2-minute Consultation: UTIs: Painful, Treatable

Author: Melinda J. Throm, PharmD, BCPS

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Dr. Throm is an assistant professor of pharmacy practice at Midwestern University College of Pharmacy?Glendale, Glendale, Arizona.

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The uncomplicated, symptomatic lower urinary tract infection (UTI; acute bacterial cystitis) is a common and costly reason for physician referral and hospital visits. In the year 2000, 8.27 million physician visits for UTIs were reported (1.41 million men, 6.86 million women), with an estimated cost of $3.5 billion for evaluation and treatment.1 UTIs are more prevalent in women; of the 429,000 hospital stays due to UTIs, approximately 75% are attributed to women.¹

Causes

The most common causative pathogen in uncomplicated, symptomatic lower UTIs is Escherichia coli, which accounts for 75% to 90% of infections. Staphylococcus saprophyticus follows, causing 5% to 15% of UTIs. The remaining infections are caused by enterococci, Klebsiella species, and Proteus mirabilis.^2,3

Signs and Symptoms

The bladder is the most common site of lower UTIs. Common signs and symptoms of acute, uncomplicated lower UTIs in nonpregnant women include dysuria, frequency, or urgency. ^2-4 Urine also may appear dark, cloudy, or pinktinged. Acute cystitis is more common in young, sexually active women with a history of UTIs.2,3 Complicated upper UTIs (eg, pyelonephritis) occur in the kidneys, are associated with systemic symptoms (eg, patients with fever, chills, flank pain), and are found more often in high-risk populations (eg, patients with diabetes, pregnancy, immunosuppression, previous pyelonephritis, symptoms lasting >14 days, or structural abnormalities of the urinary tract).^2,3

Pharmacist?s Role in the Management of Acute, Uncomplicated UTIs in Women Recommend the appropriate empiric antimicrobial agent based on local E coli resistance (antibiogram) and the patient?s drug allergies, renal function, and insurance coverage Monitor the duration of antimicrobial therapy for patient safety and cost-effectiveness Recommend the conversion from intravenous antimicrobial therapy to an appropriate oral product in the hospitalized patient who has improved and is tolerating orals Provide counseling on antimicrobial dosing and administration, duration of therapy, and adverse drug events

Treatment

Guidelines from the Infectious Diseases Society of America suggest the following empiric pharmacotherapy and recommendations for the treatment of uncomplicated UTIs in women⁴:

• Trimethoprim-sulfamethoxazole (TMP-SMX; Bactrim, Septra) for 3 days is recommended as first-line therapy for uncomplicated UTIs in areas where the rate of E coli-resistant TMP-SMX or TMP is <20%
• Fluoroquinolones are not recommended as first-line treatment of UTIs, except in communities with high rates of TMP-SMX or TMP resistance (eg, >10%-20%) to E coli
• Use of beta-lactams (ampicillin, amoxicillin) is not recommended for the routine treatment of uncomplicated UTIs due to limited efficacy
• Nitrofurantoin and fosfomycin may become more useful as resistance to TMP-SMX and TMP increases; however, they are limited by adverse events and/or cost

UTI symptoms typically subside within 1 to 3 days after antimicrobial therapy is initiated.² Some patients with severe dysuria may be initiated on the urinary analgesic phenazopyridine (Pyridium or Uristat) for 1 to 2 days.²

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

Table

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

References

1. 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.
2. Fihn Stephan. Clinical practice. Acute uncomplicated urinary tract infection in women. N Engl J Med. 2003;349:259-266.
3. Mehnert-Kay SA. Diagnosis and management of uncomplicated urinary tract infections. Am Fam Physician. 2005;72:451-458.
4. 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.
5. 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.