Renal- UTI's ============ ş Antibiotic choice April 2008 (Hank Freedy, Mercy Pharmacy): - TMP-SMX is as active as Cipro against the common enteric gram-negative pathogens (e.g. E.coli, Kleb spp, Proteus mirabilis, see attached biogram) and achieves similar cure rates as the fluoroquinolones for both cystitis and pyelonephritis.  TMP-SMX  is less likely to cause C.difficile disease than are the fluoroquinolones which we now consider high risk drugs for C.diff.  The preferred empiric therapy for cystitis would be PO TMP-SMX.   Since since the initial therapy for patients admitted to the hospital with pyelonephritis is generally administered IV and TMP-SMX needs to be given in a large volume of fluid it is not always the preferred agent especially in volume restricted patients.  Options for empiric therapy for the treatment of pyelonephritis would be: 1. Gentamicin IV  5 mg/kg (dosing wt)  Q 24 hours for CrCl  > 60 ml/min     Gentamicin has a nephrotoxic potential, but the drug needs to accumulate to cause nephrotoxicity and with pyelo 99% of the time an organism is ID with sensitivities in 48 hours and gent can be changed.  Very low potential for toxicity when administered for only 48-72 hrs.  Some authorities recommend the addition of ampicillin for enterococcal coverage.  Cystitis can be treated with gentamicin using doses of 2-3 mg/kg. The pharmacists can assist with dosing of gentamicin if needed. Other options for pelonephritis are:                                 2. Ceftriaxone 1 g IV Q 24 hours, but this like fluoroquinolones is a high risk drug for C.diff. 3. SMX-TMP  8 mg/kg/day IV in 2-4 doses.  Avoid with sulfa allergy, pts on warfarin and those with CrCl < 15 ml/mn ş Fluoroquinolone Resistance: - Resistance of coliforms is so high now (40-60%) that Dr. Hank Freedy of the Mercy Pharmacy (12/05) recommends using Bactrim instead of Cipro for Pyelo, and recommends adding a single daily dose of Gent prior to discharge, regardless of creatinine/renal function. - Usual dose of IV Bactrim is 300 mg for a 70 kg adult (based on trimethoprim component) BID ş Hemorrhagic Cystitis ş UTI Treatment - Daily cost of IV treatment [Mercy Pharmacy and Therapeutics Update, Jan/Feb 1998] + Unasyn $50.00 + Amp+Gent $3.75 + Bactrim $6.00 (8-10 mg/kg trimethoprim divided QID-BID; 80mg/5cc) + Rocephin $22.00 + Cipro $36.00 - Also note that only 75% of E. coli at Mercy is susceptible to Unasyn, compared to 90% for IV Bactrim - cost of PID treatment: + 14 days of Bactrim: <$20 + 7 days of Cipro (250 BID): $76 (June 2000); about $15 more for 500 BID - Oral cephalosporins have high relapse relase rate compared with Bactrim for UTI's. - Simple UTI: + Bactrim is better than all beta lactams + 3 days optimum to balance cure rate against side effects ref 1 [Norby 25] - Nursing home patient with UTI: worry about Cipro-resistant Pseudomonas. - The Australians use trimethoprim without sulfamethoxasole. - Position Statement on UTIs and Pyelo [Warren JW, Abrutyn E, Hebel JR, et al. Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis in women Clin Infect Dis 1999; 29 745-58,] ş Pyelo: - Complicated Outpatient Pyelo: + quinolones more effective than Bactrim. quinolones get into prostate better than Bactrim + can treat initially with: ceftriaxone, Cefonicid 1g, or Gent 2 mg/kg then Bactrim or Noroxin 400 BID or Cipro 500 BID + With Pyelo, takes 3-4 days for sx including fever to go away. [Johnson JR, Lyons MFd, Pearce W, et al. Therapy for women hospitalized with acute pyelonephritis: a randomized trial of ampicillin versus trimethoprim-sulfamethoxazole for 14 days J Infect Dis 1991;163:325-30.] Abstract: + Seven days of Cipro better than two weeks of Bactrim [Talan DA, Stamm WE, Hooton TM, et al. Comparison of ciprofloxacin (7 days) and trimethoprim-sulfamethoxazole (14 days) for acute uncomplicated pyelonephritis pyelonephritis in women: a randomized trial. JAMA 2000;283:1583-90.] Abstract: ş Cranberry Juice and Lactobacillus -