Therapeutics ID Butler – Flashcards

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Definition/Classification of Cystitis
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Bladder infection

 

Lower Tract Infection

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Definition/Classification of Urethritis
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Infection of urethra

 

Lower Tract Infection

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Definition/Classification of Prostatitis
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Infection of prostate

 

Lower Tract Infection

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Definition/Classification of Epididymitis
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Infection of epididymis

 

Lower Tract Infection

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Definition/Classification of Pyelonephritis
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Infection of Kidney

 

Upper Tract Infection

 

 

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Routes of Infection
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  1. Ascending - urethra to bladder to kidneys
  2. Hematogenous (descending) - uncommon
  3. Lymphatic
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In the urine, the defense mechanisms are:
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  • Organic acid concentration
  • Urea concentration
  • Low pH (5.5 or less)
  • Prostatic secretions
  • Micturition
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In the bladder, the defense mechanisms are:
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  • Glycoaminoglycan
  • Taam-Horsfall
  • Fimbrae
  • Lactobacilli
  • Immunoglobulin
  • PMN
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Uncomplicated UTI
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  • 15-45 yo
  • Normal, healthy females
  • Lack structural/functional abnormalities
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Complicated UTI
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  • Congenital abnormality
  • Distortion of urinary tract, such as:

-Obstructions

-Neurologic deficit

-Can affect both genders

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Predisposing Risk Factors for UTIs
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  • Obstruction (benign prostatic hypertrophy, renal cyst)
  • Metabolic (diabetes, renal failure)
  • Functional (neurogenic bladder, vesicourethral reflux)
  • Indwelling Catheters (urethral stent)
  • Pregnancy
  • Anatomy
  • Contraceptives (diaphragms, condoms w/o lubrication or spermicidal condoms)
  • Others (sexual intercourse, douching, lower estrogen levels)
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Clinical Presentation of UTIs: Adults
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Lower Tract

  • Dysuria
  • Urgency
  • Frequency
  • Suprapubic Heaviness
  • Nocturia
  • Hematuria
  • Discolored or cloudy

Upper Tract

  • Flank pain
  • Back pain
  • Abdominal pain
  • Fever
  • N/V


 

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Clinical Presentation of UTIs: Elderly
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  • Altered mental status
  • Change in eating habits
  • GI symptoms
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Diagnostic Criteria for Significant Bacteriuria: Symptomatic Female
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> 102 CFU coliforms/ml or > 105 CFU non-coliforms/ml
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Diagnostic Criteria for Significant Bacteriuria: Symptomatic Male
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> 103 CFU bacteria/ml
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Diagnostic Criteria for Significant Bacteriuria: Symptomatic Individual on Two Consecutive Specimens
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> 105 CFU bacteria/ml
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Diagnostic Criteria for Significant Bacteriuria: Catheterized Specimens
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> 102 CFU bacteria/ml
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Pathogens for Acute Uncomplicated Cystitis
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  • Proteus mirabilis
  • Escherichia coli
  • Staphylococcus saprophyticus
  • Klebsiella pneumoniae
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Empiric Therapy for Acute Uncomplicated Cystitis
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  • FIRST LINE: Trimethoprim/Sulfamethoxazole (Bactrim) Double Strength 1 PO BID x 3 days

If there is an allergy to TMP/SMX, patient was hospitalized in past 6 months, or P. aeruginosa is suspected:

  • Levofloxacin 250 mg PO daily x 3 days
  • Ciprofloxacin 250 mg PO q 12 hrs x 3 days

 

 

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Follow Up for Acute Uncomplicated Cystitis

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  • Not routinely needed
  • If symptoms do not respond to treatment or reoccur, obtain urine culture and retreat
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Pathogens for Symptomatic Abacteriuria
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Chlamydia trachomatis

Escherichia coli

Gardeneralla vaginalis

Ureaplasma urealyticum

Neisseria gonorrhoeae

Staphylococcus spp.

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Empirical Treatment for Symptomatic Abacteriuria
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  • Trimethoprim/Sulfamethoxazole (Bactrim DS) 2 tabs PO single dose

OR

  • Trimethoprim/Sulfamethoxazole (Bactrim DS) 1 tab PO BID x 3 days

 

If STD suspected:

 

Azithromycin 1 g PO single dose + TMP/SMX DS

 OR

Doxycycline 100 mg PO BID x 7 days + TMP/SMX DS

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Diagnosis of Asymptomatic Bacteriuria
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  • NO symptoms
  • Two consecutive urine cultures > 105 of the same organism
  • Patient Populations:

Elderly

Females

Pregnant

 

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Pathogens of Asymptomatic Bacteriuria
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Klebsiella pneumoniae

Escherichia coli

Enterococcus faecalis

Proteus mirabilis

Staphylcoccus saprophyticus

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For Asymptomatic Bacteriuria, who do you want to treat?
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Pediatrics

Prego

 

Do not treat adult female if not pregnant

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Symptoms for Acute Pyelonephritis
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  • High grade fever
  • Severe flank pain
  • N/V
  • Dehydration
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Pathogens for Acute Pyelonephritis
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Klebsiella pneumoniae

Proteus mirabilis

Enterococcus faecalis

Pseudomonas aeruginosa

Escherichia coli

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Treatment for Acute Pyelonephritis
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Trimethoprim/Sulfamethoxazole DS 1 PO BID x 14 days

OR

Levofloxacin 500 mg PO daily x 14 days

OR

Ampicillin 2 g IV q 6 hrs + Gentamicin 1mg/kg/dose IV x 14 days

 

Once they are stable and afebrile, can switch to PO

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Follow Up for Acute Pyelonephritis
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  • Effective therapy should stabilize patient within 12-24 hrs
  • Reduction in urine bacteria within 48 hrs
  • Once pt afebrile, D/C IV therapy
  • F/U urine culture 2 weeks after completion of therapy
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Nosocomial UTI
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  • Hospitalized within 6 months
  • Urinary Catheter
  • Nursing Home Resident
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Pathogens of Nosocomial UTI
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  • Pseudomonas aeruginosa
  • Enterococci
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UTI in Males: Complications and Duration of Treatment
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Complicated

Catheterization, obstruction of urinary tract, renal and urinary stones, bladder outlet obstruction

 

Uncomplicated

Rare


Prolonged Treatment

10-14 days

Follow up with culture and sensitivity at 4-6 weeks after completion of treatment

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Causes of UTI in Pregnancy
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  • Hormonal changes cause urinary stasis and reduce defenses
  • Increased content of amino acids, vitamins, and nutrients encourage bacterial growth
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Common Pathogen of UTI in Pregnancy
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Escherichia coli
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Treatment of UTI in Pregnancy
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DOC --> Nitrofurantoin 100 mg BID x 7 days

 

Alt:

 

Amoxicillin/Clavulanate q 12 hrs x 7 days

 

OR

 

Cephalexin 500 mg q 12 hrs x 7 days

 

 

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Follow Up for UTI in Pregnancy
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Urine collection 1-2 weeks after therapy and then monthly
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Recurrent UTIs More Common In:
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Females

 

20% with cystitis

Sexual intercourse

Contraceptives

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Recurrent UTIs: 3 or less per year
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Treat as separate infection
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Recurrent UTIs: > 3 per year
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Treat conventionally then prophylaxis for 6 months

 

Trimethoprim/Sulfamethoxazole 1/2 single strength tab PO daily

 

OR

 

Trimethoprim 100 mg PO daily

 

OR

 

Nitrofurantoin 50 mg PO daily

 

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Recurrent UTIs: Re-Infection Prevention
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Post-Coital

Void after intercourse

Single dose TMP/SMX following intercourse (not common)


Postmenopausal

Topical estrogen cream - use vaginally

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Risk Reduction for UTIs
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  • Avoid products that irritate urethra (bubble bath, scented feminine products)
  • Take showers instead of baths
  • Cleanse the genital area before sexual intercourse
  • Urinate after sexual intercourse
  • Change soiled diapers in infants and toddlers promptly
  • Drink plenty of water to remove bacteria from the urinary tract
  • Do not routinely resist the urge to urinate
  • For you dirty girls, wipe properly damnit!
  • Wear cotton undies
  • Stop smoking (nicotine irritates bladder)
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Urinary Tract Irritants
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  • Acidic Foods
  • Citrus Fruits
  • Spices
  • Tomatoes
  • Alcohol
  • Caffeine
  • Chocolate

 

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Non-Pharmacological Therapy for UTIs

 

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  • Hydration
  • Lactobacillus probiotics
  • Cranberry juice
  • Estrogen replacement
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Non-Specific Therapy for UTIs
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Urinary Analgesics, Antispasmodics, Antispectics

  • Phenazopyridine (Pyridium)
  • Urimax
  • Urised

Helps with painful urination and urgency

Should not be used for > 2 days b/c they mask the true UTI symptoms

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Why is Trimethoprim a Category C drug in terms of pregnancy?
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It decreases folic acid which is needed for nucleotide biosynthesis
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Trimethoprim should not be used in newborns because:
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it causes hyperbilirubin which increases risk for developing jaundice
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Why is levofloxacin considered category C in terms of pregnancy risk?
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It causes bone/joint deformities
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What is a counseling point for patients when taking levofloxacin?
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  • Avoid taking with antacids, calcium, iron, zinc, or multivitamins
  • Take them either at least 2 hrs before or 2 hrs after the antibiotic
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Possible Routes for Prostatitis
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  • Similar to that of UTI
  • Reflux of infected urine into prostate gland
  • Sexual intercourse
  • Catheterization
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Pathogens of Prostatitis
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G- Enterics

Escherichia coli (most common in chronic prostatitis) Klebsiella pneumoniae

Proteus mirabilis

 

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Clinical Presentation of Prostatitis: Signs/Symptoms
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  • High fever
  • Chills
  • Myalgia
  • Localized pain (perineal, rectal, sacrococcygeal)
  • Urinary symptoms (frequency, urgency, dysuria)
  • Lower back pain and suprapubic discomfort in chronic prostatitis
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Clinical Presentation of Prostatitis: Physical Examination
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Acute: swollen, tender, or indurated gland

Chronic: indurated, enlarged gland

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Clinical Presentation of Prostatitis: Labs
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  • Bacteriuria
  • Bacteria in prostatic secretions
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Treatment of Prostatitis: First line, duration of chronic prostatitis treatment, and suppressive therapy
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FIRST LINE:

Trimethoprim/Sulfamethoxazole DS 1 tab PO BID x 4 weeks

OR

Ciprofloxacin 500 mg PO BID x 4 weeks

OR

Levofloxacin 750 mg PO QD x 4 weeks

 

 

Treat Chronic Prostatitis for 6-12 weeks

 

Suppressive Therapy:

Ciprofloxacin 500 PO 3x q week

OR

TMP/SMX SS 1 tab PO QD

OR

Nitrofurantoin 100 mg PO QD

 

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