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Unit V: URINARY TRACT INFECTION

Presentation · August 2018

DOI: 10.13140/RG.2.2.10910.84805

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 Unit V: URINARY TRACT INFECTION

 A urinary tract infection (UTI) is a bacterial infection that affects part of the urinary tract. When it affects the
lower urinary tract it is known as a simple cystitis (a bladder infection) and when it affects the upper urinary
tract it is known as pyelonephritis (a kidney infection).
 The urinary system consists of the kidneys, ureters, bladder, and urethra. Depending upon the part that is
infected, UTI’s are classified as -
 Cystitis- infection in the bladder
 Pyelonephritis- infection of one or both kidneys
 Urethritis- infection of the urethra, tube that empties urine from the bladder to the outside
Urinary tract infection is the second most common type of infection in the body. Owing to the female anatomy,
women are more commonly affected by UTI than men. Shorter urethra and proximity of the urethral opening to
the anus and vagina (sources of bacteria) make women more prone to UTI.
UTI's are caused by microbes, including fungi, viruses and bacteria. However, bacteria are the most common
cause of UTI.
 Symptoms of urinary tract infection include painful and frequent urination, fever, flank pain and contain visible
pyuria (pus in the urine).
 Cause:
E. coli is the cause of 80–85% of urinary tract infections, with Staphylococcus saprophyticus being the cause
in 5–10%.Rarely they may be due to viral or fungal infections. Other bacterial causes include: Klebsiella,
Proteus, Pseudomonas, and Enterobacter. Urinary tract infections due to Staphylococcus aureus typically
occurs secondary to blood born infections.
In young sexually active women, sexual activity is the cause of 75–90% of bladder infections, with the risk of
infection related to the frequency of sex.
In post-menopausal women, sexual activity does not affect the risk of developing a UTI. Spermicide use,
independent of sexual frequency, increases the risk of UTIs.
Women are more prone to UTIs than men because, in females, the urethra is much shorter and closer to the
anus. As a woman's estrogen levels decrease with menopause, her risk of urinary tract infections increases
due to the loss of protective vaginal flora.
 The diagnosis of UTI.
 A urinalysis, to look for the presence of bacteria and 'pus' cells in the urine.
 An ultrasound examination/CT scan/ MRI of the kidney and bladder maybe necessary in some patients
to reveal urinary abnormalities and measure how well the kidneys work.
 A dip stick test.
 Voiding cystourethrogram (VCUG) is another test that may be performed.
 If the above tests are positive a urine culture can reveal the infection and type of bacteria causing the
infection.
Dr. S. Mondal_Lecturer Notes_ B. Pharm 4th Semester-Pharmacology I _GITAM University 1|P a g e
 Unit V: URINARY TRACT INFECTION

 Treatment:

 Antibiotics are the main treatment for all UTIs. A variety of antibiotics are available, and choices depend
on many factors, including whether the infection is complicated or uncomplicated or primary or recurrent.
 Antibiotic Regimen: Oral antibiotic treatment cures 94% of uncomplicated urinary tract infections,
although the rate of recurrence remains high. The following antibiotics are commonly used for
uncomplicated UTIs:
 The standard regimen has traditionally been a 3-day course of trimethoprim-sulfamethoxazole,
commonly called TMP-SMX (Bactrim). TMP-SMX combines an antibiotic with a sulfa drug. A single
dose of TMP-SMX is sometimes prescribed in mild cases, but cure rates are generally lower than with
3-day regimens. Allergies to sulfa are common and may be serious.
 Fluoroquinolone antibiotics, also called quinolones, have usually been a second choice. However, in
geographic areas that have a high resistance to TMP-SMX, quinolones are now the first-line treatment
for UTIs. Ciprofloxacin is the quinolone antibiotic most commonly prescribed. Quinolones are usually
given over a 3-day period. Pregnant women should not take these drugs.
 Nitrofurantoin is a third option. This drug must be given for longer than 3 days.
 Fosfomycin is not as effective as other antibiotics but may be used during pregnancy. Resistance rates
to this drug are very low.
 Other antibiotics may also be used, including amoxicillin (with or without clavulanate) and
cephalosporins. Doxycycline is often effective but cannot be given to children or pregnant women.
 Management of Catheter-Induced Urinary Tract Infections
Catheter-induced urinary tract infections are very common, and preventive measures are extremely important.
Catheters should not be used unless absolutely necessary, and they should be removed as soon as possible.
Reducing the risk for infections during long-term catheter use, however, remains problematic.
Intermittent Use of Catheters. If a catheter is required for long periods, it is best to use it intermittently if possible
(as opposed to an indwelling catheter). Some doctors recommend replacing it every 2 weeks to reduce the risk
of infection and irrigating the bladder with antibiotics between replacements.
Daily Hygiene. A typical catheter is one that has been preconnected and sealed and uses a drainage bag
system. To prevent infection, some of the following tips may be helpful:
 Drink plenty of fluids, including 3 glasses of cranberry juice a day.
 The catheter tube should be free of any knots or kinks.
 Clean the catheter and the area around the urethra with soap and water daily and after each bowel
movement. (Women should be sure to clean front to back.)
 Wash hands before touching the catheter or surrounding area.
 Never disconnect the catheter from the drainage bag without careful instructions from a health
professional on strict methods for preventing infection.
Dr. S. Mondal_Lecturer Notes_ B. Pharm 4th Semester-Pharmacology I _GITAM University 2|P a g e
 Unit V: URINARY TRACT INFECTION
 Keep the drainage bag off the floor.
 Stabilize the bag against the leg using tape or some other system.
Antibiotics for Catheter-Induced Infections. Patients using catheters who develop UTIs with symptoms should
be treated for each episode with antibiotics and the catheter should be removed, if possible, or changed. A
major problem in treating catheter-related UTIs is that the organisms involved are constantly changing. Because
there are likely to be multiple species of bacteria, doctors generally recommend an antibiotic that is effective
against a wide variety of microorganisms.
Catheterization is accomplished by inserting a catheter (a hollow tube, often with an inflatable balloon tip) into
the urinary bladder. This procedure is performed for urinary obstruction, following surgical procedures to the
urethra, in unconscious patients (due to surgical anesthesia or coma), or for any other problem in which the
bladder needs to be kept empty (decompressed) and urinary flow assured. Catheterization in males is slightly
more difficult and uncomfortable than in females because of the longer urethra.

Dr. S. Mondal_Lecturer Notes_ B. Pharm 4th Semester-Pharmacology I _GITAM University 3|P a g e

 Unit V: URINARY TRACT INFECTION

 Beta-Lactams
The beta-lactam antibiotics share common chemical features and include penicillins, cephalosporins, and some
newer similar drugs.
Penicillins (Amoxicillin). The standard treatment for a UTI was 10 days of amoxicillin, a penicillin antibiotic, but it
is now ineffective against E. coli bacteria in up to 25% of cases. A combination of amoxicillin-clavulanate
(Augmentin) is sometimes given for drug-resistant infections. Amoxicillin or Augmentin may be useful for UTIs
caused by Gram-positive organisms, including Enterococcus species and S. saprophyticus.
Cephalosporins: Cephalosporins are also alternatives for infections that do not respond to standard treatments
or for special populations. They are often classed as first, second, or third generation. Cephalosporins used for
treatment of UTIs include cephalexin (Keflex), cefadroxil (Duricef) cefuroxime (Ceftin),loracarbef (Lorabid), and
cefixime (Suprax, among others.
 Trimethoprim-Sulfamethoxazole (TMP-SMX)
The typical treatment is a 3-day course of the combination drug trimethoprim-sulfamethoxazole, commonly
called TMP-SMX (such as Bactrim, Cotrim, or Septra). A 1-day course is somewhat less effective but poses a
lower risk for side effects. Longer courses (7 - 10 days) work no better than the 3-day course and have a higher
rate of side effects.
 Fluoroquinolones (Quinolones)
Fluoroquinolones (also simply called quinolones) are now becoming as widely used as TMP-SMX. They are the
standard alternatives to TMP-SMX. Examples of quinolones include ofloxacin, ciprofloxacin, norfloxacin, and
levofloxacin.
Pregnant women should not take fluoroquinolone antibiotics. They also have more adverse effects in children
than other antibiotics and should not be the first-line option in most situations.
 Tetracyclines
Tetracyclines include doxycycline, tetracycline, and minocycline. Treatment with tetracycline or doxycycline may
be used for infections that are caused by Mycoplasma or Chlamydia. Tetracyclines have unique side effects
among antibiotics, including skin reactions to sunlight, possible burning in the throat, and tooth discoloration.
They cannot be taken by children or pregnant women.
 Aminoglycosides
Aminoglycosides (gentamicin, tobramycin, amikacin) are given by injection for very serious bacterial infections.
They can be given only in combination with other antibiotics. Gentamicin is the most commonly used
aminoglycoside for severe UTIs. They can have very serious side effects, including damage to hearing, sense
of balance, and kidneys.

Dr. S. Mondal_Lecturer Notes_ B. Pharm 4th Semester-Pharmacology I _GITAM University 4|P a g e

 Unit V: URINARY TRACT INFECTION

 Other Medicaments Used Specifically for UTIs

Nitrofurantoin is an antibiotic that is used specifically for urinary tract infections as an alternative to TMP-SMX
or a quinolone. Unlike many of the other drugs, however, it is usually taken for 7 - 10 days, even in cases of
simple cystitis. It is not useful for treating kidney infections. Nitrofurantoin frequently causes stomach upset and
interacts with many drugs. Other chronic or serious medical conditions may also affect its use. It should not be
used in pregnant women within 1 - 2 weeks of delivery, in nursing mothers, or in those with kidney disease.
Fosfomycin may be prescribed as a 1-dose treatment for women who are pregnant.
Doripenem is a new carbapenem antibiotic, which was approved in 2007 for the treatment of complicated
urinary tract infections. It is given by injection.
Phenazopyridine relieves pain and burning caused by the infection. Patients should not take this medicine for
more than 2 days.
Side effects include headache and stomach distress. The drug turns urine a red or orange color, which can
stain fabric and be difficult to remove. Rarely, it can cause serious side effects, including shortness of breath, a
bluish skin, a sudden reduction in urine output, shortness of breath, and confusion. In such cases, patients
should immediately call the doctor.
Antispasm Drugs: Methenamine or flavoxate reduce bladder spasms, which may occur with some UTIs.
These drugs can have severe side effects, however, that the patient should discuss with the doctor.
 Urinary tract infections are more concerning in pregnancy due to the increased risk of kidney infections.
During pregnancy, high progesterone levels elevate the risk of decreased muscle tone of the ureters and
bladder, which leads to a greater likelihood of reflux, where urine flows back up the ureters and towards the
kidneys. While pregnant women do not have an increased risk of asymptomatic bacteriuria, if bacteriuria is
present they do have a 25-40% risk of a kidney infection. Thus if urine testing shows signs of an infection—
even in the absence of symptoms—treatment is recommended. Cephalexin or nitrofurantoin is typically
used because they are generally considered safe in pregnancy. A kidney infection during pregnancy may
result in premature birth or pre-eclampsia (a state of high blood pressure and kidney dysfunction during
pregnancy that can lead to seizures).

Dr. S. Mondal_Lecturer Notes_ B. Pharm 4th Semester-Pharmacology I _GITAM University 5|P a g e

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