Infectious Disease I Urinary Tract Infections and Prostatitis

Infectious Disease I: Urinary Tract Infections and Prostatitis Courses in Therapeutics and Disease State Management Author: Michael W. Perry Pharm. D, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy http: //accesspharmacy. mhmedical. com/qa. aspx#tab 6 Copyright © 2017 Mc. Graw-Hill Education. All rights reserved

Learning Objectives • Define the differences between uncomplicated and complicated urinary tract infections (UTIs) • Identify the most common organisms that cause UTIs • Describe the various routes in which bacteria enter the urinary tract and cause infection • Discuss how host defense mechanisms and bacterial virulence factors play a role in the development of UTIs • Describe the clinical presentation of lower and upper UTIs • Evaluate the various laboratory tests utilized in the diagnosis of UTIs Author: Michael W. Perry Pharm. D, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy http: //accesspharmacy. mhmedical. com/qa. aspx#tab 6 Copyright © 2017 Mc. Graw-Hill Education. All rights reserved

Learning Objectives • Select an appropriate antimicrobial regimen for the treatment of uncomplicated and complicated UTIs • Analyze antimicrobial regimens for appropriateness given varied antibiotic resistance • Develop a monitoring plan for a treatment regimen utilizing the goals of therapy in the treatment of UTIs • Select an appropriate antimicrobial regimen for patients with acute pyelonephritis • Describe how UTIs in males differ from UTIs in females Author: Michael W. Perry Pharm. D, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy http: //accesspharmacy. mhmedical. com/qa. aspx#tab 6 Copyright © 2017 Mc. Graw-Hill Education. All rights reserved

Learning Objectives • Select appropriate treatment or prophylaxis in patients with recurrent UTIs • Design appropriate antimicrobial treatment of UTIs in special patient populations such as pregnant females • Classify bacterial prostatitis as acute or chronic and choose appropriate antimicrobial treatment and/or prophylaxis • Evaluate the patient-centered considerations in the treatment of UTIs in the selection of antimicrobial therapy Author: Michael W. Perry Pharm. D, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy http: //accesspharmacy. mhmedical. com/qa. aspx#tab 6 Copyright © 2017 Mc. Graw-Hill Education. All rights reserved

Required and Recommended Reading Required Reading Coyle EA, Prince RA. Chapter 94. Urinary Tract Infections and Prostatitis. In: Di. Piro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. eds. Pharmacotherapy: A Pathophysiologic Approach, 9 e. New York, NY: Mc. Graw-Hill; 2014. Recommended Reading • Gupta K, Hooton TM, Naber KG, 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(5): e 103–e 120. • Hooten TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infections in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis 2010; 50: 625– 663. • Nicolle LE, Bradley S, Colgan R, et al. Infectious disease society of America guidelines for diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005; 40: 643 – 654. Author: Michael W. Perry Pharm. D, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy http: //accesspharmacy. mhmedical. com/qa. aspx#tab 6 Copyright © 2017 Mc. Graw-Hill Education. All rights reserved

Overview: Urinary Tract Infections and Prostatitis • Urinary tract infections is a diverse group of infections that are caused by microorganisms in the urinary tract that cannot be accounted for by contamination • Urethritis • Cystitis • Pyelonephritis • Bacterial prostatitis is an acute or chronic infection that results in the inflammation of the prostate gland surrounding tissue Author: Michael W. Perry Pharm. D, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy http: //accesspharmacy. mhmedical. com/qa. aspx#tab 6 Copyright © 2017 Mc. Graw-Hill Education. All rights reserved

Pathophysiology Urinary Tract Infections • Route of Infection • Ascending from colonization of the urethra • Hematogenous spread from distant primary infections via the blood • Host Defense Mechanisms • • p. H Osmolality Urea concentrations Organic acid concentration Prostatic secretions (male patients) Complete Voiding glycosaminoglycan layer of bladder Estrogen levels and normal vaginal flora (female patients) • Bacterial Virulence Factors • Ability to adhere to epithelium of the urinary tract • Hemolysin and aerobactin Author: Michael W. Perry Pharm. D, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy http: //accesspharmacy. mhmedical. com/qa. aspx#tab 6 Copyright © 2017 Mc. Graw-Hill Education. All rights reserved

Most Common Pathogens Urinary Tract Infections Uncomplicated • • • Escherichia coli Staphylococcus saprophyticus Klebsiella pneumonia Proteus sp. Pseudomonas aeruginosa Enterococcus sp. Complicated • • Escherichia coli Proteus sp. Klebsiella pneumonia Enterobacter sp. Pseudomonas aeruginosa Staphylococcus sp. Enterococcus sp. Author: Michael W. Perry Pharm. D, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy http: //accesspharmacy. mhmedical. com/qa. aspx#tab 6 Copyright © 2017 Mc. Graw-Hill Education. All rights reserved

Clinical Presentation Urinary Tract Infections Signs and Symptoms • Gross Hematuria • Lower UTI • • • Dysuria Urgency Frequency Nocturia Suprapubic heaviness • Upper UTI • • Flank pain Fever Nausea & vomiting Malaise Diagnosis • Urinalysis • • Bacteriuria Pyuria ( WBC count > 10 x 106/L) Presence of nitrites Presence of Leukocyte esterase • Antibody coated UTI (upper UTI) • Urine Gram stain and Culture Author: Michael W. Perry Pharm. D, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy http: //accesspharmacy. mhmedical. com/qa. aspx#tab 6 Copyright © 2017 Mc. Graw-Hill Education. All rights reserved

Clinical Presentation Urinary Tract Infections • Diagnosis is made primarily with laboratory tests on appropriate urine samples to demonstrate a significant number of microorganisms to distinguish between infection and contamination • Urine Collection via midstream clean-catch method • Bacterial Count • Pyuria, Hematuria, Proteinuria • Chemistry • Nitrites • Leukocyte Esterase • Culture Author: Michael W. Perry Pharm. D, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy http: //accesspharmacy. mhmedical. com/qa. aspx#tab 6 Copyright © 2017 Mc. Graw-Hill Education. All rights reserved

Treatment Overview • The majority of patients with an uncomplicated UTI can be cured with a short course of antibiotics • Goals of treatment • • Eradicate the invading microorganism Prevent and treat systemic signs and symptoms of infection Prevent reoccurrence of infection Prevent antibiotic induced adverse effects • Antibiotic empiric therapy can be modified and narrowed with urine culture and sensitivity data Author: Michael W. Perry Pharm. D, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy http: //accesspharmacy. mhmedical. com/qa. aspx#tab 6 Copyright © 2017 Mc. Graw-Hill Education. All rights reserved

Nonpharmacological and Supportive Prevention and Treatment Urinary Tract Infections • Hydration • Cranberry juice is commonly recommended, but has conflicting data concerning its use in the prevention and treatment of UTIs • Lactobacillus probiotics also may aid in the prevention of female UTIs by decreasing the vaginal p. H, thereby decreasing E. coli colonization • Urinary analgesics • Phenazopyridine HCl • Topical estrogen replacement for postmenopausal women may help in the prevention of recurrent UTIs Author: Michael W. Perry Pharm. D, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy http: //accesspharmacy. mhmedical. com/qa. aspx#tab 6 Copyright © 2017 Mc. Graw-Hill Education. All rights reserved

Pharmacological Treatment Urinary Tract Infections • Type of Infection • Acute uncomplicated cystitis • Symptomatic abacteriuria • Asymptomatic bacteriuria • Complicated UTIs • Recurrent infections • Prostatitis • Local resistance rates of E. coli to commonly prescribed antibiotics must be taken into consideration Author: Michael W. Perry Pharm. D, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy http: //accesspharmacy. mhmedical. com/qa. aspx#tab 6 Copyright © 2017 Mc. Graw-Hill Education. All rights reserved

Pharmacological Treatment Acute Uncomplicated Cystitis Link: Algorithm for Management of UTIs in Females Author: Michael W. Perry Pharm. D, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy http: //accesspharmacy. mhmedical. com/qa. aspx#tab 6 Copyright © 2017 Mc. Graw-Hill Education. All rights reserved

Pharmacological Treatment Complicated UTIs in Male Patients Link: Management of UTIs in Males Author: Michael W. Perry Pharm. D, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy http: //accesspharmacy. mhmedical. com/qa. aspx#tab 6 Copyright © 2017 Mc. Graw-Hill Education. All rights reserved

Pharmacological Treatment Link: Table on Commonly Used Antimicrobial Agents in the Treatment of Urinary Tract Infections Author: Michael W. Perry Pharm. D, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy http: //accesspharmacy. mhmedical. com/qa. aspx#tab 6 Copyright © 2017 Mc. Graw-Hill Education. All rights reserved

Pathophysiology Bacterial prostatitis • An inflammation of the prostate gland surrounding tissue due to an infection • Acute • Chronic • Physiologic factors may contribute to the development of prostatitis • Altered prostate secretory functions • Decreased zinc • Decreased prostatic antibacterial factor • Altered prostatic p. H • Manipulation of prostate • Catheters • Urethral instrumentation • Transurethral prostatectomy Author: Michael W. Perry Pharm. D, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy http: //accesspharmacy. mhmedical. com/qa. aspx#tab 6 Copyright © 2017 Mc. Graw-Hill Education. All rights reserved

Most Common Pathogens • E. coli is the predominant organism • Other gram-negative organisms • • • K. pneumonia P. mirabilis P. aeruginosa Enterobacter sp. Serratia sp. Author: Michael W. Perry Pharm. D, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy http: //accesspharmacy. mhmedical. com/qa. aspx#tab 6 Copyright © 2017 Mc. Graw-Hill Education. All rights reserved

Clinical Presentation • Acute Bacterial Prostatitis Constitutional Symptoms • • High fever Chills Malaise Myalgia • Specific Chronic Bacterial Prostatitis • Voiding difficulties • Low back pain • Perineal and suprapubic discomfort • Localized pain • Voiding difficulties • Nocturia • Physical Exam reveals a swollen, tender, tense, or indurated gland Author: Michael W. Perry Pharm. D, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy http: //accesspharmacy. mhmedical. com/qa. aspx#tab 6 Copyright © 2017 Mc. Graw-Hill Education. All rights reserved

Treatment Overview • Treatment similar to the UTI treatment • Empiric antimicrobial therapy should penetrate into the prostate and cover E. coli • Duration of antibiotics is normally 4 weeks Author: Michael W. Perry Pharm. D, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy http: //accesspharmacy. mhmedical. com/qa. aspx#tab 6 Copyright © 2017 Mc. Graw-Hill Education. All rights reserved

Pharmacological Treatment Link: Table on Overview of Outpatient Antimicrobial Therapy for Lower Tract Infections in Adults Author: Michael W. Perry Pharm. D, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy http: //accesspharmacy. mhmedical. com/qa. aspx#tab 6 Copyright © 2017 Mc. Graw-Hill Education. All rights reserved

Summary • UTIs are common and require prompt treatment with antibiotics after diagnosis • E. coli is the most common pathogen isolated in all types of UTIs • Antibiotic therapy choice and duration depends on the type of UTI • Uncomplicated UTIs require short courses (3 to 5 days) • Complicated UTIs require longer courses (10 to 14 days) Author: • Michael W. Perry Pharm. D, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy of Practice; Mylan School of Pharmacy Prostatitis requires up to 4 weeks therapy http: //accesspharmacy. mhmedical. com/qa. aspx#tab 6 Copyright © 2017 Mc. Graw-Hill Education. All rights reserved

References • Coyle EA, Prince RA. Chapter 94. Urinary Tract Infections and Prostatitis. In: Di. Piro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. eds. Pharmacotherapy: A Pathophysiologic Approach, 9 e. New York, NY: Mc. Graw-Hill; 2014. • Gupta K, Hooton TM, Naber KG, 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(5): e 103 –e 120. • Hooten TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infections in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis 2010; 50: 625– 663. • Nicolle LE, Bradley S, Colgan R, et al. Infectious disease society of America guidelines for diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005; 40: 643– 654. Author: Michael W. Perry Pharm. D, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy http: //accesspharmacy. mhmedical. com/qa. aspx#tab 6 Copyright © 2017 Mc. Graw-Hill Education. All rights reserved