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 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 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 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 Dysuria and frequency – 90% UTI Urine culture Pyuria Leukocyte esterase dipstick Organism and susceptibilities are usually predictable

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 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 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 3 rd generation cephalosporin – 2 gms/day Interferes with cell wall synthesis 1 gm - $20.00 Gall bladder sludge

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 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 Pneumonia Pneumovax Influenza vaccine Antibiotics Common etiologies: pneumococcus, H. influenza, Legionella spp., Chlamydia pneumonia, Aerobic GNRs, Mycoplasma

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