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Management of Acute Uncomplicated Cystitis and Pyelonephritis

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The Finks 5 is an abbreviated review on a selected drug or pharmacotherapeutic class, which is summarized within 5-15 minutes. This Finks 5 summarized treatment for acute uncomplicated cystitis and pyleonephristis by Pharm.D. Candidate Foster Johnson.

Hey everyone this is shannon finks with the phinx 5 i have with me my third year pharmacy student foster johnson who is going to be talking about acute uncomplicated cystitis and pyelonephritis for those of you who have never joined us before a phinx 5 is a review of therapeutics and pharmacotherapy that is generally reviewed in 5 to 15 minutes sometimes we go a

Little bit over but we’re trying to hit the high points so i’m going to hand this off to foster now as he begins our discussion today today we’re going to be talking about the pathogenesis of urinary tract infections which this includes the uncomplicated accused hystitis as well as the treatment therapies how you can use urine analysis to help with diagnosis and

The differences between a complicated acute cystitis and pyelonephritis so uncomplicated acute cystitis is a common urinary tract infection or uti where bacterial infection affects the lower urinary tract and the bladder some risk factors include recent sexual history histories of usdis diabetes and the use of spermicides the main bacteria that causes uncomplicated

Acute cystitis is going to be e coli with occasional infections from other bacteria some of these refractors for other bacterium are going to be inpatient stay at a health care facility the use of fluoroquinolones or bactrum and travel outside the country with high rates of multi drug resistant organisms also it’s important to know that women are more affected um

Than men because of the shorter distance between the anus and urethra diagnosis this is mostly based off of clinical manifestations so dichiria which is painful urination urinary frequency urinary urgency and the presence of blood in the urine although urinalysis can be used as well to help confirm diagnosis where we look at leukocytes and nitrites so urinalysis

Which is used in helping diagnose for both acute uncomplicated cystitis and pilonephritis the way that this is used is that we get a clean catch so the patient will have a clean catch of midstream about five to ten milliliters of urine and then we take a strip that’s then dipped in the urine that is then used to run chemical tests and it’ll take a couple minutes

The other two ways to look at this is going to be microscopically and the other one being chemically like i mentioned before microscopically just means that you’re looking at the color of the urine as well as the clarity so we’re going to be looking for any outstanding color changes as well as whether the urine is cloudy or kind of a hazy the chemical measurements

Include leukocytes which is for white blood cells nitrites which includes the presence of bacteria blood and protein as well as many others there are difference in readings between uncomplicated acute cystitis and pilonephritis with acute cystitis we’re going to typically see an elevated leukocyte so white blood cells nitrites and blood in the urine as you can see

In the picture on the bottom left whereas in pyelonephritis we’re going to see more of positive leukocytes proteins and ketones that show that the infection has reached the kidney as well as with the clinical manifestations of hyaline nephritis we can also get a urine culture that way we can help narrow down therapeutic treatments by narrowing down susceptibility

Rates for drugs this can be helpful especially in the case of piling nephritis because it can help us narrow therapy that way we can stop the risk of this infection spreading to be more systemic than it already is so now we’re going to get into first line treatment therapies for uncomplicated acute cystitis first one we’re going to have is going to be macro bit or

Nitrofuranton and that is going to be 100 milligrams twice daily with meals for five days for women and seven days for men now the reason that this medication is considered the first line treatment is because it has lower resistance rates out in the community and has a very good tolerability so some things to note about this medication is that it is contraindicated

In a creatinine clearance of less than 30 milliliters per minute and it’s conjugated in pregnant patients at term 38 to 42 weeks and it has a potential for urine discoloration which is something that will need to be brought up to the patient next we have second line treatment which is going to be bactrim which is sulfur methoxazole and trimethoprim that’s going

To be 800-160 milligrams twice daily for three days for women and seven days for men now this medication is considered second line therapy because it does have a higher rate of resistance out in the community and so that’s why it’s going to be considered second line therapy to macrobid now this medication has a side effect risk of diarrhea hyperkalemia and signs

And symptoms of rash some major things to point out is that like i said it does have the risk of hyperkalemia which is going to be an increased potassium it’s also going to have the risk of hypoglycemia which is going to be a decrease in blood sugar as well as anaphylaxis risk with sulfur allergies and then it needs to be discontinued at the signs and symptoms

Of rash because that rash can turn into stevens johnson syndrome and now we’ll get into third and fourth line treatment therapies for uncomplicated acute cystitis fluoroquinolones so levofloxacin and ciprofloxacin are going to be considered third line therapies because they do have a increased resistance out in the community as well as they do have black box

Warnings and greater side effects than some of these other medications that we’ve talked about so far so to get into those the two way that we would use are going to be levofloxacin and ciprofloxacin moxifloxacin is not used because of its inability to reach therapeutic concentrations in the urine so to note some special things about these medications is going

To be the black box warning which is going to be key counseling points to tell your patients to watch out for because they are serious side effects that can happen with these medications so random tendinitis tendon rupture peripheral neuropathy and cns effects being the greater ones as well as the risk of qtc prolongation so you’ll want to watch out for drugs

That already have qtc prolongation as a side effect there is also the need to administer this medication with without regard to meals necessarily but they needed to be administered about two hours before two hours after antacids iron calcium and zinc contained products as well as the risk of hyper hypoglycemia and renal dose impairment adjustments then we have

Augment which is amoxicillin slash clavulanate and that’s gonna be 500 milligrams twice daily with meals for five to seven days main issues that we’re going to see with this medication is going to be diarrhea nausea and vomiting as well as the possible risk of hepatitis and an anaphylaxis reaction in patients who do have a penicillin allergy and before we get into

Pyelonephritis we need to talk about complicated and recurrent utis so recurrent cystitis is going to be an infection of a cube simple cystitis that is greater than or equal to two infections within six months or greater than equal to three infections in one year um these episodes are mostly relapses versus reinfections and a relapse is considered when recurrence

Occurs within two weeks of complicated treatment and the uropathogens the same so risk factors are going to be sexual intercourse and diaphragm spermicide use as independent risk and increase susceptibility to vaginal colonization even when asymptomatic then we also have complicated uti where patients can present with bacteremia sepsis shock and or acute renal

Failure however these are more likely to occur in elderly or those who have diabetes symptoms of cystitis along with fever and other signs and symptoms of systemic illness will be noticed such as chills rigors or acute mental status changes it is recommended in a complicated uti to do urinalysis as well as urine culture so the treatment for recurrent cystitis is

Going to be continuous prophylaxis that’s initiated for a three-month time frame just to see the response as well as the tolerability so some of those therapies is going to be nitrofuranton 50 or 100 milligrams once a day bacterium 1200-40 milligrams once a day or even three times weekly dosing and then ceflex and 125 milligrams once a day complicated uti has

A little bit more because it’s going to need impure coverage so it’s going to be necessary to treat with either immunity mirapenum or dory panel plus vancomycin or the nasolid therapy should be tailored based upon cultural results and then as well as conversion from iv to po is tolerated by the patient the total duration is going to range from five to 14 days

Based upon therapy use where fluoroquinolones are five to seven bactrons seven to ten and bail atoms are 10 to 14s if there’s worsening symptoms or persistent symptoms following the initiation of antibiotics reassessments necessary and use of pelvic imaging may be required and now we’ll get into pyelonephritis polynephritis is an upper urinary tract infection

That stemmed from an un complicated acute cystitis that’s migrated up into either the kidneys or like i said the urinary upper urinary tract this medication has the same risk factors as uncomplicated acute cystitis and the main issue with this is that this form of uti is going to be treated much more intensely with more duration for therapy as well as higher

Doses for the medications and the main bacteria that causes it is going to be e coli as well as other potential bacterium with the same risk factors that have been included before which is inpatient stay at a health care facility use of a fluoroquinolone spectrum recently as well as travel outside the country with high rates of multi drug resistant organs again

Women are more impacted than men because of the shorter length of the urethra so these patients will die will present with clinical manifestations of cystitis so this disuria the urinary frequency and the urinary urgency however these patients also present with the fever it’s greater than or equal to 37.7 degrees celsius chills rigors flank pain and the coastal

Vertebral angle tenderness which is shown in the diagram to the bottom left of how you can test for that as well as acute nausea and vomiting now because of these increased systemic effects that is why the treatment for this form of uti is going to be much more intense so there’s also the symptoms that would push you to push a patient to go in patient or to go

To a hospital which is going to be a persistently high fever at greater than 38.4 degrees celsius pain marked ability and inability to maintain oral hydration again urinalysis can help with diagnosis as well as taking urine cultures to help narrow the scope of your treatment therapy and in this powerpoint we’re only going to be talking about outpatient treatment

For pyelonephritis and we’re going to be looking at the low risk of multi-drug resistance versus high risk of multi-droid resistance so within the low risk of multi-drug resistance we have four chloramine sparing regimens which is going to be ceftriaxone or recepton plus the initiation of bactrim at 160 to 800 twice a day for seven to ten days or augment 875

Twice a day for 10 to 14 days macro bid or nitrofuranton cannot be used in this situation it does not have the ability to reach the kidneys that cannot reach therapeutic doses then we can have the fluoroquinolone regimen which can be ciprofloxacin 500 milligrams twice a day for five to seven days or levofloxacin 750 milligrams once a day for five to seven

Days now in the case of high risk of multi-drug resistance it’s going to be the initiation of urtipenum one gram once a day plus initiation of ciprofoxus in 500 milligrams twice a day or levofloxacin 750 milligrams once a day for five to seven days we can also do a different form of this which is going to be earth venom one gram once a day until susceptibility

Results come back then initiation of an oral agent which would be the bactron or augment mentioned before this is also going to be typically only if patients have contraindications to fluoroquinolones so this drug information is already going to have included uh bactrim the fluoroquinolones and augmentin so the main two that we’re gonna talk about on this slide

Is gonna be erdopenum and ceftrax um so ertopinum um some of the main side effects are gonna be some nausea diarrhea maybe some vomiting some things to watch out for are going to be anaphylaxis risk for patients who possibly have already noticed a penicillin allergy and possibly have not there’s also the increased risk of cns synthetics which include confusion

And seizures as well as the need for dose adjustments and renal impairment then the next medication is going to be ceftriaxone so this medication common side effects are going to be a warm sensation as well as possible pain or burning at the injection site and this medication is contraindicated in neonates due to biliary sludging and kernicterus it also has the

Risk of hemolytic anemia and there is an incr there is a risk of anaphylaxis in patients who have an allergy to any beta-lactams especially penicillin so in summary acute uncomplicated cystitis is an easily fixable bacterial infection of the lower urinary tract or bladder that has symptoms of disuria urinary frequency urinary urgency and hematuria pyelonephritis

Is a more complicated form of uti that shows when the bacteria has moved up to the kidneys or the upper urinary tract infection and has been noted with longer durations of therapy as well as higher doses of therapy because it is a more serious bacterial infection symptoms will include the flank pain the fever of greater than 37.7 degrees celsius chills rigor

And that coastal retail angle tenderness the treatment does vary between these two types uncomplicated cystitis some treatments that are going to be used first line therapy is going to be nitrofurantone or macrobib second line will be bactrim or trimethoprim sulfamethoxazole then you’ll have the fluoroquinolones and then augment nitrofurantone and trimethoprim

Slasher sulfur are considered first line therapy so those are going to be your mainstay pyelonephritis is going to have a loading dose of either ceftriaxone or erdopenum and that’s going to be dependent on the lower high risk factors for multi-drug resistant pathogens and a big thing to know is that macro bit is not used in pyelonephritis as it does not reach the

Kidneys so therapy cannot include macrobid for pyelonephritis thanks so much foster for your review of therapeutics within this area for those of you who are listening in on our youtube station we hope that this review was beneficial to you as well tune in to any of our other phinx 5 topics that cover a wide variety of other areas of pharmacotherapeutics until

Then above all though please use drug therapies wisely such that they’re given to the right patient at the right dose at the right time for the right purpose

Transcribed from video
Management of Acute Uncomplicated Cystitis and Pyelonephritis By Züp Med