Treatment of Urinary

Tract Infection & Sexually

transmitted disease
Presented By: Dr. Kiran Panchal
Assistant Professor
Department of Pharmacology
GMERS MC Himmatnagar
 Urinary Tract Infections
• Urinary Tract Infection (UTI) is a common
disorder at all ages and in both sexes.
• A healthy and normal urinary tract is generally
resistant to infection.
• However, for anatomical reasons, the female
lower urinary tract is more susceptible to
infection.
• UTI may present itself in acute or chronic
form.
 Acute infection
• Infection localised to the urethra and bladder
(cysto-urethritis, lower UTI) causes increased
frequency and urgency of micturition, dysuria
and pain in the perineum.
• If the kidneys are also involved
(pyelonephritis, upper UTI), the patient may
have loin pain, fever, chills and leukocytosis.
 Chronic infection
• Inadequately treated acute UTI may lead to
chronic pyelonephritis.
• General loss of health and weight, anemia and
hypertension are frequently present.
• An important cause of hypertension and
chronic renal failure.
• 95% of the cases of uncomplicated UTI in
women are due to Gram-negative bacilli. E.
coli (80%)
• 5% of the cases are Proteus mirabilis,
Klebsiella, Aerobacter and Pseudomonas
aeruginosa, Enterococci, Streptococci and
Staphylococci.
 Drug Therapy of UTI
• Goals for the treatment of UTI are:
(a) To eradicate the infecting organisms.
(b) To provide symptomatic relief by altering the
pH of urine and/or giving phenazopyridine.
(c) To prevent and treat recurrence.
(d) To identify and treat predisposing factors.
 Classification of drugs
• Bacteriostatic agents: Sulfonamides,
Doxycycline & Nitrofurantoin.
• Bactericidal agents: Cotrimoxazole, Extended
spectrum penicillins, Aminoglycosides,
Fluoroquinolones, Cephalosporins,
Azithromycin.
• Urinary antiseptics are the drugs which act as
antibacterial agents only in the urinary tract e.g.
Nitrofurantoin, Methenamine & Nalidixic acid.
• Urinary antiseptics
• Some orally antimicrobials attain antibacterial
concentration only in urine with no systemic
antibacterial effect
• They are concentrated in kidney tubules and
useful in lower urinary tract infections
• This are called urinary antiseptics
 Nitrofurantonin
• Primary bacteriostatic

• Bactericidal at higher concentration and in acidic

urine

• Gram –ve bacteria are susceptible

• M/o: bacteria enzymatically reduce nitrofurantonin

to generate reactive intermediates which damages
DNA
 Contd.
Adverse effect

 Nausea, epigastric pain, and diarrhoea

 Acute reaction: Fever, chills and leucopenia

 Hemolytic anemia with G6PD deficiency

 Peripheral neuritis on chronic use

 Liver damage and pulmonary fibrosis are rare

 Urine turns dark brown on exposure to air

 Use

• Uncomplicated lower UTI not associated with

prostatitis
• Acute infection with E.coli: treated by 50-100mg TDS
for 7-10 days
• 100 mg bed time given prophylaxis of UTI following
catheterization and women with recurrent cystitis
 Urinary analgesic
Phenylzopyridine
 Orange dye which exerts analgesic action in
urinary tract and afford symptomatic relief in
burning sensation, dysuria and urgency
 Not have antibacterial property
 Side effects: nausea and epigastric pain
 Alkalinisation of the urine
• Growth of E. coli is optimum at pH 5.0 to 6.0 and is
inhibited at pH below 5.5 and above 7.5.
• Alkalinisation (>7.5) of urine enhances the
antibacterial activity of penicillins, erythromycin
and aminoglycosides.
• Alkalinisation also helps to reduce irritation of the
urinary tract.
• Adequate alkalinisation is achieved by the
administration of 2 g (½ teaspoon) of sodium
bicarbonate, sodium citrate or potassium citrate, 4-
6 times a day.
 Lower UTI (Acute uncomplicated cystitis-
urethritis)
• Cotrimoxazole  best initial choice for
empirical therapy in a non-pregant woman.
• It is cost-effective and relatively safe.
• When low resistance to E. coli is known,
nitrofurantoin 100 mg bid for 5-7 days.
• Three day therapy provides complete
symptomatic relief but may not achieve 100%
bacteriological cure.
• Extension of therapy to 7-14 days achieves
both clinical and bacteriological cure.
 Pregnant woman with cystitis
• Amoxicillin (± clavulanic acid), cephalexin,
cefodoxime, ceftibuten and nitrofurantoin are
treatment options.
• Single dose therapy with fosfomycin (3 g) –
uncomplicated.
 Lower UTI (Complicated)
• Complicated cases, those with prostatitis or
indwelling catheters and for bacteria resistant
to cotrimoxazole/ampicillin.
• Ciprofloxacin & ofloxacin are highly effective.
(Not in pregnant women) – 2 weeks
• Cefpodoxime proxetil 200 mg BD - 2 weeks
• Norfloxacin given for upto 12 weeks may
achieve cure in chronic UTI.
 Upper UTI (Acute pyelonephritis)
• Mild to moderate cases:
• Ciprofloxacin 500 mg BD; cotrimoxazole 2
tablets BD; amoxicillin-clavulanate 500 mg BD,
Cephalexin 250–500 mg TDS for 10-21 days.
• Severe cases:
• Coamoxiclav combined with gentamicin.
• Serious Pseudomonas infection in patients
with indwelling catheters:
Piperacillin/Ticarcillin
 Prophylaxis for UTI
• (a) Women of child bearing age have recurrent
cystitis.
• (b) Indwelling catheters are placed.
• (C) Uncorrectable abnormalities of the urinary
tract are present.
• (d) Inoperable prostate enlargement or other
chronic obstruction causes urinary stasis.
• Cotrimoxazole 480 mg
• Nitrofurantoin 100 mg
• Norfloxacin 400 mg
• Cephalexin 250 mg

Once daily at bed time

Sexually Transmitted
Infection (STI) except
AIDS
1. Syphilis
2. Gonorrhoea
3. Lymphogranuloma venereum
4. Donovanosis(granuloma inguinale)
5. Chancroid
6. Genital herpes simplex
7. Trichomonas vaginitis
 General principle
• Diagnosis

• Counseling

• Proper pharmacological therapy

• Partner management
 SYPHILIS
• Organism – Treponema pallidum

• Types
– Primary syphilis
– Secondary syphilis
– Latent syphilis
– Tertiary syphilis
• Treatment
– Primary and secondary syphilis and early latent
syphilis <1 year

• 1st choice- Procaine penicillin 1.2 MU IM/day

for 10days
-Benzathine penicillin 2.4 MU IM
single dose

• Alternative therapy (Pt allergic to penicillin)

– Doxycycline 100 mg BD 15-20 days
– Erythromycin 500 mg QID for 15 -20 days
– Ceftriaxone 1 gm IM for 7 days
• Syphilis(except neurosyphilis) of >1 year
duration (late latent, cardiovascular)
– Procaine penicillin 1.2 MU IM/day for 15 days
– Benzathine penicillin 2.4 MU IM/wk for 3 wks

– Patient allergic to penicilllin

• Doxycycline 100 mg BD for 30 days
• Erythomycin 500 mg QID for 30 days
• Ceftriaxone 1 gm IM/IV for 15 days
• Neurosyphilis
– Penicillin G 18-24 MU/day IV in 6 divided doses or
as infusion for 12-14 days
– Procaine penicillin 2-4 MU IM once a day with
Probenecid 500 mg daily for 10 days

• Jarish Herxheimer reaction

Initial exacerbations of lesions
 Gonorrhea
• Organism- N. gonorrhoeae
• Therapy
– Acute uncomplicated cases
• Penicillin G 4.8 MU injected in 2 divided doses +
probenecid 1gm
• Ampicillin 3.5 gm orally single dose+probenecid
1 gm
• Procaine penicillin 1.2 MU + penicillin G 1MU
IM, followed by 2 similar injection 24 hrs a part
• Cotrimoxazole 960 mg BD for 5 days/4 tablet
BD for 2 days
 Alternatives drugs

– Ciprofloxacin 500mg orally single dose

– Levofloxacin 250mg orally single dose
– Ceftriaxone 125-250 mg IM single dose
– Cefixime 400 mg orally single dose
– Spectinomycin 2 gm IM single dose
• Complicated infection (PID)
– Procaine penicillin 2 MU daily for 10 days+ doxycycline
100 mg BD for 14 days
OR
– Cefoxitin IV 2 gm 6hrly +doxycycline 100 mg IV 12 hrly
for at least 48 hr  doxycycline 100 mg orally to
complete 14 days
OR
– Gentamycin IV/IM 2 mg/kg loading dose followed by
1.5 mg/kg every 8 hrly + clindamycin 900mg f/b
doxycycline
OR
– Ofloxacin 400mg BD orally+ clindamycin 450 mg QID
orally for 14 days
 Non specific urethritis
• Organism – Chlamydia trachomatis

• Therapy
– Azithromycin 1g oral single dose
– Doxycycline 100mg BD oral for 7 days

– Alternative therapy
– Erythomycin 500mg QID orally 7 days
 Lymphogranuloma venereum
• Organism – Chlamydia trachomatis
• Therapy
– Azithromycin 1 gm orally weekly 3 week
– Doxycycline 100 mg BD orally for 3 week

• Alternative therapy
– Erythromycin 500 mg QID orally for 3 weeks
 Granuloma inguinale / Donovanosis
• Organism- Donovania granulomatis
• Therapy
– 1st choice
• Doxycycline 100 mg BD for 3 week
• Tetracycline 500 mg QID for 10 days
• Azithromycin 500mg OD for 7 days OR 1gm
wkly for 4 wks
– Alternative therapy
• Erythromycin 500 mg QID for 3 wks
 Chancroid
• Organism- H. ducreyi
• Therapy
– 1st choice
• Ceftriaxone 250 mg IM single dose
• Erythromycin 500mg QID for 7-10 days
• Azithromycin 1gm single dose orally

– Alternative therapy
• Cotrimoxazole 960mg BD for 7 days
• Ciprofloxacin 500 mg BD orally for 3 days
• Doxycycline 100 mg BD orally for 14 days
 Genital herpes simplex
• 1st episode
– Acyclovir 200 mg 5 times a day/400mg TDS orally
for 10 days
– Valaciclovir 0.5-1.0 gm BD orally for 10 days
– Famciclovir 250 mg TDS orally for 5 days

– Mild cases- acyclovir 5% ointment locally 6 times a

day for 10 days
• Recurrent episode
– Same treatment for 3-5 days

• Suppressive therapy
– Acyclovir 400 mg BD oral for 6-12 months
– Valaciclovir 500 mg OD oral for 6-12 months
– Famciclovir 250 mg BD oral for 6-12 months
 Trichomonas vaginitis
• Therapy
– Metronidazole 2 gm single dose /400 mg TDS for 7
days
– Tinidazole 2 gm single dose /600 mg OD for 7 days

• Alternative therapy
– Clotrimazole 100 mg intravaginal every night for 6-12
days