Pharmacology Laboratory

Module 6: URINARY TRACT INFECTION CASE

RENAL & GENITOURINARY BLOCK

GENERAL DATA: JJ, 28-year-old, female, Filipino, single, Roman Catholic, a teacher from
Toledo, Cebu

CHIEF COMPLAINT: Painful urination

HISTORY OF PRESENT ILLNESS:

Morning PTA, the patient had onset of pain upon urination, associated with urinary urgency and
frequency, and lower back pain. No fever, hematuria, hypogastric, and suprapubic pain were
noted. No consultation was done, no medications were taken and the condition was tolerated.

Evening PTA, the persistence of the condition was noted thus prompted to seek consultation at
a private clinic.

REVIEW OF SYSTEMS:

● No vaginal discharge
● No vaginal irritation
● No cough/cold
● No fever
● No loose stools
● No chest pain
● No dizziness
● No palpitation

PAST MEDICAL HISTORY:

UTI (early this year) – treated, resolved

Non-hypertensive, non-diabetic, non-asthmatic
Allergic to Amoxicillin
No previous hospitalization/surgery

FAMILY HISTORY: No heredofamilial diseases

PERSONAL & SOCIAL HISTORY:

Non-smoker and non-alcoholic beverage drinker

Denies illicit drug use
OB-GYN HISTORY:

LMP: November 5, 2021

3-5 day duration, 28-30 day interval of menstruation
G0

PHYSICAL EXAMINATION:

BP: 110/70mmHg HR: 96bpm RR: 19cpm T:36.7˚C Wt.: 64kg

HEENT: anicteric sclerae, pink palpebral conjunctivae, no TPC, no CLAD, neck veins not
dilated, dry lips, moist buccal mucosae, nonhyperemic pharynx
C/L: symmetrical chest expansion, resonant on percussion, equal tactile and vocal fremitus, no
retractions, no rales, no wheezes
CVS: adynamic precordium, no heaves or thrills, apex beat is at 5th ICS MCL, NRRR, no
murmurs
Abdomen: flat, soft abdomen, normoactive bowel sounds, no tenderness, no organomegaly, no
masses
GUT: No CVA tenderness, (-) KPS
EXT: full pulses, no edema, no cyanosis, good turgor, no rashes, no lesions, no clubbing,
capillary refill time <2sec

DIAGNOSTICS:

Urinalysis:
● light yellow
● turbid
● pH 7.0
● SG 1.015
● Glucose – negative
● Protein – negative
● RBC +3 (39/hpf)
● WBC +3 (260/hpf)
● Epithelial cells 3/hpf
● Casts 0/hpf
● Bacteria 251/hpf
QUESTIONS:

Clinical questions:

1. Identify the problem/s.

Subjective findings:
- Painful urination
- Urinary urgency and frequency
- Lower back pain

Objective findings:
- Turbid appearance of urine
- Hematuria; Normal=0
- Larger than normal value for epithelial cells in urine; Normal range= 0-2/hpf
- Presence of bacteria in urine

2. Discuss the 5 P’s for Sexual Behavior History Taking.

1. Partners

To assess the risk of getting an STI, it is important to determine the number and
gender of your patient’s sex partners. Remember: Never make assumptions about the
patient’s sexual orientation or the gender identity of the patient or partners. Even if only
one sex partner is noted over the last 12 months, be certain to inquire if that partner is a
new sex partner. Ask about the partner’s risk factors, such as other concurrent partners,
past sex partners or drug use.

- “Do you have sex with men, women, or both?”

- “In the past 2 months, how many partners have you had sex with?”
- “In the past 12 months, how many partners have you had sex with?”
- “Is it possible that any of your sex partners in the past 12 months had sex with
someone else while they were still in a sexual relationship with you?”
- Are you currently having sex of any kind—so, oral, vaginal, or anal— with
anyone? (Are you having sex?)

2. Practices

Asking about sex practices will guide theassessment of patient risk,

risk-reduction strategies, the determination of necessary testing, and the identification of
anatomical sites from which to collect specimens forSTI testing.

- “To understand your risks for STDs, I need to understand the kind of sex you
have had recently.”
- “Have you had vaginal sex, meaning ‘penis in vagina sex’?” If yes, “Do you use
condoms: never, sometimes, or always?”
- “Have you had anal sex, meaning ‘penis in rectum/anus sex’?” If yes, “Do you
use condoms: never, sometimes, or always?”
- “Have you had oral sex, meaning ‘mouth on penis/vagina’?”
- Have you or any of your partners used drugs?
- Have you exchanged sex for your needs (money, housing, drugs, etc.)?
 For condom answers:

- If “never”: “Why don’t you use condoms?”

- If “sometimes”: “In what situations (or with whom) do you use condoms?”

3. Protection from STDs

Clinicians should determine the appropriate level of risk-reduction counseling for

each patient. For example, if a patient is in a mutually monogamous relationship, risk
reduction counseling may not be needed unless the patient or their partner is engaging
in activities that will put them at risk. You may need to explore the subjects of
abstinence, or not having sex, number of sex partners, condom use, the patient’s
perception of their own risk and their partner’s risk, and STI testing. It is important to not
assume risk or lack of risk for any patient.

- “What do you do to protect yourself from STDs and HIV?”

- How often do you use this/these method(s)? More prompting could include
specifics about: ○ Frequencies: sometimes, almost all the time, all the time. ○
Times they do not use a method.
- If “sometimes,” in which situations, or with whom, do you use each method?
- Have you received HPV, hepatitis A, and/or hepatitis B shots?
- Are you aware of PrEP, a medicine that can prevent HIV? Have you ever used it
or considered using it?

4. Past history of STDs

A history of prior STIs may place your patient at greater risk now.

- “Have you ever had an STD?”

- “Have any of your partners had an STD?”
- Have you ever been tested for STIs and HIV? Would you like to be tested?
- Have you been diagnosed with an STI in the past? When? Did you get
treatment?
- Have you had any symptoms that keep coming back?
- Has your current partner or any former partners ever been diagnosed or treated
for an STI? Were you tested for the same STI(s)? Do you know your partner(s)
HIV status?

5. Pregnancy intention and plans

Based on information from the prior section, you may determine that the patient
or the patient’s partner(s) could become pregnant. Questions should be focused on
determining pregnancy intention and what information they need.

- “Do you think you would like to have(more) children at some point?”
- “When do you think that might be?”
- “How important is it to you to prevent pregnancy (until then)?”
- “Are you or your partner using contraception or practicing any form of birth
control? Would you like to talk about ways to prevent pregnancy? Do you need
any information on birth control?”
-
 3. What are the types of UTI?

Type Details

Significant bacteriuria w/o features of UTI

Asymptomatic Bacteriuria (ASB)

Urinary Tract Infection (UTI) Bacteriuria and clinical features of UTI

Lower UTI Infection of the bladder (cystitis), the most common

location of UTIs, and/or urethra (urethritis)

Commonly associated w/ infection of prostate (prostatitis)

in men

Upper UTI Infection of the kidneys and ureter (pyelonephritis)

Uncomplicated UTI Infection in non-pregnant, premenopausal women w/o

further risk factors for infection, treatment failure, or serious
outcomes.

Complicated UTI Infection in patients w/ risk factors for infection, treatment

failure, or serious outcomes, including:

● Male sex
● Pregnancy
● Post-menopause
● Childhood and preadolescence
● Significant anatomical or functional abnormalities
● Immunosuppression
● Renal failure
● Metabolic disorders (e.g. DM)
● History of UTIs in childhood

Infection associated w/ recent instrumentation or medical

devices:

● Cystoscopy
● Indwelling catheter
● Drainage devices (ureteral stents, nephrostomy
tubes)
● Health care associated UTIs
 Urosepsis UTI that leads to life-threatening organ dysfunction

Community-acquired UTI UTI acquired outside a health setting and/or UTI that
manifests within 48 hrs of hospital admission

Healthcare-associated UTI ● UTI acquired in health setting

● Among the most prevalent health-care associated
infections
● Nosocomial UTI
● MC: catheter associated-UTI (CAUTI)
● Can also occur secondary to urinary tract
instrumentation

Recurrent UTI > 3 episodes of symptomatic, culture-proven UTI in one

year or

> 2 episodes in 6 months

Ronald A. The etiology of urinary tract infection: traditional and emerging pathogens. Am
J Med .2002; 113(1): p.14-19. doi: 10.1016/s0002-9343(02)01055-0

4. What are the risk factors, etiology, pathogenesis, clinical presentation,

diagnostics in UTI?

Risk Factors:

Risk factors for development of UTI in women include the following:

- Sexual intercourse
- Diaphragm and spermicide use
- Antibiotic use
- New sex partner within the past year
- History of UTIs in 1st-degree female relatives
- History of recurrent UTIs
- First UTI at early age

Risk factors for UTI in males include the following:

- Benign prostatic hyperplasia with obstruction, common in men over 50 years
- Any other cause of obstruction of the urinary tract (eg, prostate cancer, urethral
stricture)
- Recent instrumentation or indwelling catheters
- Structural abnormalities, such as bladder diverticula
- Neurologic conditions that interfere with normal voiding (eg, spinal cord injury)
- Cognitive impairment, fecal or urinary incontinence
Etiology:

- Most commonly due to infection with Escherichia coli species (80-90% of cases).
Other causes include Klebsiella, Enterococcus, Proteus mirabilis and
Staphylococcus saprophyticus.
- Periurethral colonization by the invading pathogen appears to be the initiating
step in a cascade of events leading to a UTI.
- Most of the causative organisms are naturally present in the GI tract, which acts
as a natural reservoir for potential UTIs.

Pathogenesis:

Clinical Presentation:

In urethritis, the main symptoms are dysuria and, primarily in men, urethral
discharge. Discharge can be purulent, whitish, or mucoid.

Cystitis onset is usually sudden, typically with frequency, urgency, and burning or
painful voiding of small volumes of urine. Nocturia, with suprapubic pain and often low
back pain, is common. The urine is often turbid, and microscopic (or rarely gross)
hematuria can occur. A low-grade fever may develop.

In acute pyelonephritis, symptoms may be the same as those of cystitis. One

third of patients have urinary frequency and dysuria. However, with pyelonephritis,
symptoms typically include chills, fever, flank pain, colicky abdominal pain, nausea, and
vomiting. If abdominal rigidity is absent or slight, a tender, enlarged kidney is sometimes
palpable. Costovertebral angle percussion tenderness is generally present on the
infected side.

Diagnostics:

Reference: Jameson, J. L., Kasper, D. L., Longo, D. L., Fauci, A. S., Hauser, S. L., &
Loscalzo, J. (2018). Harrison's Principles of Internal Medicine. McGraw-Hill Education.
Pharmacology guide questions:

1. What are the goals and considerations of drug treatment for UTI?

The goals of pharmacotherapy are to eradicate the infection, prevent

complications, and provide symptomatic relief to patients. Early treatment is
recommended to reduce the risk of progression to pyelonephritis.

It is important to identify antimicrobial resistance patterns when considering

empirical antimicrobial selection. Oral therapy with an empirically chosen antibiotic that is
effective against gram-negative aerobic coliform bacteria, such as Escherichia coli, is the
principal treatment intervention in patients with lower urinary tract infections. Appropriate
antimicrobials for the treatment of cystitis include trimethoprim-sulfamethoxazole
(TMP-SMX), nitrofurantoin, fluoroquinolones, or due to severe dysuria.

2. List the recommended medications used to treat UTI, dose and frequency,
duration, and prices.
 What Is the First-Line Antibiotic for UTI? (2021, May 28). MedicineNet. Retrieved
November 24, 2021, from
https://www.medicinenet.com/what_is_the_first-line_antibiotic_for_uti/article.htm

FOR UNCOMPLICATED UTI

-
 Drug name Price pesos

Nitrofurantoin monohydrate and 7-18

macrocrystal

Fosfomycin Trometamol 370-439

Cefixime 105-1697

Trimethoprim-sulfamethoxazole 400

Ciprofloxacin 20

FOR RECURRENT UTI

Drug name Price

Cephalexin (Keflex) 22.00-60.20

Ciprofloxacin (Cipro) 1.13-19.35

Nitrofurantoin (Macrodantin) 7.00-18.00

Trimethoprim (Proloprim) 150-174

Trimethoprim/Sulfamethoxazole 400

FOR COMPLICATED UTI

Drug name Price

Ciprofloxacin 1.13-19.35

Ofloxacin 1.78-4.85

Levofloxacin 11.80-63.05

Amoxicillin 1.19-4.48

Amikacin 18.32-36.45

Gentamicin 3.12-15.00

Piperacillin-Tazobactam 66.98-300.00

CATHETER ASSOCIATED UTI

 Drug name Price

Amikacin 19.11-93.44

Entapenem 2562.57-3016.02

Vancomycin 149.24-2302.00

Ampicillin 9.12-24.65

Cefepime 193.33-245.33

Levofloxacin 11.80-63.05

Reference: - Philippine clinical practice guidelines on UTI 2015 update  : Part 2

https://dpri.doh.gov.ph/index.php?page=downloads

3. How effective are non-pharmacologic interventions in preventing or treating UTI?

One of the non-pharmacological treatments advised to patients is to maintain

high fluid intake, which is essential in keeping the urinary tract working and pushing the
urine through the body. This is very effective in flushing bacteria out of the bladder and
clearing the infection, which results in an improvement of symptoms. Many people tend
to drink less when they have a UTI because it is painful to urinate; however, it is
important that they understand that drinking promotes a healthier urinary tract. However,
some doctors speculate that increased fluid may be detrimental because it may
decrease the urinary concentration of antimicrobial agents.

Drinking cranberry juice has also been suggested as a possible treatment for
UTIs, particularly for the management of symptoms. However, the scientific evidence to
support this claim is lacking and, based on the available data, cranberry juice should not
be recommended for the treatment of UTIs. However, it is unlikely to result in significant
side effects.

Reference: Mehnert-Kay S. A. (2005). Diagnosis and management of uncomplicated

urinary tract infections. American family physician, 72(3), 451–456.