TRIPASS XR تري باس

 

CASE 71-10, QUESTION 2: If P.M. had additional symptoms of fever, chills, flank pain, and vomiting, how

would her treatment differ?

In seriously ill patients with possible sepsis, broad-spectrum parenteral antibiotics

with activity against P. aeruginosa are usually preferred as initial therapy (Table 71-

4). Suitable antibiotic choices include antipseudomonal cephalosporins (e.g.,

ceftazidime, cefepime), extended-spectrum penicillins (e.g., piperacillintazobactam), carbapenems (imipenem-cilastatin, meropenem), IV fluoroquinolones

(e.g., ciprofloxacin, levofloxacin), and aztreonam. These antibiotics are at least as

effective as the aminoglycosides and lack the ototoxic and nephrotoxic potential.

However, these fluoroquinolone and β-lactam agents are more costly and associated

with the emergence of resistant organisms and superinfection.

In general, antipseudomonal β-lactam antibiotics remain the drugs of choice for

nosocomial urologic sepsis.

103 Although combination therapy may be useful initially

in neutropenic patients with urologic sepsis, it should be narrowed to single-agent

therapy once culture results are available.

103 The recommended duration of antibiotic

therapy in seriously ill patients is 10 to 14 days.

23

Urinary Catheters

CASE 71-11

QUESTION 1: J.W., an 18-year-old woman, was hospitalized after a diving accident that resulted in a spinal

cord injury with paralysis. Included among several initial interventions was insertion of an indwelling catheter

with a closed drainage system because of bladder incontinence. Two weeks after admission to the hospital,

J.W. has developed asymptomatic bacteriuria. Should this be treated?

A systemic antibiotic selected specifically for the infecting organism will

temporarily result in sterile urine. Reinfection, often by a resistant organism, occurs

in 30% to 50% of these cases if closed drainage catheterization is continued during

therapy.

1

,

23 For this reason, it generally is recommended that systemic antimicrobial

therapy be initiated after or just before catheter removal.

1

,

23

,

104 Because long-term

catheterization is necessary in many patients and because bacteriuria is an inevitable

consequence, it is often recommended that asymptomatic patients (such as J.W.) be

left untreated to avoid the complications of recolonization and potential infection

with resistant organisms.

1

,

13

,

23

,

104 Therapy must be started, however, if fever, flank

pain, or other symptoms indicative of an actual UTI develop.

1

,

23

CASE 71-11, QUESTION 2: Is systemic antimicrobial prophylaxis useful for J.W.?

The benefits of systemic antibiotics in preventing catheter-induced UTI are not

clear. Studies using closed drainage systems with diligent catheter care indicate that

systemic antibiotics decrease the daily and overall incidence of infection in patients

with sterile urines before catheterization.

35

,

36 The preventive effect of antimicrobials

is greatest for short-term catheterizations or during the first 4 to 7 days of long-term

catheterization.

35

,

36 Thereafter, the rate of infection increases. Although the overall

infection rate remains lower than in untreated patients, the emergence of resistant

organisms is significant. Therefore, in deciding to use systemic antimicrobials, it is

important to consider the patient’s underlying diseases, risk factors, probable

duration of catheterization, and potential complications of drug toxicity or resistant

organisms that can result from the chronic use of antimicrobials. Because long-term

catheterization is anticipated for J.W., antimicrobial prophylaxis for J.W. is not

recommended.

23

CASE 71-11, QUESTION 3: J.W. eventually recovers urinary continence and the catheter is able to be

removed. However, 2 days after removal of the catheter, she still has asymptomatic bacteriuria. How should

she be managed?

p. 1502

p. 1503

Because asymptomatic bacteriuria in patients with urinary catheters is very

common (approximately 25% with short-term catheterization and virtually 100%

long-term) but is associated with few complications, antibiotic therapy for

asymptomatic bacteriuria is not recommended as long as the catheter remains in

place.

23 However, antibiotic treatment may be considered in asymptomatic women

with catheter-acquired bacteriuria that persists >48 hours after catheter removal.

13

,

23

Such patients may be treated with either a single large dose or a 3-day regimen of

TMP–SMX, even if the patient is asymptomatic.

13

,

23

,

24 Older women (>65 years)

probably should be treated with a 10-day course; however, the optimal duration in

this age group is unknown. Whether these same treatment regimens are advisable in

male patients requires further study.

23

PROSTATITIS

Incidence, Prevalence, and Epidemiology

Prostatitis is an acute or chronic inflammatory condition affecting the prostate,

approximately 5% of cases being caused by proven bacterial infections.

11

,

12 Other

noninfectious types of prostatitis include chronic calculus prostatitis, nonbacterial

prostatitis, and prostatodynia.

11

,

12 Chronic bacterial prostatitis, defined as prostatitis

in which symptoms persist for at least 3 months, is one of the most common causes of

recurrent UTI in men. The lifetime probability of a man being diagnosed with

prostatitis is greater than 25%; recurrence rates reportedly range from 20% to

50%.

11

,

12 Approximately 5% of men with acute prostatitis will experience chronic

infection.

11

Etiology, Pathogenesis, and Predisposing Factors

ACUTE BACTERIAL PROSTATITIS

Acute bacterial prostatitis in most patients probably begins as an ascending infection

of the urethra. A simple UTI then eventually involves reflux of infected urine into the

ejaculatory and prostatic ducts through the prostate gland, where bacteria are difficult

to eradicate.

12 Acute prostatitis may also result from urethral stricture or after

instrumentation of the urinary tract or prostate biopsy, especially in the presence of

bacteriuria at the time of the procedure.

12 Bacterial prostatitis is predominantly

caused by aerobic gram-negative bacilli, with E. coli causing 50% to 90% of cases.

Other Enterobacteriaceae such as Proteus and Klebsiella account for an additional

10% to 30% of cases, followed by Enterococcus (5% to 10%) and Pseudomonas

(<5%); less common causes include staphylococci, streptococci, and atypical

organisms such as C. trachomatis, T. vaginalis, and Ureaplasma urealyticum.

11

,

12

CHRONIC BACTERIAL PROSTATITIS

Chronic prostatitis is commonly associated with spinal cord injuries, infectious

stones, anatomic or physiologic abnormalities of the urinary tract such as obstruction

or voiding dysfunction, and immune dysfunction. However, recurrent infections are

also commonly caused by relapses of acute prostatitis caused by persistence of

bacteria in the prostate.

11

,

12 Normally, men secrete a prostatic antibacterial factor;

however, this substance is often absent or significantly reduced in men with chronic

prostatitis. The most common pathogens isolated from chronic bacterial prostatitis

a r e E. coli (>80% of cases) and other gram-negative bacilli, although atypical

bacteria have also been more commonly reported in chronic prostatitis compared to

acute infections.

11

,

12

Clinical Presentation and Diagnosis

ACUTE BACTERIAL PROSTATITIS

Acute bacterial prostatitis is characterized by the sudden onset of chills and fever;

perineal and low back pain; urinary urgency and frequency; nocturia, dysuria, and

generalized malaise; and prostration. Patients may also complain of myalgias,

arthralgias, and symptoms of bladder outlet obstruction. Rectal examination usually

discloses an exquisitely tender, swollen prostate that is firm and warm to the touch.

The pathogens generally can be identified by culture of the voided urine. In patients

with acute bacterial prostatitis, prostatic massage (see following discussion) should

be avoided because of patient discomfort and the risk of bacteremia.

11

,

12 The

diagnosis of acute prostatitis is therefore usually based on clinical presentation and

physical examination.

CHRONIC BACTERIAL PROSTATITIS

The clinical manifestations of chronic bacterial prostatitis are highly variable and

many patients are asymptomatic. The disease usually is suspected when a male

patient treated for UTI or acute prostatitis relapses. The diagnosis of chronic

prostatitis is confirmed by examination of expressed prostatic secretions.

11

,

12 To

ensure accurate localization (i.e., to distinguish prostatic from urethral bacteria),

segmented urine samples are taken. The first 10 mL of voided urine represents the

urethral sample, the midstream urine collected represents the bladder sample, and the

first 10 mL voided immediately after prostatic massage represents the prostate

sample. When the bladder sample is sterile or nearly so, bacterial prostatitis is

diagnosed if the bacterial count in the prostate sample is at least one logarithm

greater than that in the urethral sample.

11

,

12

Overview of Treatment

Treatment of bacterial prostatitis is challenged by poor penetration of many

antibiotics across the non-fenestrated prostatic capillaries and through prostatic

epithelium into infected tissues and fluids. Fluoroquinolones are often considered the

preferred antibiotics for treatment of acute or chronic prostatitis because of good

penetration into the prostate (10%–50% of serum concentrations) and good activity

against most causative pathogens, although fluoroquinolone resistance has become a

growing problem.

11

,

12 Trimethoprim alone or TMP–SMX are also commonly used

agents. β-Lactams, tetracyclines, macrolides, and clindamycin have also been

successfully used in the treatment of both acute and chronic infections, but their

penetration into the prostatic tissues and fluids may be somewhat less than the

fluoroquinolones or TMP–SMX. Also, the antimicrobial activity of these drugs is not

necessarily ideal for covering the most common causative pathogens.

11

,

12 The

duration of antibiotic therapy in acute prostatitis is usually 2 to 4 weeks, depending

on the severity of the infection and rate of response to treatment.

11

,

12 Chronic

prostatitis is usually treated for 4 to 6 weeks, although longer courses may be

required in the presence of prostate stones or other types of genitourinary pathology,

and long-term suppressive therapy is sometimes used for patients with a history of

rapid and/or multiple recurrences.

11

,

12 Monitoring parameters consist primarily of

clinical signs and symptoms, and the end point of treatment is complete resolution of

clinical findings.

11

,

12 Supportive treatment consists primarily of drugs for

symptomatic relief such as acetaminophen or nonsteroidal anti-inflammatory agents;

warm compresses to the perineal area are also sometimes recommended, although

there are few data to support this practice.

11

,

12

p. 1503

p. 1504

CASE 71-12

QUESTION 1: D.G., a 60-year-old man, experienced his first UTI at age 40, with symptoms of frequency,

dysuria, nocturia, perineal pain, fever and chills but no flank pain. Acute prostatitis was diagnosed. E. coli was

cultured from the urine, and treatment with a sulfonamide was successful. After 12 asymptomatic years, acute

prostatitis caused by E. coli recurred and again responded to sulfonamide therapy. Two more E. coli infections

that responded to sulfonamide therapy occurred during the next 8 years. Why were sulfonamides appropriate

treatment for D.G.’s repeated acute episodes of bacterial prostatitis?

Most antibacterial drugs appropriate for UTI, including sulfonamides, can be used

to treat acute bacterial prostatitis because the diffuse, intense inflammation of the

prostate gland allows many drugs to readily penetrate into the prostatic fluid and

tissues. Antimicrobial therapy should be continued for at least 2 to 4 weeks to

prevent the development of chronic prostatitis.

11

,

12

,

24

CASE 71-12, QUESTION 2: Taking into account the pathophysiology of prostatitis, what would be a

reasonable choice of therapy for D.G. should he have future recurrences of prostatitis?

In addition to antibiotics, other supportive measures may provide symptomatic

relief to patients with acute bacterial prostatitis. These measures include liberal

hydration, nonsteroidal anti-inflammatory drugs for pain relief, sitz baths, and stool

softeners.

In retrospect, sulfonamides were appropriate for D.G. because they effectively

treated his infections. Other options, particularly the fluoroquinolones, would also

have been appropriate in the treatment of D.G.’s episodes of acute prostatitis.

Most antibiotics that are acidic do not readily cross the prostatic epithelium into

the alkaline prostatic fluid except in the presence of acute inflammation.

Theoretically, the high alkalinity of prostatic fluids should impair the diffusion of

trimethoprim and enhance the diffusion of tetracyclines, certain sulfonamides, and

macrolide antibiotics, such as erythromycin. Nevertheless, TMP–SMX historically

has the best documented cure rates in the treatment of acute and chronic bacterial

prostatitis. Long-term therapy of chronic bacterial prostatitis with TMP–SMX for 4

to 16 weeks is associated with a cure rate of 32% to 71%, which significantly

exceeds the cure rate associated with short-term therapy of 2 or fewer weeks.

11

,

12

The fluoroquinolones are alternatives to TMP–SMX and are now considered by

many to be the agents of choice for the treatment of prostatitis.

11

,

12

,

24 A number of

studies have documented bacteriologic cure in 80% to 90% of patients treated with

norfloxacin, ciprofloxacin, or levofloxacin for 4 to 12 weeks, rates comparable to or

substantially higher than those achieved with TMP–SMX.

11

,

12 The fluoroquinolones

have an important role in the treatment of prostatitis owing to their bactericidal

activity against common pathogens and excellent penetration into prostatic tissues

and fluid. The fluoroquinolones are often used as initial empiric therapy of prostatitis

and are also excellent alternatives to other agents in patients who are unresponsive or

intolerant to conventional therapy, or in those infected with resistant organisms.

11

,

12

,

24

Fluoroquinolones also have been used for chronic suppressive therapy (one-half

normal doses) in patients who relapse after conventional treatment.

1

D.G. should be treated with TMP–SMX for a minimum of 6 weeks; some

authorities recommend a 2- to 3-month total course of therapy. If an adequate trial of

TMP–SMX is unsuccessful, fluoroquinolone therapy can be used. Alternatively, a

fluoroquinolone could be used as initial therapy for this or future episodes.

11

,

12

,

24

If D.G. continues to experience recurrent infections after a trial of fluoroquinolone

therapy, chronic low-dose treatment with TMP–SMX, fluoroquinolones, or

nitrofurantoin can alleviate the symptoms of episodic bladder infection associated

with chronic bacterial prostatitis. Infections eventually recur with greater frequency

in most of these patients. Chronic, low-dose antibacterial therapy sterilizes the

bladder, alleviates symptoms, confines bacteria to the prostate, and prevents

infection of and damage to the rest of the urinary tract. Chronic bacterial prostatitis is

one of the few indications for continuous antibiotic therapy.

KEY REFERENCES AND WEBSITES

A full list of references for this chapter can be found at

http://thePoint.lww.com/AT11e. Below are the key references for this chapter, with

the corresponding reference number in this chapter found in parentheses after the

reference.

Key References

Craig JC et al. Antibiotic prophylaxis and recurrent urinary tract infection in children [published correction appears

in N EnglJ Med. 2010;362:1250]. N EnglJ Med. 2009;361:1748–1759. (84)

Epp A et al. Recurrent urinary tract infection. J Obstet Gynaecol Can. 2010;250:1082–1101. (34)

Gupta K et al. 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. Clin Infect Dis. 2011;52:e103–e120. (20)

Hooton TM Jr. Uncomplicated urinary tract infection. N EnglJ Med. 2012;366(11):1028–1037. (2)

Hooton TM et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009

international clinical practice guidelines from the Infectious Diseases Society of America. Clin Infect Dis.

2010;50:625–663. (23)

Karlowsky JA et al. Fluoroquinolone-resistant urinary isolates of Escherichia coli from outpatients are frequently

multidrug resistant: results from the North American Urinary Tract Infection Collaborative Alliance-Quinolone

Resistance Study. Antimicrob Agents Chemother. 2006;50:2251–2254. (69)

Katsarolis I et al. Acute uncomplicated cystitis: from surveillance data to a rationale for empirical treatment. Int J

Antimicrob Agents. 2010;35:62–67. (49)

Lipsky BA et al. Treatment of bacterial prostatitis. Clin Infect Dis. 2010;50:1641–1652. (11)

Nicolle LE et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of

asymptomatic bacteriuria in adults. Clin Infect Dis. 2005;40:643–654. (13)

Nicolle LE. Uncomplicated urinary tract infection in adults including uncomplicated pyelonephritis. Urol Clin North

Am. 2008;35:1–12. (5)

Popovic M et al. Fosfomycin: an old, new friend? Eur J Clin Microbiol Infect Dis. 2010;29:127–142. (44)

Raynor MC et al. Urinary infections in men. Med Clin North Am. 2011;95:43–54. (7)

Schito GC et al. The ARESC study: an international survey on the antimicrobial resistance of pathogens involved in

uncomplicated urinary tract infections. Int J Antimicrob Agents. 2009;34:407–413. (47)

Shuman EK et al. Recognition and prevention of healthcare-associated urinary tract infections in the intensive care

unit. Crit Care Med. 2010;38(Suppl):S373–S379. (22)

Vouloumanou EK et al. Early switch to oral versus intravenous antimicrobial treatment for hospitalized patients

with acute pyelonephritis: a systematic review of randomized controlled trials. Curr Med Res Opin.

2008;24:3423–3434. (78)

COMPLETE REFERENCES CHAPTER 71 URINARY TRACT

INFECTIONS

SobelJD, Kaye D. Urinary tract infections. In: Bennett JE et al, eds. Mandell, Douglas, and Bennett’s Principles

and Practice of Infectious Diseases. 8th ed. New York, NY: Churchill Livingstone; 2015:886–913.

Hooton TM Jr. Uncomplicated urinary tract infection. N EnglJ Med. 2012;366:1028–1037.

Dielubanza EJ, Schaeffer AJ. Urinary tract infections in women. Med Clin North Am. 2011;95:27–41.

Ramakrishnan K, Scheid DC. Diagnosis and management of acute pyelonephritis in adults. Am Fam Physician.

2005;71:933–942. [published correction appears in Am Fam Physician. 2005;72:2182]

Nicolle LE. Uncomplicated urinary tract infection in adults including uncomplicated pyelonephritis. Urol Clin North

Am. 2008;35:1–12.

Brown P et al. Acute pyelonephritis among adults: cost of illness and considerations for the economic evaluation of

therapy. Pharmacoeconomics. 2005;23:1123–1142.

Raynor MC, Carson CC 3rd. Urinary infections in men. Med Clin North Am. 2011;95:43–54.

Kucheria R et al. Urinary tract infections: new insights into a common problem. Postgrad Med J. 2005;81:83–86.

Paintsil E. Update on recent guidelines for the management of urinary tract infections in children: the shifting

paradigm. Curr Opin Pediatr. 2013;25(1):88–94.

Beetz R. Evaluation and management of urinary tract infection in the neonate. Curr Opin Pediatr.

2012:24(2):205–211.

Lipsky BA et al. Treatment of bacterial prostatitis. Clin Infect Dis. 2010;50:1641–1652.

Wagenlehner FME et al. Urinary tract infections and bacterial prostatitis in men. Curr Opin Infect Dis.

2014;27(1):97–101.

Nicolle LE et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of

asymptomatic bacteriuria in adults. Clin Infect Dis. 2005;40:643–654. [published correction appears in Clin

Infect Dis. 2005;40:1556]

Guzzo TJ, Drach GW. Major urologic problems in geriatrics: assessment and management. Med Clin North Am.

2011;95:253–264.

Rowe TA, Juthani-Mehta M. Diagnosis and management of urinary tract infection in older adults. Infect Dis Clin

North Am. 2014;28:75–89.

Al Salman J et al. Infection in long term care facility in the Kingdom of Bahrain. J Infect Public Health.

2014;7:392–399.

Nicolle LE. Urinary tract infections in the elderly. Clin Geriatr Med. 2009;25:423–436.

Richards CL. Urinary tract infections in the frail elderly: issues for diagnosis, treatment and prevention. Int Urol

Nephrol. 2004;36:457–463.

Eriksson I et al. Prevalence and factors associated with urinary tract infections (UTIs) in very old women. Arch

Gerentol Geriatr. 2010;50:132–135.

Gupta K et al. 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. Clin Infect Dis. 2011;52:e103–e120.

Bagshaw SM, Laupland KB. Epidemiology of intensive care unit-acquired urinary tract infections. Curr Opin

Infect Dis. 2006;19:67–71.

Shuman EK, Chenoweth CE. Recognition and prevention of healthcare-associated urinary tract infections in the

intensive care unit. Crit Care Med. 2010;38(Suppl):S373–S379.

Hooton TM et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults:

2009 international clinical practice guidelines from the Infectious Diseases Society of America. Clin Infect Dis.

2010;50:625–663.

Wagenlehner FM, Naber KG. Current challenges in the treatment of complicated urinary tract infections and

prostatitis. Clin Microbiol Infect. 2006;12(Suppl 3):67–80.

Kalita A et al. Recent advances in adherence and invasion of pathogenic Escherichia coli. Curr Opin Infect Dis.

2014;27:459–464.

AgarwalJ et al. Pathogenomics of uropathogenic Escherichia coli. Indian J Med Microbiol. 2012;30:141–149.

Gupta K, Trautner BW. Diagnosis and management of recurrent urinary tract infections in non-pregnant women.

BMJ. 2013;346:f3140.

Schneeberger C et al. Asymptomatic bacteriuria and urinary tract infections in special patient groups: women with

diabetes mellitus and pregnant women. Curr Opin Infect Dis. 2014;27:108–114.

Lumbiganon P et al. Screening and treating asymptomatic bacteriuria in pregnancy. Curr Opin Obstet Gynecol.

2010;22:95–99.

Golebiewska JE et al. Urinary tract infections during the first year after renal transplantation: one center’s

experience and a review of the literature. Clin Transplant. 2014;28:1263–1270.

Chen SL et al. Diabetes mellitus and urinary tract infection: epidemiology, pathogenesis and proposed studies in

animal models. J Urol. 2009;182:S51–S56.

Nicolle LE. Urinary tract infection in diabetes. Curr Opin Infect Dis. 2005;18:49–53.

Gorter KJ et al. Risk of recurrent acute lower urinary tract infections and prescription pattern of antibiotics in

women with and without diabetes in primary care. Fam Pract. 2010;27:379–385.

Epp A et al. Recurrent urinary tract infection. J Obstet Gynaecol Can. 2010;250:1082–1101.

Johnson JR et al. Systematic review: antimicrobial urinary catheters to prevent catheter-associated urinary tract

infection in hospitalized patients. Ann Intern Med. 2006;144:116–126.

Tenke P et al. An update on prevention and treatment of catheter-associated urinary tract infections. Curr Opin

Infect Dis. 2014;27:102–107.

Gupta K, Trautner B. In the clinic: urinary tract infection. Ann Intern Med. 2012;156:ITC3-1–ITC3-15.

Bent S et al. Does this woman have an acute uncomplicated urinary tract infection? JAMA. 2002;287:2701–2710.

Medina-Bombardo D, Jover-Palmer A. Does clinical examination aid in the diagnosis of urinary tract infections in

women? A systematic review and meta-analysis. BMC Fam Pract. 2011;12:111–125.

Schmiemann G et al. The diagnosis of urinary tract infection: a systematic review. Dtsch Arztebl Int.

2010;107:361–367.

Simerville JA et al. Urinalysis: a comprehensive review. Am Fam Physician. 2005;71:1153–1162. [published

correction appears in Am Fam Physician. 2006;74:1096]

Deville WL et al. The urine dipstick test useful to rule out infections. A meta-analysis of the accuracy. BMC

Urol. 2004;4:4.

Koeijers JJ et al. Evaluation of the nitrite and leukocyte esterase activity tests for the diagnosis of acute

symptomatic urinary tract infection in men. Clin Infect Dis. 2007;45:894–896.

Popovic M et al. Fosfomycin: an old, new friend? Eur J Clin Microbiol Infect Dis. 2010;29:127–142.

Aypak C et al. Empiric antibiotic therapy in acute uncomplicated urinary tract infections and fluoroquinolone

resistance: a prospective observationalstudy. Ann Clin Microbiol Antimicrob. 2009;8:27.

Olson RP et al. Antibiotic resistance in urinary isolates of Escherichia coli from college women with urinary tract

infections. Antimicrob Agents Chemother. 2009;53:1285–1286.