Tutorial clinical cases for Urinary tract infections

1. Urinary tract
infections Cases
Dr. Sameh Ahmad Muhamad abdelghany
Lecturer Of Clinical Pharmacology
Mansura Faculty of medicine

2. Urinary tract
Infections

3. CAS(1)

4. Chief Complain
4
“I have to go to the bathroom
more often and it is getting
really annoying.”

5. Present History
5
Elizabeth Wilson is a 26-year-old woman who
presents to the emergency department with
complaints of increased urinary urgency over the
past 4 days. The patient reports that she had been
diagnosed with a urinary tract infection at the age
of 14 years but has had no other urinary tract
issues since that time.

6. PAST HISTORY
6
UTI at age 14 years (treated with trimethoprim–
sulfamethoxazole)

7. Review of Systems
7
-ve chest pain, Shortness of breath , abdominal pain
(+ve) Dysuria; (+ve) increase in urinary frequency or
urgency (every 1–3 hours during the past 2 days)

8. PHYSICAL EXAMINATION
8
General:
 Well appearing, obese 26-year-old Caucasian woman
in no acute distress
Vital Signs
 BP 122/78 mm Hg, P 72, RR 16, T 38.5°C
Skin
 Dry appearing skin; (–) rashes or lesions.

9. PHYSICAL EXAMINATION
9
 Chest
 Clear to auscultation
 Cardiovascular
 RRR, normal S1, S2; (–) S3 or S4
 Abdomen
 Not tender; not distended; (–) organomegaly
 Genitourinary
 Normal external genitalia; (–) vaginal discharge

10. LABORATORY
10
 Urine Cultures
 (+) Gram-negative rods—final results pending

11. 11
Assessment
 Twenty-six-year-old woman with s/s and laboratory
tests consistent with an uncomplicated UTI

12. Questions
12
Q1. What signs and symptoms of an uncomplicated
UTI does the patient have?
Q2: What risk factors does the patient have for
uncomplicated UTIs?
Q3: Which organisms are the most likely cause of
this infection?

13. Questions
13
Q4. What treatment options including duration of therapy
should be considered in this patient?
One day later, the patient’s urine culture and sensitivity
results are reported: Urine culture: Escherichia coli .
Q5: Based on the above culture and susceptibility results
along with the patient’s clinical status, how would you
change the patient’s UTI therapy?

14. Answer of Question 1
14
 (+ve) Dysuria; (+ve) increase in urinary frequency or urgency
(every 1–3 hours during the past 2 days)
 (+) Gram-negative rods
Back

15. Answer of Question 2
15
 The patient if female who are more susceptible to UTI
(shorter urethra)
 History of previous UTI
Back

16. Answer of Question 3
16
 Escherichia coli : cause about 80% of UTI
 20% of UTI caused by Gram negative enteric bacteria –
Klebsiella, Proteus
 Gram positive cocci : Streptococcus faecalis ,
Staphylococcus saprophyticus
Back

17. Answer of Question 4
17
3 day therapy:
 Efficacy same as 7 day therapy with less adverse effects
 Drugs used include
o Quinolones ,TMP-SMZ,betalactam antibiotics
7 day therapy:
 Better in this case due to presence of risky factors:
o Female – History of previous UTI
Back

18. Answer of Question 5
18
Escherichia coli is more susceptible to Ceftriaxone
Back

19. CAS(2)

20. Chief Complain
20
“There’s pain in my
stomach and back.”

21. Present History
21
Theresa Mitch is a 53-year-old woman with a history of
asthma, GERD and HTN. She reports that she has had pain in
her left flank region over the last 3 days, as well as pain in her
abdomen. She complains of some nausea and reports four
episodes of vomiting over the past 3 days. She has recently
skipped several meals as a result. The patient reports urinary
burning and frequency. She states that often she feels feverish
and at times has chills. She reports no substernal chest pain,
shortness of breath, cough, or sputum production. She denies
any diarrhea.

22. PAST HISTORY
22
Hypertension (duration unknown); BP averages 142/84
mm Hg on medication
GERD (duration unknown)
Asthma (duration unknown)

23. PHYSICAL EXAMINATION
23
General:
 Conscious, alert, and oriented middle-aged, African-
American woman in mild distress
Vital Signs
 BP 142/84, P 77, RR 21, T 38.2°C

24. PHYSICAL EXAMINATION
24
 Chest
 Clear to auscultation
 Cardiovascular
 RRR, normal S1, S2; (–) S3 or S4
 Abdomen
 Mildly obese; active bowel sounds; soft with suprapubic tenderness to deep
palpation; no rebound or guarding. There is no hepatosplenomegaly or
masses.
 Genitourinary
 Normal external genitalia; (–) vaginal discharge

25. LABORATORY
25
 Urine Analysis
 Appearance Hazy - Color Amber - pH 5.0 - Specific gravity 1.017 -
Blood 2+ - Ketones Negative - Urine protein, qualitative Trace -Urine
glucose, qualitative Trace -WBC/hpf 487 -RBC/hpf 102 -Bacteria
Many -WBC casts 2+.
Urine Gram Stain
 Many Gram-negative rods.

26. LABORATORY
26

27. RADIOLOGICAL
27
 Chest X-Ray
 No infiltrates, no consolidation seen
 CT Abdomen with Contrast
 Findings: Liver, gallbladder, pancreas, spleen, and adrenals are unremarkable.
No evidence of pneumoperitoneum or hemoperitoneum. No evidence of
ascites or focal areas of fluid collection.
 The right kidney is unremarkable. A hypoattenuating lesion is seen involving
the left kidney from mid-pole to lower-pole.
 Impression: Hypoattenuating lesion in left kidney consistent with
pyelonephritis, correlate with clinical picture.

28. 28
Assessment
 53-year-old woman with s/s and laboratory tests
consistent with an Acute Pyelonephritis (Complicated
UTI)

29. Questions
29
Q1. What information (signs, symptoms, laboratory tests)
indicates the presence and severity of pyelonephritis in
this patient?
Q2: What risk factors does the patient have for
Complicated UTIs?
Q3: What are the goals of pharmacotherapy in this
patient?

30. Questions
30
Q4. What nondrug therapies might be useful for this
patient?
Q5. What feasible pharmacotherapeutic alternatives are
available for the empiric treatment of pyelonephritis?

31. Answer of Question 1
31
 pain in her left flank region
 pain in her abdomen.
 nausea and vomiting
 urinary burning and frequency.
 Fever & chills.
 suprapubic tenderness
 WBC/hpf 487 -RBC/hpf 102 -Bacteria Many -WBC casts 2+.
 Urine Gram Stain :Many Gram-negative rods.
 CT Abdomen with Contrast : Hypoattenuating lesion in left kidney consistent
with pyelonephritis, correlate with clinical picture.
Back

32. Answer of Question 2
32
 The patient is female & old age so susceptible to UTI as
she has shorter urethra & incomplete bladder emptying
with age
 Also with aging, immunity decline
Back

33. Answer of Question 3
33
Goals of therapy:
 Elimination of infection
 Relief of acute symptoms
 Prevention of recurrence and long term complications
Back

34. Answer of Question 4
34
 more water intake.
 Maintaining acidity of urine by fluids like cranberry juice
or use of ascorbic acid.
Back

35. Answer of Question 5
35
 Paranteral antibiotics
o Cefuroxime – 750mg i.v. Q8h
o Gentamycin - 80-120g i.v. Q12h
o Ciprofloxacin – 200mg i.v. Q12h
 10-14 days treatment
Back

36. CAS(3)

37. Scenario
37
 A pregnant woman aged 26 years is found to have
bacteriuria at her first antenatal visit. There are no white
or red cells seen in her urine. Urine culture
demonstrates E. coli at a count of more than 100,000
bacteria/mL, sensitive to trimethoprim, nitrofurantoin
and cefalexin but resistant to amoxicillin. Other than a
degree of urinary frequency, which she ascribes to the
pregnancy itself, the patient does not complain of any
urinary symptoms.

38. Questions
38
Q. Does this patient need antibiotic treatment,
and if so, which drugs could be safely used?

39. Answer of Question 1
39
 Yes she needed to be treated.
 This case correlates with Asymptomatic bacteriuria and
because of presence of pregnancy it should be treated like
symptomatic case
 The patient should receive 7 day course with
Cephalaxin(more safety than nitrofurantoin) or
Nitrofurantoin
 Amoxicillin not used due to resistance
 Trimethoprim is teratogenic in early pregnancy

40. T H A N K Y O U !
A N Y Q U E S T I O N S ?