Therapeutics Id Exam 1- Uti

Front 1

uncomplicated UTI

Back 1

Describes a UTI in a patient with a structurally and functionally normal
urinary tract (often referred to as acute bacterial cystitis)

Front 2

complicated UTI

Back 2

Describes an infection which involves signs/symptoms of an upper
urinary tract infection (most often pyelonephritis) or used to describe an infection in a patient
who has a structural or functional abnormality of the urinary tract

Front 3

pyelonephritis

Back 3

Interstitial inflammation of the renal parenchyma and collecting system

Front 4

chronic pyelonephritis

Back 4

Describes a shrunken, scarred kidney which may be
postinfectious but often is not associated with a UTI

Front 5

3 factors affecting ability of bacteria to cause UTI

Back 5

virulence- helps overcome host defense
inoculum size- amount of bacteria-->too much and body can't eradicate
host defense- many barrier in place-->if these fail then you're effed

Front 6

3 routes of UTI

Back 6

ascending route (most infections)- rectal flora colonize female urethra-->ascend from urethra and upwards (pyelonephritis)

hematogenous route- unlikely (distant site bacteremia reaching UTI- descending); usually more virulent

lymphatic- little evidence for this route except maybe from adjacent organs (severe bowel infxn)

Front 7

uncomplicated UTI- 6 bugs

Back 7

e.coli (mostly this)
staph saprophyticus- more aggressive than e. coli since it causes more upper tract **** and relapse
klebsiella
proteus spp
enterococcus faecalis
s. epidermis (CONTAMINANT something about that)

Front 8

how to approach complicated vs uncomplicated UTI in terms of empirical therapy

Back 8

if complicated, get a culture. If uncomplicated treat empirically and only culture if it doesn’t work.

Front 9

6 bugs of complicated uti

Back 9

-The percentage of infections due to E. coli decreases to ~50% while the number of infections
from Proteus spp., Klebsiella spp., Enterobacter spp., Enterococcus, and Pseudomonas all
increase

Front 10

10 risk factors of UTI

Back 10

female
hx of previous episodes
frequent/recent sexual activity
hospitalized
prolonged cathing
conditions leading to residual urine
obstruction to urine flow
pregnancy
DM
immunocompromised >65/post menopause

Front 11

4 conditions leading to residual urine

Back 11

• BPH
• Anticholinergic medications
• Bladder strictures, stones, tumors
• Neurologic malfunction

Front 12

urine host defense mechanisms (4 and 1 specific to male)

Back 12

rine at low pH, extremes in osmolality, high urea concentration, high organic acid concentration, prostatic secretions (male)- helps to decrease infections

Front 13

4 host defenses against uti

Back 13

urine ****

micturition

antiadherence mechanisms
accumulation of PMN leukocytes

Front 14

4 sx of UPPER uti

Back 14

Differentiating a lower tract infection from an upper tract infection based solely on signs/symptoms is
inadequate

Flank pain
b. Costovertebral tenderness
c. Abdominal pain
d. Systemic symptoms (fever, rigors, malaise, nausea/vomiting)

Front 15

4 things to note on pt interview

Back 15

pt complaints- consistency, other sx that would rule out uti
hx of previous infxns/factors (esp immunocomrpomised)
detailed description of pattern of infections (frequency, sex, contraception...)
previous response to therapy- any cultures? recurrent (diff organiisms) or relapse?

Front 16

usually positive dipstick can just continue with tx...when do you have to do a culture? (3)

Back 16

suspect an upper tract or complicated infection,
negative dipstick in situation where pretest probability for infection is high, recurrence of symptoms within 2-4 weeks after completion of treatment

Front 17

2 modes of rapid testing

Back 17

dipsticks for nitrates (bacteria)- if pt positive for this and has sx they can be put on empirical tx (if uncomplicated)

leukoesterase dipstick for pyuria

Front 18

3 bacteria who don't convert nitrates to nitrites

Back 18

Enterococcus, S. saprophyticus, and Pseudomonas

Front 19

urine sample- best question to ask if you see this

best way to get urine sample

Back 19

important to ask how they obtained sample. Best way is urinary catheter. As outpatient, tends to be midstream. So Catheter is best way to get sample in hospital.

Front 20

steps for getting pee sample (midstream)

Back 20

clean pee opening with moist gause (no antiseptics)
if female spread labia and catch midstream
collect sample then refrig immediately and culture within 24 h

Front 21

how to tell if urine sample contaminated

Back 21

The presence of vaginal epithelial cells indicates contamination of the specimen and one
should obtain a new specimen

Front 22

disadvantage of using cath to get sample

Back 22

Risk of infection in 1-2% of patients due to placement of catheter

Front 23

avoid what type of cath for sampling

Back 23

Avoid obtaining a urine specimen from an indwelling catheter as this will be colonized with
bacteria and will not provide you with an accurate specimen (the sample will be contaminated)

Front 24

suprapubic aspiration (3) what is it, reserved forw hom, accuracy

Back 24

1. A needle is introduced into the bladder (local anesthetic is used) and urine is aspirated out
2. This technique will provide the most accurate specimen but this is an invasive procedure and
thus tends to be reserved for newborns or paraplegics

Front 25

3 things to look for in UA

Back 25

presence of bacteria
presence of leukocytes- if not present, question the dx of UTI until cultures come back
presence of hematuria- indicator of inflammatory response

Front 26

the most reliable method of diagnosing a urinary tract infection

Back 26

urine culture

Front 27

4 limintations to using just a cut off of bacteria (10^5) in urine as dx for UTI

Back 27

a. 30-50% of women who present with symptomatic UTIs will have bacterial counts
of 102 to 105 CFU/ml
b. Patients predisposed to UTIs tend to harbor large quantities of pathogenic bacteria
(perineum in women or foreskin in uncircumcised men) which may contaminate the
specimen and lead to overdiagnosis
c. Not all patients with 105 CFU/ml of bacteria are symptomatic
d. Various collection techniques will also affect the cut points

Front 28

Polymicrobial growth usually indicates

Back 28

contamination and a new specimen should be obtained

Front 29

Patients in which cultures/urinalysis ideally should be obtained as part of the initial evaluation: conditions (4) ppl with sx obv

Back 29

-Age over 65 years
-Pregnancy
-Immunosuppression (including medications)
-Known or suspected urologic abnormality

Front 30

4 sx where you want to take cultures and not just treat empirically

Back 30

Gross hematuria- fine to have a little blood, but if blood is super red you might want to delve further.
-Unresolved or recurrent symptoms of UTI
-Symptoms of UTI for > 3 days (some say 7 days)
-Fever, chills, or flank pain

Front 31

historical characteristics where you'd want to take cultures (4)

Back 31

-Antimicrobial therapy within 2 weeks
-Hospitalization or nursing home stay within 2 weeks
-Urethral catheterization within 2 weeks
-History of childhood UTIs

Front 32

rationale behind not treating
a UTI
(3)

Back 32

don't have to treat otherwise healthy individual

a. There are no long term adverse effects on renal function or increased mortality
associated with uncomplicated infections in non-pregnant women
b. The significance of the infection is limited to symptoms which may have an effect
on quality of life. We tend to treat but don’t have to.

Front 33

choice of UTI abx depends on..(5)

Back 33

i. Nature of the infection (i.e. - complicated versus uncomplicated)
ii. Allergies, side effect/toxicity profile
iii. Spectrum of activity
-Ideally would like to use an agent which is active against the most likely
pathogen but minimal activity on normal vaginal flora
iv. Cost
v. Resistance patterns --> growing concern for E. coli

Front 34

cure of uTI depends on what cultures

Back 34

depends on urine culture not blood with exception of bacteremia

Front 35

Phenazopyridine (Pyridium) - used for what/when to use

what does it do

Back 35

adjunctive tx OTC

works as an analgesic in the urinary tract to help minimize symptoms
until the antibiotics exert their effects; suggested to use if symptoms are severe

Front 36

how to dose phenazopyridine

Back 36

200 mg orally TID for 2 days then done because after 2 days abx should be working.

Front 37

3 AE of phenazopyridine

Back 37

renal fxn decline
urinary discloration (red/orange)
yellow skin/sclera (if accumulation)

Front 38

GFR where you want to avoid phenazopyridine

Back 38

best avoided in those with moderate to severe renal
failure defined by a glomerular filtration rate of < 50 ml/min

Front 39

does acidification of urine work?

Back 39

Doesn’t appear to have much use as you are unable to clinically
provide enough acidification via ingestion of things such as orange juice

Front 40

cranberry juice usage

Back 40

There may be some use of cranberry juice in prevention of bacterial adherence – not used to treat per se but used in those with recurrent UTIs as ppx

Front 41

cranberry juice- 2 things in it that work for UTI

Back 41

Proanthocyanidins and high fructose content contained in cranberry juice inhibit attachment of urinary
pathogens to the epithelium

Front 42

recent cochrane review on cranberry juice said what?

Back 42

a recent Cochrane Review found that the evidence does not support use
of cranberry products for the prevention of UTI’s. but makes you pee…so…

Front 43

Methenamine hippurate (Hiprex)- often used how?

what's it do?

Back 43

often used as an alternative to antibiotics for prevention of UTI’s in recurrent infections in women who have failed other ppx

• antiseptic Converted to formaldehyde in acidified urine which is then thought to have antibacterial activity

Front 44

methenamie hippurate does not work in whom (2)

Back 44

it does
not work in those with neurogenic bladder or in patients with renal tract abnormalities

Front 45

methenamine dosing

Back 45

1 gram twice daily

Front 46

nitrofurantoin dosing and duration

Back 46

100 mg twice daily for 5 days with meals

Front 47

nitrofurantoin advantages (3)

Back 47

• Minimal resistance and minimal effects on flora (narrow spectrum of activity); low risk for collateral damage (ecologic adverse effects of antimicrobial therapy)
• Preferred in pregnancy except near term
• Five day treatment comparable to three days of trimethoprim/sulfamethoxazole

Front 48

disadvantages of nitrofurantoin (2)

Back 48

• Not effective if CrCl is <60 ml/min (unable to get adequate urine concentration)
• Rapidly undergoes renal excretion and does not produce any high therapeutic levels in many body tissues

Front 49

when to avoid NF (2)

Back 49

o Avoid in complicated UTI’s or bacteremia
o Avoid if suspect early pyelonephritis

Front 50

NF not effective in what 3 bugs

(limited to what bug )

Back 50

Pseudomonas, Serratia, or Proteus (often limited to E. coli infections)

Front 51

3 AE of nF

Back 51

• GI intolerance; neuropathies and pulmonary fibrosis associated with use

Front 52

bactrim dosing and duration

Back 52

160/800 mg (one DS tablet) BID x 3 days

Front 53

bactrim does not cover what 2 bugs

Back 53

• Does not cover Enterococcus or Pseudomonas

Front 54

when to avoid bactrim (2)

Back 54

• Avoid if local resistance known to be > 20%
or if used to treat a UTI within the previous 3 months

Front 55

bactrim AE (2)

Back 55

• GI side effects and potential for skin rash

Front 56

courses of bactrim longer than 5 days have been assoc with what? why

Back 56

• Courses longer than 5 days have been associated with hyperkalemia (trimethoprim acts like a potassium-sparing diuretic)

Front 57

fosfomycin trometamol dosing

Back 57

3 gram single dose

Front 58

2 advantages of fosfomycin

Back 58

• Minimal resistance and narrow spectrum of activity
• One dose treatment

Front 59

2 disadvantages of fosfomycin

Back 59

• Less efficacious than other recommended agents; but more viable now in outpatient for uncomplicated UTI due to growing resistance in other drugs

GI/diarrhea may be worse with this drug than other agents

Front 60

fosfomycin when to avoid

Back 60

• Avoid use if suspect early pyelonephritis

Front 61

when to use second line agents (3)

Back 61

reserve use for those with allergies, unable
to tolerate previous regimens, or have failed previous regimens

Front 62

3 FQs you can use and the duration of therapy

Back 62

cipro
levo
ofloxacin

3 days
NO moxifloxacin low urine lvls

Front 63

3 FQ advantages

Back 63

• Broad spectrum of coverage
• May be effective against Pseudomonas and Enterococcus depending on sensitivities
• Highly efficacious in 3 day regimens

Front 64

3 disadvantages of FQ

Back 64

• Broad spectrum of activity  higher risk for collateral damage
• Some are expensive
• Best reserved for more severe infections (e.g. pyelo)

Front 65

3 beta lactam choices

Back 65

augmentin 7 days
cefdinir 5 days
cefpodoxime 3 days

Front 66

2 disadvantages of beta lactams

Back 66

• Generally have inferior cure rates and more adverse effects compared to other antimicrobials; recommended to be used with caution
• Poor to no Enterococcus coverage

Front 67

2 beta lactams not to use and why

Back 67

• Ampicillin and amoxicillin should not be used for empirical treatment due to poor efficacy and high prevalence for resistance

Front 68

2 labs that must be done in pt with pyelo

Back 68

a. All patients diagnosed with pyeoloneprhitis should ideally have urinalysis completed
b. Blood cultures are generally obtained for hospitalized patients

Front 69

supportive care for pyelo

Back 69

consider hydration
with crystalloids as part of the treatment regimen especially if they are febrile

Front 70

outpatient drugs for complicated UTI (pyelo) and drug of choice (2)

Back 70

similar to those for acute uncomplicated cystitis,
although generally higher doses are used and for longer periods of time


FQs (cipro/levo)***
bactrim

Front 71

FQ dosing and duration for cipro and levo for pyelo

Back 71

• Ciprofloxacin (Cipro) 500 mg twice daily or 1 gram (extended-release) once daily for 7 days
• Levofloxacin (Levaquin) 750 mg daily for 5 days

Front 72

how does local resistance rates of bugs chance how you treat for outpatient pyelo

Back 72

• Need to ensure local resistance rates do not exceed 10%; if resistance rates are in excess of 10%, recommended to provide an initial IV dose of a long-acting parenteral antibiotic (i.e. – ceftriaxone 1 gram) or a consolidated 24-h dose of an aminoglycoside

Front 73

bactrim dosing/duration for pyelo outpatient

Back 73

160/800 mg twice daily for 14 days (FDA approved labeling)

Front 74

bactrim is only appropriate in complicated UTI iff...

Back 74

• Only appropriate if pathogen is known to be susceptible; so empirically never going to start with this drug

Front 75

inpatient mgmt of pyelonephritis started on what?

initial selection based on what?

Back 75

These patients are started on intravenous antibiotics and may be switched to oral agents
after afebrile for 24-48 hours
b. Initial selection is usually with broad spectrum antibiotics but these can be tailored
depending on culture results

Front 76

6 IV choices for inpatient pyelo

Back 76

• Fluoroquinolone (levofloxacin, ciprofloxacin)
• Aminoglycoside with or without ampicillin
• Extended-spectrum cephalosporin (i.1. – cefepime, cefotetan, ceftriaxone)
• Extended-spectrum penicillin (i.e. – ticarcillin/clavulanate, pipercillin/tazobactam) with or without an aminoglycoside
• A carbapenem (i.e. – imipenem, meropenem)

Front 77

only drug that can treat IV pyelo ESBL producing **** (some e coli)

Back 77

, the carbapenems are the only drugs to treat ESBL-producing microorganisms (e.g. some e. coli)

Front 78

7 examples of resistant species seen in complicated UTI

Back 78

a. Methicillin-resistant Staphylococcus aureus (MRSA)
b. Methicillin-resistant coagulase-negative staphylococci
c. Vancomycin-resistant enterococci (VRE)
d. Gram-negative organisms producing extended beta-lactamases (ESBL)
e. Pseudomonas, Proteus, and Candida species

Front 79

The decision to provide prophylaxis for recurrent UTIs will depend on

expand on this in more detail

Back 79

the number of recurrent infections
per year:
a. Less than 3 symptomatic episodes/year  treat each episode as an individual infection
i. Some will give the patient the antibiotic and the patient will initiate treatment
upon development of symptoms
b. More than 3 symptomatic episodes/year  eligible for prophylaxis

Front 80

3 common regimens for recurrent UTI ppx and how long to treat (i guess know dosing)

Back 80

i. Nitrofurantoin 50 mg QD
ii. Trimethoprim 100 mg QD
iii. TMP/SMX 40/200 mg or 80/400 mg QD


treat 6-12 months

Front 81

how to treat post coital UTI - non pharm and pharm

commonly used agents and duration (3)

Back 81

2. Voiding soon after sexual activity may help to diminish the occurrence of infections and
patients may also use single-dose prophylaxis after sexual activity
3. Commonly used agents include TMP/SMX, nitrofurantoin, or a quinolone

Front 82

why are geriatric women at increased risk of UTI

Back 82

loss of estrogen decreases the growth of Lactobacillus resulting in reduced production of lactic acid which may allow the vaginal pH to increase

Front 83

why are geriatric men at increased risk of UTI

Back 83

reduction of prostatic secretions occurs

Front 84

geriatric changes that predispose them to UTI


because of this predisposition what is different with how we approach treating elderly?

Back 84

estrogen/prostate secretion issues
disease states that impair immune systems are more common in old people

people over 65 years old should be treated
for a minimum of 7 days with antibiotics if they develop a UTI (not considered uncomplicated)

Front 85

changes in pregnancy that cause asymptomatic UTI to progress into pyelo (3)

Back 85

pregnancy (decreased bladder tone, decreased urinary
peristalsis, dilation of renal pelvis) which may predispose women with asymptomatic
bacteriuria (ASB) to development of pyelonephritis

Front 86

is preg a risk factor for asymptomatic bacteruria?

Back 86

Pregnancy itself is not a risk factor for the development of ASB with an incidence
of 4-6% in both pregnant and non-pregnant women

Front 87

why do we not leave ASB untreated in preggos? (2)

Back 87

b. If ASB is left untreated in pregnancy, ~20-40% of these women will develop
pyelonephritis later in pregnancy as compared to 1-2% of non-pregnant women
c. In addition, untreated ASB is associated with prematurity, low birth weight, IUGR (intrauterine growth restriction- small babies),
and neonatal death

Front 88

when to screen preggos for ABS

Back 88

For this reason, pregnant women are screened early in pregnancy for the presence of bacteria;
ideal time is ~16 weeks gestation

Front 89

duration of treatment for ABS in preggos (normal and then if they fail)

Back 89

the duration is
generally accepted at 3 days for most antibiotics; if patient fail, a 7-10 day regimen with
culture guided treatment is recommended

Front 90

safe in pregnancy abx (2)

Back 90

penicillins (PCN, AMP/AMOX)
cephalosporins- usually cephalexin or 3rd gen agents (mainly for pyelo- IV)

Front 91

nitrofurantoin in pregnancy- usage

when not to use and why

Back 91

first line if 1st or 2nd trimester

theoretical risk for hemolytic anemia in mother with G6PD deficiency

Front 92

3 abx to use cautiously in pregnancy and why

Back 92

aminoglycosides- • Theoretical risk of oto- nephrotoxicity in fetus (cross placenta)
sulfisoxazole- folate antagonist in 1st trimester, kernicterus in 3rd
trimpethoprim- don't use in 1st trimester it's a folate antagonist

Front 93

drugs to avoid in preg (2)

Back 93

FQ- impairs bone growth
tetracyclines- preg cat D

Front 94

2 abx with increasing e coli resistance

Back 94

sulfisoxazole
trimethoprim

Front 95

NF not effective in what?

rare AE in pregnancy

Back 95

• Not effective in pyelonephritis
• Rare maternal pulmonary reaction (pneumonitis)

Front 96

NF a good choice in preggos when?

Back 96

• Good choice for PCN allergic patients with UTI limited to lower urinary tract

Front 97

3rd gen cephalosporins/cephalexin for UTI- lack coverage of what?


used when?

Back 97

• Lack enterococcus coverage
• Used for GBS in PCN allergic

Front 98

• PCNG used for ...(in preggos)

Back 98

group B strep

Front 99

how to deal with developing resistance in aminopenicillins

Back 99

• Resistance developing for aminopenicillins  recommend susceptibility testing to help guide treatment

Front 100

IV ampicillin- downside

Back 100

• IV ampicillin used however dosage adjustments may be required due to rapid renal elimination

Front 101

male UTI- complicated or uncomplicated

Back 101

If a male develops a UTI then this is considered to be a complicated infection

Front 102

men with what comorbidities tend to develop UTI (2)

Back 102

BPH or partial prostatic obstruction are the ones who generally develop infections

Front 103

usual culprit in UTI (bug) for men...then other 5

Back 103

3. Enterobacteriaceae are usually the culprits and inparticular, one should consider coverage for
Proteus, Klebsiella, and Serratia
4. In addition, Pseudomonas and Enteroccocus are potential causes

Front 104

peds: infants/young kids may present with what sx for UTI

Back 104

a. Infants and young children can present with fever as the only manifestation of a UTI

Front 105

if UTI suspected in peds what do you do next

Back 105

urine cultures should be performed for most patients

Front 106

imaging reqiured for peds in what circumstance s(age,etc) (5)

Back 106

a. Children less than 5 years of age with febrile UTI
b. Girls less than 3 years of age with first UTI

c. Males of any age with first UTI
d. Children with recurrent UTI
e. Children with UTI who do not respond quickly to therapy

Front 107

UTI tx in kids vs adults (2 differences in peds)

Back 107

same as adults except no FQ (or tetracyclines i guess) and you want to repeat cultures to document eradication of infection

Front 108

UTI duration of tx in older kids
younger? (indicate age range)

when should kids be admitted

Back 108

older kids-->3 days duration
2 mo to 2 years- 7-14 days
< 3 mo or dehydrated kids should be hospitalized

Front 109

when would you treat asymptomatic bacteruria (2)

Back 109

Generally, providers would treat an asymptomatic patient if >105 CFU of bacteria/ml was obtained
on 2 separate clean cath catches


or preg

Front 110

patients who mayyyy benefit from treating ASB

Back 110

Patients who have underlying structural abnormalities or who will undergo instrumentation
may benefit from treatment

Front 111

5 organisms for symptomatic abacteruria

Back 111

E. coli, Chlamydia trachomatis,
Neisseria gonorrhoeae, Gardenerella, and Ureaplasma urealyticum

Front 112

how to treat symptomatic bacteruria (what drug)

2 bugs that you look out for and treat differently

Back 112

Empiric treatment with TMP/SMX and look to see if there is Chlamydia and if so, treat
for that and empirically for gonorrhea

Front 113

2 types of catheter associated issues

Back 113

catheter-associated asymptomatic bacteriuria (CA-ASB) and
catheter-associated urinary tract infection (CA-UTI)

Front 114

pyuria in catheterized people - diagonstic of anything?

Back 114

In catheterized people, pyuria is not diagnositic of CA-ASB or CA-UTI nor
should the degree of pyuria be used to differentiate between CA-ASB from
CA-UTI

Front 115

2 things in catheterized people that should not be used to constitute treatment

Back 115

pyuria in CA-ASB
presence/absence of odorous/cloudy urine alone (no urine culture shoudl be taken either)

Front 116

systemic abx for ppx in catheterized pt- rec'd?

Back 116

Systemic antibiotics for prophylaxis should not routinely be used in patients
with short-term or long-term catheterization

Front 117

screening for ABS in cath'd patients- recommended?

exception to this rule

Back 117

Screening for and treating asymptomatic bacteriuria is not recommended to
reduce subsequent CA-bacteruria or CA-UTI in patients with short-term or long-term
indwelling catheters

except in pregnant women or those who undergo urologic
procedures for which visible mucosal bleeding is anticipated