UTI treatment-according to MOH protocol.pptx

UTI Treatment Protocol
Alaa F. Hassan (MSc Pharmacology)
Drug Information Centre
Al-Mahmoudiya General Hospital

Points to consider when prescribing
antimicrobials
Diagnose - the clinical diagnosis & the evidence of a significant bacterial infection.
Decide - are antibiotics really needed? culture sensitivity or other tests?
Drug (medicine) - the prescribed antibiotic, is it Access or Watch or Reserve?
any allergies, interactions, or contraindications exist.
Dose - dose, time intervals, dosage adjustments hepatic/renal impairment?
Delivery - used formulation, quality product?
lf intravenous treatment when is step down to oral possible?
Duration - how long & when to stop?
 Discuss - inform the patient of the diagnosis, duration of symptoms & medicine, toxicity
and what to do if not recovering.
Document - write down all the decisions and the management plan.

Intravenous to oral antimicrobial switching
Reassess the need for ongoing intravenous therapy & switch to oral/enteral
therapy once the patient is clinically stable (i.e. met all of the following criteria):
Clinical improvement.
Improved or resolved fever.
No unexplained hemodynamic instability.
Tolerate oral therapy (no malabsorption concerns).
Oral antimicrobials of a similar spectrum are available.
lntravenous therapy may be continued if high tissue concentrations or
prolonged parenteral therapy is required (e.g. meningitis, endocarditis)

Urinary Tract Infections
oUncomplicated - usually occur in non-pregnant women who do not have
functional or anatomical abnormalities of the urinary tract, common pathogens
causing acute uncomplicated cystitis and pyelonephritis are Escherichia coli and
Staphylococcus saprophyticus.
oComplicated - occurs in patients with functional or anatomical urinary tract
abnormalities ex. neurogenic bladder & kidney stones. The common pathogens ex.
E coli, Klebsiella, Proteus & Pseudomonas species.
Multidrug-resistant E. coli, particularly extended-spectrum beta-lactamase (ESBl)-
producing strains, are increasing in prevalence in the Eastern Mediterranean
region, including Iraq (limited oral and intravenous treatmentoptionsn for
infections caused by such organisms).

Urinary Tract Infections
oIn asymptomatic patients, positive urine culture is not an indication
for antibiotic treatment nor post-treatment urine culture is performed
to confirm the resolution of infection (pregnant women or patients
with prostatitis/undergoing urological procedures in which bleeding is
anticipated are exceptions).
oThe growth of mixed bacteria or large quantities of squamous
epithelial cells on microscopy usually indicates contamination with
normal genital tract flora.
oA diagnosis of acute UTI is unlikely if there is no pyuria on microscopy.

Lower urinary tract infection
Urine culture (before administration of antimicrobials whenever possible) is
recommended in:
Pregnant women.
Men.
Patients on recent antibiotics/with recurrent infection.
The presence of significant bacteriuria in midstream urine samples (> 108 CFU/L)
in patients with urinary symptoms can help to confirm the diagnosis of UTl &
lower bacterial counts (> 105 CFU/L) may be indicative of UTI in some patients
ex. those on antimicrobial therapy or those with a UTI caused by organisms
other than E. coli and Proteus species.

Lower urinary tract infection
Patient risk Empiric treatment Treatment duration
Uncomplicated (absence of
functional or anatomical
abnormalities of the urinary
tract)
Nitrofurantoin l00 mg orally
q12hr (modified-release
formulation)
5 days (non-pregnant women)
7 days (men)
Complicated (presence of
functional and/or anatomical,
abnormalities of the urinary
tract)
Fosfomycin 3g single oral dose
or
Norfloxacin 40O mg oral q12hr
Single dose
3 days (non-pregnant women)
7 days (men)

Upper urinary tract infection
oBlood cultures (before administration of antimicrobials whenever
possible) or urine cultures are recommended.
oConsider imaging (e.g. ultrasound) to exclude urinary obstruction,
kidney stone disease or kidney abscess, especially if the patient
remains febrile after 72 hours of treatment.
oPerform urological evaluation for men with acute pyelonephritis.

Upper urinary tract infection
Infection severity Empiric treatment Treatment duration
Mild/moderate
(patients who are not
systemically ill)
Ciprofloxacin 500 mg oral q12hr 7 days
Severe (patients
who are
systemically ill)
Gentamicin 4-7 mg/kg
(use upper end of range in patients without kidney
impairment) lV for the first dose, with review prior
to subsequent doses; maximum 3 doses for empiric
treatment
plus
Ciprofloxacin 400mg IV q12hr
until oral ciprofloxacin can be tolerated
10 to 14 days (lV +
oral)

Urinary tract infection and bacteriuria in
pregnancy
Urine culture (a second urine culture should be used for confirmation of
asymptomatic bacteriuria).
untreated bacteriuria in pregnancy is associated with an increased risk of
developing pyelonephritis in later pregnancy, as well as preterm birth and low
birth weight.
Repeat urine culture 1 to 2 weeks after treatment is completed to confirm
resolution of infection.

Urinary tract infection and bacteriuria in
pregnancy
Patient risk Empiric treatment Treatment duration
Asymptomatic
bacteriuria
Nitrofurantoin l00mg orally, 12-
hourly (modified-release formulation)
5 days
Acute cystitis
Acute pyelonephritis Gentamicin 4-7mg/kg
(use upper end of range in critically ill patients
without kidney impairment) IV for the
first dose, with review prior to
subsequent doses; maximum 3 doses for
empiric treatment
plus
Ciprofloxacin 400mg lV, 12-hourly
until oral ciprofloxacin can be tolerated
10 to 14 days (lV + oral)

Sepsis and septic shock
from a urinary tract source
The quick Sequential Organ Failure Assessment (qSOFA) is used to
recognize and stratify the risk of patients presenting with suspected
sepsis
Parameter Value Score
Altered mental status Glasgow coma score < 15^ +1
Respiratory rate > 22 breaths/min +1
Systolic blood pressure < 100 mmHg +1

Sepsis and septic shock from a urinary tract
source
oThe 6lasgow come scale [used to measure a person's level of
consciousness based on the assessment of 3 parameters: eye-opening
response (max 4 points), best verbal response (max 5 points) and best
motor response (max 5 points), the total score range 3 (completely
unresponsive) - 15 (responsive) while scores below 8 usually indicate
a comatose state].
oA qSOFA score of 2 or more helps to identify adult patients with
suspected infection who are likely to have poor outcomes (prolonged
ICU admission and death) and should therefore be prioritized for
timely investigation and intervention.

source
Blood cultures (prior to administration of antimicrobials whenever possible)
Urine culture
oThere is a high risk of mortality in both sepsis and septic shock (it is increased in the
latter), & prompt recognition and treatment is essential, since appropriate
resuscitation, organ support and commencement of antimicrobial therapy within
1hour reduces mortality.
oThe signs of sepsis can be subtle, especially in elderly patients, and may include hypo-
or hyperthermia, tachycardia, reduced urine output or, in older adults functional
decline.
o Consider risk factors for sepsis (e.g. immunosuppression, recent surgery, underlying
malignancy).

source
Not every patient with infection has sepsis and the term 'sepsis'
should be used carefully as this can lead to the inappropriate use of
broad-spectrum antibiotics
Source of infection Empiric treatment Treatment duration
Urinary tract infection Meropenem 1g lV, 8-hourly 10 to 14 days (lV + oral)

Asymptomatic bacteriuria
oPrevalence increases with age.
oAntibiotic therapy does not reduce mortality, the incidence of symptomatic
UTI or UTI-related complications, and significantly increases the risk of
adverse events including the emergence of AMR.
oScreening for and treatment for asymptomatic bacteriuria is not
recommended, except for pregnant women & patients undergoing invasive
elective urological interventions.

Urinary tract infection associated with
instrumentation of the urinary tract
olndwelling urinary catheter, remove the indwelling catheter and
obtain a midstream urine sample when possible or replace the
catheter, then collect a urine sample from the port of the drainage
system or by separating the catheter from the drainage system [Do
not collect a urine sample from the drainage bag for culture].
oUrinary stent: A midstream urine sample is used.
oDo not investigate catheterized patients with non-specific or no
symptoms of catheter-associated UTl. lnappropriate investigation of
asymptomatic patients may result in incorrect diagnosis and
treatment.

Urinary tract infection associated with
instrumentation of the urinary tract
Bacteriuria associated with instrumentation is common and increases with time
that the instrument is in situ.
Bacteriuria, pyuria and cloudy or malodorous urine are not reliable signs of UTI if
genitourinary symptoms are not present.
Antibiotic therapy is often only transiently effective if the catheter/stent is not
removed/replaced, as most antibiotics penetrate poorly into catheter biofilm.
Treatment without removal of instrumentation may lead to superinfection with
resistant organisms.
Source of infection Treatment Treatment duration
lndwelling urinary
catheter or urinary stent'
Guided by results of urine culture and
susceptibility testing
7 days (lV + oral)

Prostatitis
Urine culture
o Blood cultures (if admitted to hospital; prior to administration of
antimicrobials whenever
possible)
Consider imaging to identify prostatic abscesses that may require
drainage.
. Repeat urine culture 1 week after treatment is completed to confirm
resolution of infection.

Prostatitis
Infection severity Empiric treatment Treatment
duration
Mild/moderate (patients who
are not systemically ill)
acute bacterial prostatitis
Norfloxacin 400mg orally, 12-hourly 14 days
Severe (patients who re
systemically ill)
acute bacterial prostatitis
Gentamicin 4-7mg/kg
(use upper end of range in patients without
kidney impairment) lV for the first dose, with
review prior to subsequent doses; maximum 3
doses for empiric treatment
plus
Ciprofloxacin 40Omg lV, 12-hourly until oral
ciprofloxacin can be tolerated
28 days (lV + oral)
Chronic bacterial prostatitis Norfloxacin 400 mg orally, 12-hourly 28 days

REFERENCE
MOH Urinary Tract lnfection (UTl)
treatment protocol 2022

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UTI treatment-according to MOH protocol.pptx

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