Tuberculosis, Prophylaxis Medications

Drugs associated with Tuberculosis, Prophylaxis

The following drugs and medications are in some way related to, or used in the treatment of Tuberculosis, Prophylaxis. This service should be used as a supplement to, and NOT a substitute for, the expertise, skill, knowledge and judgment of healthcare practitioners.

Tuberculosis

Tuberculosis is an infectious disease caused by Mycobacterium tuberculosis (MTb). Almost all infection in humans is caused by inhalation of droplet nuclei - infectious particles of aerosolized respiratory secretions coughed up by a person with pulmonary tuberculosis. It may either result in a lifelong silent (latent) infection or in a clinically recognizable disease.

The need for improved detection and treatment of tuberculosis has been significantly increased by the recent outbreaks of multidrug-resistant TB, especially in HIV-infected persons.

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Background

Epidemiology

The most common disease is pulmonary tuberculosis; however, extrapulmonary cases do occur. In low-incidence areas such as the United States, most TB cases are attributed to endogenous reactivation of latent infection; however, significant outbreaks can occur from exposure to a person with active pulmonary tuberculosis.

Over 26,000 cases of TB were reported in 1991, and an estimated 15 million persons in the United States are infected with tubercle bacilli. Incidence is higher in urban settings, among populations with low socioeconomic status, among racial and ethnic minority groups (particularly Hispanics and African Americans), and in medically underserved areas. The risk of TB is higher for persons living in crowded, confined areas, such as residential drug treatment programs, homeless shelters, nursing homes, correctional institutions, migrant worker camps, and long-term care facilities.

Since 1986, the morbidity from TB has been increasing. The increase has occurred mostly in geographic areas and demographic groups with a high incidence of HIV/AIDS cases. The 1991 data also show:

• Twenty-seven percent of cases of active TB occurred in foreign-born persons, compared with 20 percent in 1985. Forty-one percent of these persons had been in the United States less than 5 years.
• Seventy-one percent of reported TB cases were in racial and ethnic minorities.
• Twenty-three percent of cases occurred in the elderly.

Among children with TB, 86 percent of cases occurred in minority groups. Screening for TB should be provided for any child exposed to a person who is or should be receiving treatment for active TB.

Course of the Disease

Most persons who are exposed to a person with active TB and become infected do not develop active disease, but rather have latent, asymptomatic infection for long periods of time. Such patients may benefit from preventive therapy with isoniazid.

Active TB is usually the result of reactivation of latent infection. The symptoms of active disease include fatigue, fever, weight loss, cough, pleuritic chest pains, and hemoptysis. TB is, however, a treatable disease. Treatment requires taking multiple anti-TB drugs for at least 6 to 9 months. The length of treatment may vary, especially in HIV-positive persons. Adherence to the appropriate drug regimen and adequate medical followup are required to complete successful treatment.

Although active TB is usually the result of reactivation of latent infection, health care providers need to be aware that with the increasing numbers of cases of active TB, some patients may present with active disease following recent exposure to a person with active tuberculosis. HIV-infected persons are at particular risk for the development of active TB following a recent exposure. Reactivation of latent TB because of the immunosuppression associated with HIV infection, as well as TB following exposure to a person with active TB, occurs more frequently in the HIV-infected person. There may be rapid progression of the TB infection in such an HIV-infected person.

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Program Issues for Drug Treatment Settings

Drug treatment programs funded under the Substance Abuse Prevention and Treatment Block Grant are now required by law to provide tuberculosis services to patients or to ensure that patients receive such services. Section 1924(a) of the ADAMHA Reorganization Act of 1992 (P.L. 102-321) states that

States must require treatment entities receiving funds under grant to make available tuberculosis services to each individual receiving treatment; in the case of an individual denied admission due to lack of capacity, the treatment entity will refer the individual to another provider of tuberculosis services (defined as counseling, testing, treatment).

Transmission of tuberculosis is most effectively reduced by identifying and treating persons with active pulmonary tuberculosis. A full course of isoniazid preventive therapy can reduce the risk of developing active TB in infected persons (i.e., persons with positive skin tests) by more than 90 percent.

Because patients receiving methadone maintenance come to drug treatment centers frequently - often on a daily basis - for extended time periods, methadone maintenance treatment programs are in a unique position to provide daily or twice weekly preventive therapy for the recommended 6- to 12-month period. This preventive service can usually be provided in collaboration with the public health agency.

Screening and Treatment

• In general, all persons entering drug treatment programs should have a Mantoux intradermal skin test for tuberculosis.
• Persons who have a negative skin test for TB, as well as nonreactive control skin tests, should be considered to be anergic. HIV-infected persons are especially at high risk for the development of TB. Any person who fails to react to the TB skin test as well as the skin tests controls and is, therefore, anergic needs to be carefully evaluated to be certain there is no evidence of active TB and to be tested for HIV if the person's HIV status is unknown.
• Persons who have a positive skin test or who have symptoms compatible with TB should be medically evaluated for possible active TB and appropriate treatment or for TB preventive therapy.
• Tuberculin skin tests using the Mantoux method should be repeated annually for patients whose initial skin test is negative.
• Patients with chronic cough (over 3 weeks duration), fever, and other symptoms should be rapidly evaluated for possible active tuberculosis disease. If active tuberculosis is suspected or confirmed, the client should be immediately placed on multiple anti-TB medication and placed in respiratory isolation if institutionalized.

Special Considerations With Infected Patients

Persons with close contact to a person with untreated tuberculosis of the lungs or larynx are at greatest risk of acquiring infection.

The treating physician should inform the case manager in the drug treatment program about patients who are being treated for active TB concerning activity restrictions and possible need for isolation methods to ensure compliance, and about precautions for staff. The need to monitor drug adherence and to determine drug efficacy and potential drug toxicity all highlight the importance of monitoring. For short-term treatment programs, treatment needs to be supervised and aftercare should be provided, including followup with a specific provider and case manager.

Medications for TB preventive therapy and treatment may interact with other drugs, such as methadone and disulfiram (Antabuse), thus requiring careful monitoring and possible dosage adjustment. Rifampin (RIF) may interact with either methadone or disulfiram and may require an increase in methadone dosage. Isoniazid (INH) must be given with care to patients on disulfiram, since such patients can have psychotic episodes or ataxia.

Considerations for Drug Treatment Staff

All health care personnel should have PPD skin tests every 6 to 12 months and at the time of and 3 months after any exposure to a patient with active, untreated TB. The following testing should be done:

• In general, all staff of drug treatment programs should receive a PPD skin test using the Mantoux method when they are first employed.
• Staff with initial negative skin tests should be retested every 6 to 12 months.
• Staff with positive skin tests should receive a prompt medical evaluation for possible active TB, should be considered for TB preventive therapy, and should be evaluated if symptoms of active TB develop.

Staff reading the results of tuberculin skin tests should be trained in the procedure. Training materials on skin testing produced by the Centers for Disease Control and Prevention (CDC) are available through each State health department TB program. See also the section at the end of this chapter, Role of the Health Department, on assistance that the local or State health department may offer to drug treatment centers in setting up a screening program.

Other Program Considerations

Patients Who Refuse Testing

The patient should have the right to refuse screening. However, to protect the safety and health of the other patients and staff, an individual seeking treatment who is thought to have active tuberculosis may be denied admission until it has been medically determined if the patient needs treatment prior to being admitted to the program. A program's drug treatment policies and procedures must be consistent with current local, State, and Federal laws. See section on Access to Treatment in "Legal and Ethical Issues" for further guidance on patients who refuse to be tested.

Local legal guidelines should be consulted for dealing with noncompliant patients who are public health risks, especially given cases of multidrug-resistant TB. (Any patient who is noncompliant with treatment for drug-susceptible or MDR-TB should not be allowed to enter the drug treatment facility; see the following MDR-TB guideline.)

Isolation of Persons With Infectious TB

Prompt, correct drug treatment of an active case of TB is essential. For persons with active or suspected tuberculosis, initiation of treatment as an outpatient may be considered if the person is only mildly ill and is able to care for himself or herself at home. For those with complicated illness or unable to care for themselves, hospitalization is indicated. Hospitalization should be strongly considered for persons with MDR-TB, and the decision not to hospitalize such a patient should be made only after consultation with a physician experienced in caring for patients with MDR-TB. Patients in residential drug treatment programs should be hospitalized unless appropriate respiratory isolation can be provided at the facility.

An active case of TB is usually not communicable once the sputum smears are negative for acid-fast bacilli (AFB) and the patient's symptoms, e.g., cough, have improved. The drug susceptibility of any given TB isolate may not be available, however, for 6 to 12 weeks. If there is any concern that the infected person may have resistant tuberculosis, appropriate respiratory isolation, with hospitalization if it is deemed necessary, should be continued until the person has smear-negative sputum samples or until the drug susceptibilities are known. When the drug susceptibilities are available, the therapy must be reevaluated to be certain that the person is on appropriate therapy and that the patient's adherence can be ensured by placing him or her on directly observed therapy.

General Guidelines

Programs should develop guidelines and procedures for decreasing transmission of tuberculosis through identification, appropriate isolation, and treatment of persons with infectious TB. For general environmental guidelines, refer to the CDC Guidelines in the Summary Statement in chapter 6; see also chapter 4, "Issues for Treatment Program Administrators." There should be adequate ventilation of living and work areas where persons with possible or proven TB congregate. Persons with known infectious TB should not be allowed to enter the living and work areas of a treatment facility until three sputum specimens have been obtained and are smear negative for AFB.

Sputum induction, sputum collection, and aerosolized pentamidine treatments should be done in areas with correct exhaust. If such areas are not available, sputum collection may be done outside the building. Consideration should be given to placing ultraviolet lights in clinic and residential areas where adequate ventilation and air exchange are not possible.

Reporting Procedures

All new cases of active TB must be reported to local/State health departments. Reporting is obligatory in all States. All suspected cases of TB should also be reported to the health department. Any cases of INH- or multidrug-resistant TB should be promptly reported. Contact tracing of all active TB cases must be implemented. Contact tracing is not required for most persons with only a positive PPD. However, in the case of a child with a positive PPD, an investigation should be undertaken to identify the source case.

• Persons with positive skin tests after exposure to MDR-TB should be reported.
• All persons with TB and all suspects, contacts, and others at high risk must have medical services made available by local/State health departments; services to screen for and treat TB should be available to such persons regardless of their ability to pay.
• Prompt attention should be given to any household where contacts of the infectious cases include children or immunosuppressed persons.
• State and local health departments should initiate prompt followup of contacts

prophylactic treatment for Bacterial Meningitis

Perhaps no admission causes so much consternation and dread amongst caregivers and families as a case of suspected bacterial meningitis. Will the patient live? What infection control precautions are necessary? And, perhaps most urgently, do I need antibiotic prophylaxis? In this article I answer the questions hospitalists most often need to address in such circumstances.

1. Who should have a head CT prior to lumbar puncture (LP) for suspected meningitis? Patients with immunocompromise, papilledema, preexisting CNS disease, new onset seizures, altered level of consciousness, and focal neurological findings should have a head CT prior to LP.1 While herniation is rare after LP for purulent meningitis, patients with increased intracranial pressure at risk for herniation often have normal head CT scans. Therefore, herniation may be an uncommon but unpredictable complication of LP in this setting. The cause-and-effect relationship of herniation and LP has also been questioned.

2. Are there any cerebrospinal fluid (CSF) findings that exclude bacterial meningitis? A number of CSF findings make bacterial meningitis quite likely, including total leukocyte counts of more than 2,000/mm3, a positive gram stain, or very low CSF glucose. It is difficult, if not impossible, however, to exclude bacterial meningitis in patients with any degree of CSF pleocytosis. For example, 10% of patients with bacterial meningitis have less than 100 WBCs/mm3 in CSF, and 10% have lymphocyte predominance at presentation. Therefore, the safest course of action when bacterial meningitis is suspected on clinical grounds and CSF pleocytosis is present is to continue antibiotics until results of CSF cultures are available.

3. Which patients with suspected or proven meningitis should receive steroids? Steroids reduce neurologic damage from the inflammatory surge provoked by antibiotic-induced pneumococcal lysis. In a large European trial, dexamethasone given in 10-mg doses every six hours for four days (before or with the first dose of antibiotics) reduced mortality in pneumococcal meningitis.2 Benefits were not seen in patients with bacterial meningitis from other pathogens. Dexamethasone can be safely stopped as soon as pneumococcal meningitis is excluded.

4. How soon should patients receive antibiotics? When bacterial meningitis is likely, antibiotics should be given immediately, prior to imaging studies and lumbar puncture. In patients with a lower clinical likelihood of bacterial meningitis, antibiotics can be deferred, awaiting the results of diagnostic studies.

5. What empiric antibiotic therapy is appropriate? Adults 18-50 with suspected bacterial meningitis should receive therapy directed against Streptococcus pneumoniae and Neisseria meningitidis. Vancomycin should be dosed to achieve a relatively high trough level of 15-20 mcg/mL. For a 70-kg adult male with normal renal function, doses of vancomycin given at the rate of 1.5 gm IV every 12 hours and ceftriaxone at 2 gm IV every 12 hours are appropriate. Adults over 50, alcoholics, and immunocompromised adults of any age should also receive ampicillin doses of 2 gm IV every four hours to cover Listeria, in addition to vancomycin and ceftriaxone.3,4

6. What infection control precautions are required? Meningococcal meningitis patients should be placed on droplet precautions (private room, mask for all entering the room) until they have completed 24 hours of appropriate antibiotic therapy. Negative pressure ventilation is not required. Patients with pneumococcal or viral meningitis do not require isolation.

7. Who needs antibiotic prophylaxis after patient exposure? Chemoprophylaxis is overprescribed after exposures to patients with meningococcal meningitis. The only social contacts who should receive prophylaxis are household contacts, childcare contacts, and people who have had direct exposure to the patient’s oral secretions through actions such as kissing or sharing utensils or toothbrushes. The only healthcare workers requiring chemoprophylaxis are those who performed mouth-to-mouth resuscitation or any staff who were unmasked during intubation or suctioning of a patient. Regimens for chemoprophylaxis in adults include ciprofloxacin, 500 mg taken orally as a single dose, rifampin taken in doses of 600 mg twice daily for two days, or 250 mg of ceftriaxone, given intramuscularly. Ceftriaxone is preferred for pregnant women. Chemoprophylaxis is unnecessary after exposure to patients with pneumococcal or viral meningitis.

8. What is the significance of arthritis after meningococcal meningitis? A significant number of patients with meningococcal disease develop inflammatory polyarthritis about a week after the onset of infection. In most cases, this is a sterile, immune complex phenomenon that responds to anti-inflammatory therapy. If joint effusions are present, they should be aspirated to exclude septic arthritis and crystalline arthritis. TH

Dr. Ross is a hospitalist at Brigham and Women’s Hospital (Boston) and a fellow of the Infectious Diseases Society of America.

TYPES OF BACTERIA MENINGTIS:

Infectious meningitis is classified as viral, bacterial, fungal, or parasitic, depending on the type of organism causing the infection. Viral meningitis, also called aseptic meningitis, is the most common type. It is rarely fatal and usually resolves with treatment.

Types of Meningitis

Bacterial meningitis

The most common types of bacterial meningitis seen today are;

1. Meningococcal disease (meningococcal meningitis and/or meningococcalsepticaemia)
2. Pneumococcal meningitis.

There are various strains of meningococcal meningitis, the most common in New Zealand being B and C, with babies, young children, teenagers and young adults at the greatest risk.  We do not currently have a vaccine available in New Zealand for immunisation against Meningococcal B so it is vital to know the signs and symptomsso that you can seek immediate medical attention if needed.

Antibiotics are still the most effective form of treatment but death does occur in 5% of cases. In addition, about 20% are left with permanent disabilities such as cerebral palsy, limb amputations, 

learning

 difficulties and deafness.

In the past, Haemophilus Influenza type b (Hib) meningitis used to be the most common cause of bacterial meningitis but it has become much less common since the introduction of Hib vaccines.

Some forms of bacterial meningitis affect newborn babies. The most common are E coli, group B streptococcus and Listeria. These types are rare outside of the neonate period. (The neonate period may be defined as the period from birth to approximately 28 days following birth).

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Viral meningitis

Viral meningitis is an uncommon complication of some viral illnesses (eg, herpes). Most cases are mild but more severe illnesses sometimes do occur. It is rarely fatal. No antibiotic treatment or vaccine is available for most viral meningitis.

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Amoebic meningitis

Amoebic meningitis is a very rare infection. It is caught from stagnant water in waterholes and in poorly chlorinated swimming pools, especially when the water temperature rises above 30°C. Children can become infected when contaminated water is forced up the nose. The organism then reaches the base of the brain directly.

Children should not be allowed to swim in poorly chlorinated swimming pools or stagnant waterholes, particularly on very hot days. Young children should be discouraged from playing with hoses that may force water up their noses.

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Fungal meningitis

Some fungi can occasionally cause meningitis, but the disease is rare and usually occurs only in patients whose immune system has been severely depressed by disease, (eg. AIDS, leukaemia, or as a result of drug therapy). Fungal meningitis may be slow and difficult to diagnose and treat. 

Prophylactic Treatment for Migraine Headache

Migraine Treatment

The physician analyzes the patient's migraine history to devise an appropriate treatment program. The goals of treatment are to prevent or reduce the number of migraines (called prophylactic treatment) and to alleviate symptoms and shorten the duration of the migraine (called abortive or acute treatment).

Prevent Migraines

Preventative medication may be prescribed for patients who have frequent headaches (3 or more a month) that do not respond to abortive treatment. Studies have shown that as many as 40 percent of these patients may benefit from preventative treatment.

Using one medication (monotherapy) is tried first, but a combination of medicines may be necessary. Many of these medications have adverse side effects. If migraines become controlled, the dosage is often reduced or the drug discontinued.

Beta blockers (e.g., propranolol [Inderal®], atenolol [Tenormin®]) are the preferred medications to prevent migraines. These drugs produce an effect on heart rate. They should not be taken by patients with asthma and should be used with caution in patients with diabetes.

Side effects include gastrointestinal upset, insomnia, low blood pressure (hypotension), slowed heart rate (bradycardia), and sexual dysfunction. Some beta blockers pass into breast milk and may cause problems in nursing infants.

Antiseizure drugs such as valproic acid (Depakote®), topiramate (Topamax®), and gabapentin (Neurontin®) may be used to prevent migraine headaches. Topiramate was approved by the FDA in March 2014 to treat migraines in adolescents between the ages of 12 and 17—the first medication approved forprevention in this age group.

Medications that contain valproate sodium—including Depacon, Depakote, Depakote CP, and Depatote ER—valproic acid (Depakene, Stavzor), and generic versions of these drugs should not be used in women who are pregnant. These medicines contain a boxed warning indicating that they may cause birth defects. In May 2013, the U.S. Food and Drug Administration (FDA) warned that children born to mothers who used these drugs to prevent migraines during pregnancy are at increased risk for lower-than-normal IQs.

Side effects include nausea, gastrointestinal upset, sedation, liver damage, and tremors.

Calcium channel blockers (e.g., verapamil, amlodipine [Norvasc®]) inhibit artery dilation and block the release of serotonin. They should not be taken by patients with heart failure or heart block.

Side effects include constipation, flushing, low blood pressure, rash, and nausea.

Tricyclic antidepressants (TCAs; e.g., amitryptaline [Elavil®], nortryptaline [Pamelor®], desipramine [Norpramin®]) block serotonin reabsorption and take 2–3 weeks be effective.

Side effects include the following:

• Constipation
• Dry mouth
• Low blood pressure (hypotension)
• Increased heart rate (tachycardia)
• Urinary retention
• Sexual dysfunction
• Weight gain

High doses of TCAs have been implicated in seizures, stroke, and heart attack. Abrupt discontinuation of these medications may cause headache, nausea, and malaise, and may intensify side effects.

Selective serotonin reuptake inhibitors (SSRIs; e.g., paroxetine [Paxil®], fluoxetine [Prozac®], sertraline [Zoloft®]) are usually better tolerated than TCAs, but may not be as effective.

Side effects include nausea, insomnia, sexual dysfunction, and loss of appetite.

Methysergide maleate (e.g., Deseril®, Sansert®) may be prescribed for patients with frequent, severe migraines.

Side effects include insomnia, drowsiness, lightheadedness, and hair loss. This drug should not be used by patients with coronary artery disease and must be discontinued for 3–4 weeks after 4–6 months of use because it can cause retroperitoneal fibrosis, a condition in which the blood vessels in the abdomen thicken, which reduces blood flow to organs.

In October 2010, the U.S. Food and Drug Administration (FDA) approved botulinum toxin injection therapy (also known as "BOTOX® therapy" or onabotulinumtoxinA) to treat chronic migraine in adults who experience headaches 14 or more days per month. This treatment, which involves several injections, is administered every 12 weeks. The most common side effects of treatment are head and neck pain.

In March 2014, the FDA approved the first device to prevent migraine headaches in people 18 years of age and older. Called Cefaly, this battery-powered headband is worn above the ears and across the forehead. Cefaly—available by prescription to help reduce the frequency of migraines—is the first transcutaneous electric nerve stimulation (TENS) device approved by the FDA for use prior to the onset of pain. This device is uses electric current to stimulate the trigeminal nerve—which is associated with migraine headaches.

Cefaly is used once per day, for 20 minutes. In clinical studies, people who used this device experienced fewer days with migraine pain each month and were able to use less medication to prevent headaches. Some people experienced a tingling or massaging sensation at the electrode site, which may be uncomfortable or irritating. Others experienced sleepiness during treatment or a headache after wearing the device.

The Medical Fitness Association

The Medical Fitness Association

The Medical Fitness Association, a non-profit organization, was formed in 1991 to assist medically integrated health and fitness centers achieve their full potential. The Association is a professional membership organization whose mission is to ascertain and respond to the needs of medically integrated centers throughout the world. As a resource to the medical fitness industry, Medical Fitness Association is 100% focused on medical fitness, and is the first association to have focused on hospital fitness and wellness. Medical fitness is our #1 mission---and our ONLY mission.

Mission Statement

The Medical Fitness Association is a member-driven, non-profit organization. Our mission is to foster opportunities for the development and operational success of medically integrated fitness centers. Medical Fitness Association provides industry standards,educational programs.

, benchmarks, outcome measurements, professional development and networking opportunities for the medical fitness industry.

Vision Statement

To lead a global network of medically integrated centers and programs in the pursuit of well-being.

Medical Fitness

Medically integrated health and fitness centers are defining the future of professionally administered programs and services to an aging population, and are improving outcomes for clients/patients with chronic diseases and multiple risk factors. These centers have proven they can provide a continuum of care, fulfill the mission of their sponsoring institution, and be financially viable in a variety of communities. The pioneers in the medical fitness industry believe the future of hospitals and other wellness/fitness organizations is in improving the health status of the communities they serve. Preventing disease is the key to the future.

Notable growth and success throughout the medical fitness industry is becoming more prevalent each year. Based on information obtained through industry surveys and other sources, the number of centers has grown from 79 centers in 1985 to 950 in 2008. The number of members served has grown to over 3 million and over 4 million by 2010.

Benchmarks for success.

• Medical Fitness Association membership gives you access to in-depth research on the latest industry trends. We report on programs, practices, operations and more. What works. What doesn't. By sharing vital data, we help members formulate standards and protocols that foster excellence and optimize success.

Professional Development. 

• Medical Fitness Association-sponsored conferences, seminars and educational programs provide exceptional learning and networking opportunities. The goal? Expand the knowledge base of all involved-hospital executives, physicians and medical fitness center professionals alike-and help our members improve the overall health of the communities they serve.

Promoting the Difference.

• As a medically integrated health and fitness center, the services you offer your community are exceptional and unique. And it's important that the public understands the added value your facility offers over other health clubs. Your active membership in Medical Fitness Association helps identify your organization as a leader in proactivehealth care.

Medical Fitness Facility Certification

• With our health care system continuing to be stressed and the incidence of disease on the rise, the need for more medically supervised, outcomes and accountability based delivered fitness was never more relevant in our industry than today. The certification earned shows the seal of approval that a facility meets the highest industry standards.

Increasing public awareness.

• Medical Fitness Association has made it a top priority: increase public awareness of the benefits of medical fitness. By cultivating media relationships, providing source materials for articles, features and news stories, and distributing press releases, the Association is carrying the message--one that resonates loud and clear with your target prospects.

Grow with us.

• The Medical Fitness Association informs, promotes, provides exceptional networking and educational opportunities, serves as an effective advocate, and defines industry-wide standards of professional excellence.

Urinary Tract Infection - Adults

Treatment

Antibiotics are the main treatment for all UTIs. A variety of antibiotics are available, and choices depend on many factors, including whether the infection is complicated or uncomplicated or primary or recurrent. Treatment decisions are also based on the type of patient (man or woman, a pregnant or nonpregnant woman, child, hospitalized or nonhospitalized patient, person with diabetes). Treatment should not necessarily be based on the actual bacteria count. For example, if a woman has symptoms, even if bacterial count is low or normal, infection is probably present, and the doctor should consider antibiotic treatment.

TREATMENT FOR UNCOMPLICATED UTIS

UTIs in low-risk women can often be successfully treated over the phone. In such cases, a health professional provides the patients with 3-day antibiotic regimens without requiring an office urine test. This course is recommended only for women at low risk for recurrent infection, who do not have symptoms (such as vaginitis) suggesting other problems.

Antibiotic Regimen . Oral antibiotic treatment cures 94% of uncomplicated urinary tract infections, although the rate of recurrence remains high. The following antibiotics are commonly used for uncomplicated UTIs:

• The standard regimen has traditionally been a 3-day course of trimethoprim-sulfamethoxazole, commonly called TMP-SMX (Bactrim, Cotrim, Septra). TMP-SMX combines an antibiotic with a sulfa drug. A single dose of TMP-SMX is sometimes prescribed in mild cases, but cure rates are generally lower than with 3-day regimens. Allergies to sulfa are common and may be serious.
• Fluoroquinolone antibiotics, also called quinolones, have usually been a second choice. However, in geographic areas that have a high resistance to TMP-SMX, quinolones are now the first-line treatment for UTIs. Ciprofloxacin (Cipro) is the quinolone antibiotic most commonly prescribed. Quinolones are usually given over a 3-day period. Pregnant women should not take these drugs.
• Nitrofurantoin (Furadantin, Macrodantin) is a third option. This drug must be given for longer than 3 days.
• Fosfomycin (Monurol) is not as effective as other antibiotics but may be used during pregnancy. Resistance rates to this drug are very low.
• Other antibiotics may also be used, including amoxicillin (with or without clavulanate) and cephalosporins. Doxycycline is often effective but cannot be given to children or pregnant women.

After a week of antibiotic treatment, most patients are free of infection. If the symptoms do not clear up within the first few days of therapy, doctors generally suggest that women discontinue their antibiotic and provide a urine sample for culturing in order to identify the specific organism causing the condition.

Treatment for Relapsing Infection . A relapsing infection (caused by treatment failure) occurs within 3 weeks in about 10% of women. Relapse is treated similarly to a first infection, but the antibiotics are usually continued for 7 - 14 days. (Relapsing infections may be due to structural abnormalities, abscesses, or other problems that may require surgery, and such conditions should be ruled out.)

TREATMENT FOR RECURRENT INFECTIONS

Women who have two or more symptomatic UTIs within 6 months or three or more over the course of a year may need preventive antibiotics. A woman's own perception of discomfort can generally guide her decisions on whether or not to use preventive antibiotics. All women should use lifestyle measures to prevent recurrences.

Intermittent Self Treatment . Many, if not most, women with recurrent UTIs can effectively self-treat recurrent UTIs without going to a doctor. In general, this requires the following steps:

• As soon as the patient develops symptoms, she takes the antibiotic. Infections that occur less than twice a year are usually treated as if they were an initial attack, with single-dose or 3-day antibiotic regimens.
• In some cases, she also performs a clean-catch urine test before starting antibiotics and sends it to the doctor for culturing to confirm the infection.

A woman should consult a doctor under the following circumstances:

• If symptoms have not gone away within 48 hours
• If there is a change in symptoms
• If the patient suspects that she is pregnant
• If the patient has more than four infections a year

Women who are not good candidates for self-treatment are those with impaired immune systems, previous kidney infections, structural abnormalities of the urinary tract, or a history of infection with antibiotic-resistant bacteria.

Postcoital Antibiotics . If recurrent infections are clearly related to sexual activity and episodes recur more than two times within a 6-month period, a single preventive dose taken immediately after intercourse is effective. Antibiotics for such cases include TMP-SMX, nitrofurantoin, cephalexin, or a fluoroquinolone (such as ciprofloxacin). (Fluoroquinolones are not appropriate during pregnancy.)

Continuous Preventive Antibiotics (Prophylaxis) . Continuous preventive (prophylactic) antibiotics are an option for some women who do not respond to other measures. With this approach, low-dose antibiotics are taken continuously for 6 months or longer.

TREATMENT FOR KIDNEY INFECTIONS (PYELONEPHRITIS)

Patients with uncomplicated kidney infections (pyelonephritis) may be treated at home with oral antibiotics. Patients with moderate-to-severe acute kidney infection and those with severe symptoms or other complications may need to be hospitalized. In such cases, antibiotics are usually given intravenously for several days. Chronic pyelonephritis may require longterm antibiotic treatment.

TREATMENTS FOR SPECIFIC POPULATIONS

Treating Pregnant Women . Pregnant women should be screened for UTIs, since they are at high risk for UTIs and their complications. The antibiotics used during pregnancy include amoxicillin, ampicillin, nitrofurantoin, and cephalosporin. Fosfomycin (Monurol) is not as effective as others but may be used during pregnancy. Pregnant women should not take fluoroquinolones.

Pregnant women with asymptomatic bacteriuria (evidence of infection but no symptoms) have a 30% risk for acute pyelonephritis in their second or third trimester. They need screening and treatment for this condition. In such cases, they should be treated with a short course of antibiotics (3 - 5 days). For an uncomplicated UTI, pregnant women may need longer-term antibiotics (7 - 10 days).

Treating Children with UTIs . Children with UTIs are generally treated with TMP-SMX, cephalexin (Keflex) and other cephalosporins, amoxicillin,or amoxicillin/clavulanic acid (Augmentin). These drugs are usually taken by mouth in either liquid or pill form. Doctors sometimes give them as a shot or IV. Children usually respond to treatment within a few days.

Vesicoureteral reflux (VUR) is a concern for children with UTIs. (See "Risk Factors" section.) VUR can lead to kidney infection (pyelonephritis), which can cause kidney damage. The two treatment options for children with VUR are long-term antibiotics to prevent infections or surgery to correct the condition. However, there is debate as to the benefit of these approaches. Recent studies indicate that preventive treatment with antibiotics may not be much help for preventing recurrent urinary tract infections in children, and that VUR itself may not substantially increase the risk for recurrent UTIs.

Children with acute kidney infection are treated with oral cefixime (Suprax) or a short course (2 - 4 days) of an intravenous (IV) antibiotic (typically gentamicin, given in one daily dose). An oral antibiotic then follows the IV.

MANAGEMENT OF CATHETER-INDUCED URINARY TRACT INFECTIONS

Catheter-induced urinary tract infections are very common, and preventive measures are extremely important. Catheters should not be used unless absolutely necessary, and they should be removed as soon as possible. Reducing the risk for infections during long-term catheter use, however, remains problematic.

Intermittent Use of Catheters . If a catheter is required for long periods, it is best to use it intermittently if possible (as opposed to an indwelling catheter). Some doctors recommend replacing it every 2 weeks to reduce the risk of infection and irrigating the bladder with antibiotics between replacements.

Daily Hygiene . A typical catheter is one that has been preconnected and sealed and uses a drainage bag system. To prevent infection, some of the following tips may be helpful:

• Drink plenty of fluids, including 3 glasses of cranberry juice a day.
• The catheter tube should be free of any knots or kinks.
• Clean the catheter and the area around the urethra with soap and water daily and after each bowel movement. (Women should be sure to clean front to back.)
• Wash hands before touching the catheter or surrounding area.
• Never disconnect the catheter from the drainage bag without careful instructions from a health professional on strict methods for preventing infection.
• Keep the drainage bag off the floor.
• Stabilize the bag against the leg using tape or some other system.

Antibiotics for Catheter-Induced Infections . Patients using catheters who develop UTIs with symptoms should be treated for each episode with antibiotics and the catheter should be removed, if possible, or changed. A major problem in treating catheter-related UTIs is that the organisms involved are constantly changing. Because there are likely to be multiple species of bacteria, doctors generally recommend an antibiotic that is effective against a wide variety of microorganisms.

Although high bacteria counts in the urine (bacteriuria) occur in most catheterized patients, administering antibiotics to prevent a UTI is rarely recommended. Many catheterized patients do not develop symptomatic urinary tract infections even with high bacteria counts. If bacteriuria occurs without symptoms, antibiotic therapy has little benefit if the catheter is to remain in place for a long period.

Catheterization is accomplished by inserting a catheter (a hollow tube, often with an inflatable balloon tip) into the urinary bladder. This procedure is performed for urinary obstruction, following surgical procedures to the urethra, in unconscious patients (due to surgical anesthesia or coma), or for any other problem in which the bladder needs to be kept empty (decompressed) and urinary flow assured. Catheterization in males is slightly more difficult and uncomfortable than in females because of the longer urethra