Urinary Tract Infection

"You're working in a busy community pharmacy and are approached by a 30-year-old woman who asks to have a quiet word with a pharmacist. With an embarrassed expression, she asks for something to treat cystitis."

What symptoms may she be experiencing?

• bad smelling or cloudy urine

• dysuria or hematuria

• high-grade fever

• urgency or frequent urination

• bladder distension

Answer explanation

Cystitis (lower UTI) may presents as LOW-GRADE FEVER.

Bladder distension is NOT a typical cystitis symptoms.

"After further questioning, you learn that she has had the symptoms since last night, is not taking any other medications, either from the doctor or OTC, and is 4 months pregnant with her first child."

What would be your course of action, and why?

• No antibiotic is indicated since uncomplicated UTI will resolves itself in 4-9 days.

• Consider PO nitrofurantoin macro-crystals 50-100mg q6h for 5 days

• Avoid Nitrofurantoin due to risk of hemolyticanemia in newborn.

• Obtain urine culture before treatment and 1-2 weeks after completion to ensure eradication.

• Consider Cefuroxime PO 250mg q12h as alternative if first-line is unavailable.

Answer explanation

Pregnant women are vulnerable to UTI complications, hence require treatment.

Risk of hemolyticanemia in newborn is relevant for THIRD TRIMESTER pregnancy only.

"The woman asks you what has caused the cystitis"

How do you respond?

• Hormonal and physical changes due to pregnancy

• Slowing down of urine flow

• Bacterial infection

• Increased vaginal discharge

• Glucosuria due to gestational diabetes mellitus

Answer explanation

Vaginal discharge is sterile hence not the root cause of infection.

No mention of gestational diabetes by patient, hence it is to be ruled out.

"The patient's GP diagnosed an uncomplicated lower UTI and prescribed nitrofurantoin 50mg tablet 4 times a day for 7 days."

What is the likely causative organism in this patient?

• E. coli

• Klebsiella pneumoniae

• Streptococcus agalactiae

• Staphylococcus epidermidis

• Enterococci spp.

Answer explanation

S. epidermidis is part of skin flora, hence not likely the cause.

Enterococci spp. is common in GIT, hence not likely the cause.

"When you hand her the medication, she tells you that her friend has recommended drinking cranberry juice"

What do you think of this recommendation?

• She can take it if she wish but recommend sugar-free version.

• Suggest against it since it increases stomach acidity which may affect the fetus.

• Highly recommend it since it has significant role in UTI prevention.

• Suggest that cranberry juice is used as prevention and not treatment since no good evidence to suggest its significant roles.

• Suggest against it due to potential proanthocyanidin in the juice metabolizes into potassium cyanide, which is teratogenic.

Answer explanation

Stomach acidity doesn't affect the fetus.

Despite numerous studies, the use of cranberry juice in UTI prevention or treatment especially in pregnancy is still questionable.

Proanthocyanidin doesn't metabolized into potassium cyanide, hence safe to consume even in pregnancy.

What lifestyle modifications can you offer to this patient?

• Increase daily fluid intake

• Wipe from back to front to avoid fecal flora

• Fully emptying the bladder when urinating

• Suggest against sexual intercourse until labor

• Suggest frequent use of body wash

Answer explanation

Wipe from FRONT TO BACK to avoid fecal flora.

Intercourse could still be done but should be followed by urinating after it.

Body wash is a harsh soap hence not recommended to be used.

The following is true regarding post coital UTI

• Antibiotic is first-line therapy

• Antibiotic used is oral cefazolin 250mg

• Duration of treatment is continuous for 3-12 months

• Should be taken 2 hours post-intercourse

• Indicated in recurrent UTI

Answer explanation

Hygiene and lifestyle modification is first-line.

Antibiotic used is Cephalexin 250mg.

Duration of treatment is intermittent.