2-minute Consultation: UTIs: Painful, Treatable

Dr. Throm is an assistant professorof pharmacy practice at MidwesternUniversity College of Pharmacy?Glendale,Glendale, Arizona.

The uncomplicated, symptomaticlower urinary tract infection(UTI; acute bacterial cystitis)is a common and costly reason forphysician referral and hospital visits. Inthe year 2000, 8.27 million physicianvisits for UTIs were reported (1.41 millionmen, 6.86 million women), with anestimated cost of $3.5 billion for evaluationand treatment.1 UTIs are moreprevalent in women; of the 429,000hospital stays due to UTIs, approximately75% are attributed to women.¹

Causes

The most common causative pathogenin uncomplicated, symptomaticlower UTIs is Escherichia coli, whichaccounts for 75% to 90% of infections.Staphylococcus saprophyticus follows,causing 5% to 15% of UTIs. The remaininginfections are caused by enterococci,Klebsiella species, and Proteusmirabilis.^2,3

Signs and Symptoms

The bladder is the most commonsite of lower UTIs. Common signs andsymptoms of acute, uncomplicated lowerUTIs in nonpregnant women includedysuria, frequency, or urgency.^2-4 Urinealso may appear dark, cloudy, or pinktinged.Acute cystitis is more commonin young, sexually active women witha history of UTIs.2,3 Complicated upperUTIs (eg, pyelonephritis)occur in thekidneys,are associated with systemicsymptoms (eg, patients with fever, chills,flank pain), and are found more often inhigh-risk populations (eg, patients withdiabetes, pregnancy,immunosuppression,previous pyelonephritis,symptomslasting >14 days, or structural abnormalitiesof the urinary tract).^2,3

Pharmacist?s Role in the Management of Acute, Uncomplicated UTIs in Women

• Recommend the appropriateempiric antimicrobial agent basedon local E coli resistance (antibiogram)and the patient?s drug allergies,renal function, and insurancecoverage
• Monitor the duration of antimicrobialtherapy for patient safety andcost-effectiveness
• Recommend the conversion fromintravenous antimicrobial therapyto an appropriate oral product inthe hospitalized patient who hasimproved and is tolerating orals
• Provide counseling on antimicrobialdosing and administration,duration of therapy, and adversedrug events

Treatment

Guidelines from the Infectious DiseasesSociety of America suggest thefollowing empiric pharmacotherapy andrecommendations for the treatment ofuncomplicated UTIs in women⁴:

• Trimethoprim-sulfamethoxazole(TMP-SMX; Bactrim, Septra) for 3days is recommended as first-linetherapy for uncomplicated UTIs inareas where the rate of E coli-resistantTMP-SMX or TMP is <20%
• Fluoroquinolones are not recommendedas first-line treatment ofUTIs, except in communities withhigh rates of TMP-SMX or TMP resistance(eg, >10%-20%) to E coli
• Use of beta-lactams (ampicillin,amoxicillin) is not recommended forthe routine treatment of uncomplicatedUTIs due to limited efficacy
• Nitrofurantoin and fosfomycin maybecome more useful as resistanceto TMP-SMX and TMP increases;however, they are limited by adverseevents and/or cost

UTI symptoms typically subside within1 to 3 days after antimicrobial therapyis initiated.² Some patients with severedysuria may be initiated on the urinaryanalgesic phenazopyridine (Pyridium orUristat) for 1 to 2 days.²

Uncomplicated UTIs are common,and although the rate of TMP-SMX?resistant E coli is increasing, TMP-SMXis still a feasible first-line antibiotic.⁵The pharmacist plays an important rolein antimicrobial management in thepatient with an acute, uncomplicatedUTI. PT

Table

UTIs = urinary tract nfections; bid = twice daily; N = nausea; V = vomiting; HA = headache; D = diarrhea.Adapted from references 2-4.

References

• National Institutes of Health. National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC). Kidney and Urologic Diseases Statistics for the United States. Accessed December 16, 2007.
• Fihn Stephan. Clinical practice. Acute uncomplicated urinary tract infection in women. N Engl J Med. 2003;349:259-266.
• Mehnert-Kay SA. Diagnosis and management of uncomplicated urinary tract infections. Am Fam Physician. 2005;72:451-458.
• Warren JW, Abrutyn E, Hebel JR, Johnson JR, Schaeffer AJ, Stamm WE. Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis in women. Infectious Diseases Society of America (IDSA). Clin Infect Dis. 1999;29:745-758.
• Karlowsky JA, Thornsberry C, Jones ME, Sahm DF. Susceptibility of antimicrobial-resistant urinary Escherichia coli isolates to fluoroquinolones and nitrofurantoin. Clin Infect Dis. 2003;36:183-187.