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Management of Common Infections. Will Roland, MD. Urinary Tract Infections. 8 million physician visits/year – cystitis 100,000 admits/yr – pyelonephritis Bacteruria is not a disease Tests for bacteruria or pyuria do NOT establish the diagnosis of UTI

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urinary tract infections
Urinary Tract Infections
  • 8 million physician visits/year – cystitis
  • 100,000 admits/yr – pyelonephritis
  • Bacteruria is not a disease
  • Tests for bacteruria or pyuria do NOT establish the diagnosis of UTI
  • Bacteruria alone is rarely an indication for abx treatment
  • Routine culture is not required to manage cystitis in women
acute uncomplicated cystitis in young women
Acute Uncomplicated Cystitis in Young Women
  • E. coli – 80%
  • Risk factors – intercourse, diaphragm and spermicide use, delayed postcoital micturition, previous UTI
  • Abrupt onset, dysuria, frequency, urgency, suprapubic pain or LBP
  • Must differentiate it from other causes of dysuria
differential diagnosis
Differential Diagnosis
  • URETHRITIS
    • C. trachomatis, N. gonorrheae, HSV
    • Gradual onset, mild symptoms, vaginal d/c or bleeding, lower abd pain, new sexual partner, cervicitis or HSV lesions
  • VAGINITIS
    • Candida, T. vaginalis
    • Vaginal d/c or odor, pruritis, dyspareunia, vulvovaginitis
diagnosis
Diagnosis
  • Dysuria and frequency – 90% UTI
  • Urine culture
  • Pyuria
  • Leukocyte esterase dipstick
  • Organism and susceptibilities are usually predictable
therapy
Therapy
  • 3 day regimens appear optimal
  • Trimethoprim-sulfamethoxazole (Bactrim, Septra)
  • PABA -- Dihydrofolic acid – -Tetrahydrofolate – Purines
  • TMP/SMX 1 double strength tab (160 mg TMP) po BID x 3 days
tmp smx
TMP/SMX
  • Cost – Generic $0.15; Brand $0.90
  • Side effects
  • Rash – urticaria, maculopapular, mobilliform
  • Triggers asthma in sulfite-sensitive pts
  • HIV – CNS, renal effects
  • Avoid in megaloblastic anemia
fluoroquinolones
Fluoroquinolones
  • Ciprofloxacin 250 mg po BID x 3 days
  • Cost - $5.00/tab
  • Side f/x – CNS (0.4%): HA, rstlessness, insomnia, nightmares, psychosis
  • Crystalluria with high doses in alkaline urine
  • Not recommended for children, pregnancy
ceftriaxone
Ceftriaxone
  • 3rd generation cephalosporin – 2 gms/day
  • Interferes with cell wall synthesis
  • 1 gm - $20.00
  • Gall bladder sludge
uti s in men
UTI’s In Men
  • Rare, r/o prostatis
  • Risk factors: homosexual, uncircumcised, colonized sex partner
  • Usually E. coli
  • 14 days fluoroquinolone
  • Obtain urine culture
  • No need to w/u if responds to therapy
community acquired pneumonia
Community-Acquired Pneumonia
  • 915,900 episodes of CAP in adults >65 per year in the US
  • Precise etiology remains uncertain in about 50%
  • Inhalation, aspiration, hematogenous
  • Risk factors: Cigarrettes, chronic bronchitis, alcoholism, poor nutrition, change in mental status
community acquired pneumonia1
Community-Acquired Pneumonia
  • Pneumovax
  • Influenza vaccine
  • Antibiotics
  • Common etiologies: pneumococcus, H. influenza, Legionella spp., Chlamydia pneumonia, Aerobic GNRs, Mycoplasma
empiric abx
Empiric Abx
  • Previously healthy and no use of abx in last 3 months – macrolide, doxycycline
  • Presence of comorbidities or use of antimicrobials within the previous 3 months - respiratory fluoroquinolone, beta-lactam plus a macrolide