T., Naber, K., Wullt, B., Colgan, R., Miller, L., . . . Soper, D. (2011). International Clinical Practice Guidelines For The Treatment Of Acute Uncomplicated Cystitis And Pyelonephritis In Women: A 2010 Update By The Infectious Diseases Society Of America And The European Society For Microbiology And Infectious Diseases. Clinical Infectious Diseases, E103-E120.
 
4. Hooton, Thomas. "Uncomplicated Urinary Tract Infection." The New England Journal of Medicine 366.11 (2012): 1028-037. Print.
 
5. Stamey TA, Fair WR, Timothy MM, et al. Antibacterial nature of prostatic fluid. Nature 1968;218:444–447
 
6. Naber KG. Management of bacterial prostatitis: what's new? BJU International 2008;101(Suppl 3):7–10
 
7. Parsons CL, Schrom SH, Hanno P, et al. Bladder surface mucin: Examination of possible mechanisms for its antibacterial effect. Invest Urol 1978;6:196–200.
 
8. Czaja CA, Scholes D, Hooton TM, Stamm WE. Population-based epidemiologic analysis of acute pyelonephritis. Clin Infect Dis 2007; 45:273.
 
9. Echols RM, Tosiello RL, Haverstock DC, Tice AD. Demographic, clinical, and treatment parameters influencing the outcome of acute cystitis. Clin Infect Dis 1999; 29:113.
 
10. Bent S, Nallamothu BK, Simel DL, et al. Does this woman have an acute uncomplicated urinary tract infection? JAMA 2002; 287:2701.
 
11. Gupta, Kalpana, Thomas Hooton, Kurt Naber, Bjorn Wullt, Richard Colgan, Loran Miller, Gregory Moran, Lindsay Nicholle, Raul Raz, Anthony Schaeffer, and David Soper. "Executive Summary: International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectio." IDSA Clinical Practice Guidelines 52 (2011): E103-120. IDSA. IDSA. Web. 30 Apr. 2015. View source.
 
12. Cimolai N, Cimolai T. The cranberry and urinary tract. Eur J Clin Microbiol Infect Dis 2007;26:767–776.
 
13. Masson P, Matheson S, Webster AC. Meta-analyses in prevention and treatment of urinary tract infections. Infect Dis Clin N Am 2009;23:355–385.
 
14. Barrons R, Tassone D. Use of Lactobacillus Probiotics for bacterial genitourinary infections in women: A Review. Clin Ther 2008;30(3):453–468.
 
 
 
 
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