PHC 551

Case-Based Learning (CBL):

Urinary Tract Infection
Group D3
 Case Presentation
BB, a 55-year-old female presents to the hospital with the chief complaints of increased
urine frequency, urgency and lower backpain. She claims that she was in her usual state of
health until about 2 days ago, when she first noticed an increased frequency and urgency to
use the bathroom. She attributed her symptoms to trying a different brand of coffee. She
became more concerned when she began experiencing a slight fever and lower back pain
(5/10) yesterday evening. From reviewing her chart, she had medical history of
hypertension for 10 years, type 2 diabetes mellitus for 8 years and nephrolithiasis. Her
father died of myocardial infarction (MI) at the age of 70. She doesn’t smoke and
occasionally drinks alcohol on weekends.

For past medication history, she took Atenolol 25 mg PO OD, Metformin 500 mg PO BID,
Aspirin 325 mg PO OD, Multivitamin 1 tab PO OD, Calcium carbonate + vitamin D 500 mg
PO BID. BB has no known drug allergy.
Physical Examination:

GEN : Pleasant woman in mild discomfort

VS : T 37.5 °C, BP 146/90, HR 70, RR 20, O2 Sat 98 % RA
HEENT : PERRLA, EOMI
CV : Regular rhythm rate (RRR), normal S1,S2, no M/R/G
CHEST : Lungs Clear To Auscultation Bilaterally (CTAB)
ABD : Soft NTND, (+) BS
EXT : Warm, no C/C/E
NEURO :A&Ox3
Laboratory Tests:

BUSE/Creat & Hematology:

Na : 140 mmol/ L Hct : 0.35 (Low)
K : 4.1 mmol/ L Hgb : 135 g/L
Cl : 100 mmol/ L Lkc : 14.1 x 109/ L (High)
HCO3 : 24 mmol/ L Plt : 330 x 109/ L
BUN : 4.99 mmol/ L HbA1c : 7.8 % (High)
SCr : 88.4 μmol/ L Glucose : 13.3 mmol/L (High)

Urinalysis:
WBC 3+
Gram (-) rods > 10⁵ CFU/ mL
(+) Hematuria
(+) Nitrite

Blood cultures: Pending

 Pharmaceutical Plan
Step 1 Step 2

Describe the DRP Types of DRP (N, E, S, P) Priority (High (H) / Low (L))

1. Atenolol 25 mg PO OD N H
• No indication that patient
have cardiovascular problem

2. Metformin 500 mg Po BID P H

• Patient does not adhere to the
therapy/does not practice
healthy lifestyle

3. Aspirin 350 mg PO OD E L
• Too high dose of aspirin for
prophylaxis of MI
 Pharmaceutical Plan
Step 1 Step 2

Describe the DRP Types of DRP (N, E, S, P) Priority (High (H) / Low (L))

4. Calcium carbonate + vitamin D N H

500 mg PO BID
• No clear indication for the use
of calcium carbonate and
vitamin D

5. No treatment for UTI. N H

 Step 3 Step 4
Recommendation & Justification Monitoring Parameters
Atenolol 25 mg PO OD
1. Recommendation: 1. Blood Pressure
• Initiate dual combination drug therapy
• Goal: BP reduction to <140/80 mmHg
2. Justification: • Have patient to follow up 4 weeks after initiate
treatment
• According to risk stratification, patient is at very high risk.
• If patient does not have hyperkalemia and BP is
• For dual combination therapy, drug combination of an ACE inhibitor or ARB
decreasing not static, follow up every 6 months. If BP
with a CCB or thiazide/thiazide-like diuretic
does not decrease, consider increase the dose
3. Counselling points
2. Serum Creatinine and Potassium level
• Patient may experience dry cough as the side effect of ACEi
• Patient may experience dizziness due to reduction in blood pressure (Side • Check before and after initiating treatment as ACEi
effect of ACEi and CCB) might increase potassium and serum creatinine level
• Patient may have palpitations (fast HB) and flushing due to CCB
• Avoid grapefruit products as may interact with CCB
• Advise patient on lifestyle changes
Drug recommendation:
Lisinopril 10 mg OD + Amlodipine 5 mg OD

Ref:
1. Clinical Practice Guidelines Management of Hypertension 5th Ed 2018, ESC/ESH
Guidelines for the management
 Step 3 Step 4
Recommendation & Justification Monitoring Parameters
Metformin 500 mg PO BID
1. Recommendation: 1. HbA1c (target: <6.5%)
• Change therapy to Metformin 1000 mg OD Follow up with HbA1c levels of the patient after 3
• Imply dietary intervention in the patient months, if it remains abnormal, consider Dual
Combination Therapy
2. Justification:
2. Glucose levels (target: <7.8 mmol/L)
• Single-dose regimen improves patient adherence to multiple drug therapy
• Dietary modifications may reduce diabetic complications

3. Counselling points:

• To be taken with food/after meals to reduce side effects

• Remind patient that she may experience nausea, anorexia and diarrhea due to
side effects of Metformin
• Advise patient to comply with the medication upon discharge and stress on
Ref: the importance of medication compliance
4. Ministry of Health Malaysia. Clinical Practice Guidelines (CPG) on Management of Type 2 Diabetes
Mellitus. Igarss 2014. 2015;5th editio(1):1–5.
5. Raveendran A V. Non-pharmacological Treatment Options in the Management of Diabetes Mellitus.
Eur Endocrinol [Internet]. 2018 [cited 2020 Nov 10];14(2):31. Available from:
/pmc/articles/PMC6182920/?report=abstract
6. Brown MT, Bussell JK. Medication adherence: WHO cares? [Internet]. Vol. 86, Mayo Clinic
Proceedings. Elsevier Ltd; 2011 [cited 2020 Nov 10]. p. 304–14. Available from:
/pmc/articles/PMC3068890/?report=abstract
 Step 3 Step 4
Recommendation & Justification Monitoring Parameters
Aspirin 350 mg PO OD
1. Recommendation:
• Low dose Aspirin 81 mg OD for prophylaxis 1. Monitor the platelet aggregation:
2. Justification: • This test helps to monitor the risk of
• Aspirin is recommended for primary prevention of heart disease for persons; bleeding.

o with diabetes age > 40 years or

o additional risk factors for CVD (family history of CVD, hypertension
or dyslipidaemia) and
o not at risk of bleeding.
3. Counselling point
• Remind patient to take aspirin with food/after meal if aspirin upset the stomach
(common side effect).
• Avoid taking alcohol together with aspirin because it can increase the risk of Ref:
bleeding. 2. Lordkipanidzé M. Advances in monitoring of aspirin
therapy. Vol. 23, Platelets. 2012. p. 526–36.
Ref:
1. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease - American College of
Cardiology [Internet]. [cited 2020 Nov 11]. Available from:
https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2019/03/07/16/00/2019-acc-aha-guideli
ne-on-primary-prevention-gl-prevention
2. Aspirin Therapy in Diabetes [Internet]. Vol. 27, Diabetes Care. American Diabetes Association Inc.; 2004
[cited 2020 Nov 11]. p. s72–3. Available from: https://care.diabetesjournals.org/content/27/suppl_1/s72
 
 Step 3 Step 4
Recommendation & Justification Monitoring Parameters
Calcium carbonate + vitamin D 500 mg PO BID
1. Recommendation:
• Stop medication 1. Perform CT Scan/Ultrasound to check kidney stone
formation
2. Justification:
• Patient is already consuming multivitamin, hence no need for calcium 2. Examine urine to check the level of urine calcium,
carbonate oxalate, uric acid, pH, creatinine, citrate

• The use of calcium carbonate and Vitamin D can increase intestinal

calcium absorption, increase risk to redevelop kidney stone
Ref:
Ref: 3. Han, H. et al. (2015) ‘Nutritional Management of Kidney
3. Han, H. et al. (2015) ‘Nutritional Management of Kidney Stones (Nephrolithiasis)’, Clinical Stones (Nephrolithiasis)’, Clinical Nutrition Research.
Nutrition Research. Korean Society of Clinical Nutrition, 4(3), p. 137. doi: Korean Society of Clinical Nutrition, 4(3), p.
10.7762/cnr.2015.4.3.137.
4. Sorensen, M. D. (2014) ‘Calcium intake and urinary stone disease’, Translational Andrology
and Urology. AME Publishing Company, pp. 235–240. doi: 10.3978/j.issn.2223-
4683.2014.06.05.

 
 Step 3 Step 4
Recommendation & Justification Monitoring Parameters
No treatment for UTI
1. Recommendation:
• Empiric antibiotic therapy 1. Perform urine culture test to check whether the
Amoxicillin/clavulanate 625mg PO q8h for 7 days infection is fully resolved

• Specific antibiotic shall be started after obtaining the blood culture

result
2. Counselling points

• Ensure that patient finish the antibiotic course

• Common side effects of Augmentin (nausea, diarrhea, headache)
• Stop consume caffeinated and alcoholic beverages, may irritate the
bladder
• Drink enough water (8-10 glasses) to flush out the bacteria Ref:
Ref:
2. Gradwohl, S., Greenberg, G. and Van Harrison, M. (2016)
3. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease - American
‘Guidelines for Clinical Care Ambulatory Urinary Tract
College of Cardiology [Internet]. [cited 2020 Nov 11]. Available from:
Infection Guideline Team Team Leader Ambulatory Clinical
https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2019/03/07/16/00/2019-acc-a
ha-guideline-on-primary-prevention-gl-prevention Guidelines Oversight Urinary Tract Infection Objective:
4. Aspirin Therapy in Diabetes [Internet]. Vol. 27, Diabetes Care. American Diabetes Association Implement a cost-effective strategy for uncomplicated UTI in
Inc.; 2004 [cited 2020 Nov 11]. p. s72–3. Available from: women’, Umhs, pp. 1–8.
https://care.diabetesjournals.org/content/27/suppl_1/s72
 Question 1
What organism is the most prevalent in urinary tract infection
(UTIs)?
The most common bacteria found to cause UTIs
is Escherichia coli (E. coli). Other bacteria can cause
UTI, but E. coli is the culprit about 90 percent of the time.
 Question 2
What is the most common route of organism
entry into the urinary tract?
Urinary tract infection can be acquired via three possible
routes which are the ascending, hematogenous, and
lymphatic pathways
 Question 3
BB most likely has what type of UTI?
Complicated Urinary Tract Infection (UTI)
 Question 5
If BB develops frequent UTIs, what alternative therapies exist to
decrease the frequency of UTI recurrence??
Pharmacological treatment
Nitrofurantoin 50-100mg PO ON (macrocrystals) or 100mg
PO ON (monohydrate/macrocrystals) OR
Cephalexin 250mg PO ON for 3 to 6 months

Non-pharmacological treatment
1. Drink plenty of water and relieve yourself often
2. Wipe from front to back
3. Wash up before sex and urinate after it
4. Avoid irritating feminine products
5. Change birth control method
Thank You