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Urinary Tract Infection in Women - Complicated (1 of 13)

Urinary Tract Infection in Women - Complicated (1 of 13)

Urinary Tract Infection in Women - Complicated (1 of 13)

1 Patient presents w/ dysuria & urinary frequency

2 EVALUATION TREATMENT See UTI - Are there factors suggestive No of a potential complicated Uncomplicated disease (UTI)? management chart

Yes

3 DIAGNOSIS No ALTERNATIVE Is complicated UTI DIAGNOSIS confi rmed?

Yes

3 OBTAIN URINE CULTURE & SENSITIVITY

TREATMENT See nextMIMS page ©

B1 © MIMS 2020 UTI - COMPLICATED *Initiate parenteral therapy fi rst w/ single-dose (preferred), or an aminoglycoside then follow w/ a follow then aminoglycoside an or Ertapenem (preferred), Ceftriaxone fi therapy w/ single-dose rst parenteral *Initiate fl uoroquinolone allergy or intolerance, or if w/ unmodifi able drug interactions interactions w/ drug unmodifi if able or intolerance, or fl allergy uoroquinolone a has patient if w/ anon-fl agent >10% follow is or uoroquinolone fl resistance Ecoli local fl if uoroquinolone uoroquinolone A A culture &sensitivity culture on therapy based modify If available, • • • • • Any ofthefollowing: therapy Pharmacological known are results &sensitivity culture once Modify therapy appropriately • • • • the following: w/any therapy empiric of oral *Start uropathogens of patterns resistance local Consider therapy Pharmacological therapy) forinitial (ifnotused Quinolone inhibitor beta-lactamase / Antipseudomonal (3rd or4th generation) orquinolone Aminoglycoside plus Quinolone Co-trimoxazole Cephalosporin inhibitor /beta-lactamase No © Urinary Tract InfectioninWomen -Complicated(2of13) Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not beta-lactam beta-lactam Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing No PATIENT W/ COMPLICATED UTI HOSPITAL ADMISSION INDICATIONS FOR Should patient be Should patient be hospitalized? respond to respond therapy? patient

MIMS Does 4 B2 A B Follow-up culture & sensitivity results are known are results &sensitivity culture once Modify therapy appropriately • • • • • agents: IV following w/any therapy empiric ofthe Start uropathogens of patterns resistance local Consider therapy Pharmacological • • • Quinolone Quinolone (2ndor3rd generation) Cephalosporin Carbapenem inhibitor Aminopenicillin/beta-lactamase Aminoglycoside beta-lactam w/orwithout or metabolic abnormalities or metabolic anatomical, &correct functional Identify warranted investigation if genitourinary further Do analysis urine Repeat Yes Yes © MIMS 2020 UTI - COMPLICATED • • • Etiology • • • • • • • • • • • • • • • • • • • • • • • Factors that aPotential UTI: Suggest Complicated • • • • • &Symptoms Signs • • • Diabetes mellitus Ecoli mirabilis , patients: , P (DM) Diabetes - aeruginosa Short-term Pseudomonas Ecoli, (<1week): - UTI Catheter-associated - antibiotic-resistantlikely tobe  is much causing of complicated larger UTI than e spectrum that & more of uncomplicated UTI thanvirulent foundinuncomplicated those UTI that microbiology w/altered favors more antimicrobial-resistant strainsthat less Associated are sometimes therapy failing of acquiring orhaving recurrent infection, infections the risks which increases that interferesthe defense mechanisms, presence w/host ofanunderlying disease or tract(GUT)] w/acondition ofthe abnormalities genitourinary [eg orfunctional structural associated UTI Isolated extended-spectrum beta-lactamase (ESBL)-producing ormultidrug-resistant organisms (ESBL)-producing beta-lactamase extended-spectrum Isolated Foreign body Residence care extended inaninstitution providing Vesicoureteral refl abnormalities orother functional ux tractmodifiUrinary orpouch) cations (eg loop ileal toantibiotic therapy response duetofailed UTI Unresolved Renal insuffi &transplantationciency tractintervention orinstrumentation Recent urinary Recent antimicrobial use catheter ofintermittent oruse Presence ofanindwelling bladder catheterization urinary UTI Peri- &postoperative stricture, tumor) uropathy Obstructive stones, (eg calculi, bladder outlet obstruction, Incomplete bladder emptying urine w/>100mLofresidual Immunosuppression orhospital-acquired infection Healthcare-associated Pregnancy Elderly spinfection) Pseudomonas abuse, analgesic DM, (eg severe necrosis sickle cell topapillary disease, thatComorbidities predispose orradiationChemical injuries ofthe uroepithelium duetointrinsic renalAzotemia disease topresentation prior >7 days ofsymptoms Concomitant conditions (eg medical renal present DM, are failure) often post-operativeciated UTI to a catheter-asso- w/ imminent acute pyelonephritis urosepsis obstructive severe from Symptoms may vary vomiting temperature Hypotension, tender orintractable subcostal >40°C, & nausea May ofsepsis: present w/signs present not be urgency, frequency,Dysuria, fl may suprapubic ormay pain&fever ank pain,costovertebral angletenderness, present symptoms w/clinical notnecessarily does A complicated UTI Pmirabilis Paeruginosa, Kpneumoniae, Ecoli, Patients w/anatomic abnormalities: sp Candida aureus, Staphylococcus Paeruginosa, bacilliespecially Gram-negative patients: Neutropenic urealyticum sp,Acinetobacter sp,Serratia sp, Enterococci spp, Corynebacterium sp,Citrobacter Renal transplant Ecoli, patients: spp sp,Candida Enterococcus spp sp,Candida sp,EnterobacterCitrobacter sp, Enterococcus (>1 week): Long-term cultureurine coli, Escherichia Urinary Tract InfectioninWomen -Complicated(3of13) © , Proteus Proteus mirabilis, E coli, P aeruginosa, Providencia stuartii, Morganella morganii, stuartii, Providencia mirabilis, Paeruginosa, Ecoli, Proteus Klebsiella, P mirabilis P , Pseudomonas 1 COMPLICATED UTI 2 , K pneumoniae, MIMS EVALUATION B3 Serratia Serratia Gram-positive cocci,Enterobacter Gram-positive P aeruginosa, spp &enterococci are the usualstrainsfoundin , , aeruginosa P Enterobacter © MIMS 2020 sp, UTI - COMPLICATED • Signifi Bacteriuria cant • • Studies Diagnostic • History • • Pyuria • Diff Diagnosis erential • • Abnormality Further Work-up Functional Anatomical, orMetabolic &Correct toIdentify • • Urine Culture &Sensitivity • Urine Dipstick • • Outpatient • • • • • exist: any if ofthefollowing Consider hospitalization • Women: ≥10 age doneinwomen may ofreproductive test be A pregnancy therapyafter & during before, performed shouldbe testing culture urine w/microscopicUrine &sensitivity analysis exam, predispositions disease &other sickle cell associated hematuria, gross disease nephrolithiasis, Specifi &therapy, infections forthec questioning surgeries, presence orabsence urinary ofprior genitourinary Asymptomatic patients: 2 consecutive urine samples showing ≥10 samples showing urine 2consecutive patients: Asymptomatic catheter sample urine ≥10 WBC/mm the species samebacterial transmitted infections (STIs)] infections transmitted sexually cervicitis, & treat patientDiagnose vaginitis, appropriately states [eg urethritis, for other disease Cystoscopy foraconvenient ofthe urethra &the bladder inspection - defi ismore fornephrolithiasis, sensitive scan CT ning renal &suprarenal pathology - - - - - tract abnormalities &urinary stonedisease forhydronephrosis, undertaken toevaluate tractshouldbe oftheImaging urinary tofi studiesare indicated Radiologic nd the ofcomplicated cause UTI toavoid culture the urine If possible, emergence by therapy guided shouldbe ofresistant strains, once available become culture results re-evaluated ofantibiotic Selection shouldbe - removed patients the been catheter after Urine incatheterized has culture isobtained - tothe prior administration ofantibiotics obtained forculture shouldbe Urine specimen reaction hemoglobin &nitrite test, esterase For including routine leukocyte assessment patients incatheterized UTI forcatheter-associated isnotdiagnostic Pyuria Patients who do not meet the above categories may be considered may fortreatment be categories thePatients above onanoutpatient whodonotmeet basis debility ofsepsis Marked &signs pain &severe w/highfever illness Severe tractobstruction urinary suspected eg Uncertainty ofdiagnosis, Concerns patient regarding adherence totreatment Patient &unable tomaintain w/complicated oralhydration UTI ortakeoralmedications  of the illness the patient onthe tohospitalize severity depend edecision will abscesses &perirenal pyonephrosis forhydronephrosis, isanextremelyRenal toevaluate ultrasonography tool valuable the presence ofvesicoureteral reflux Voiding ofthe neurogenic bladder &urethral forevaluation &todetermine diverticulum, cystourethrogram obstruction images forradiographic ofthe pyelogram bladder,IV extent &ureters todetermine ofurinary kidneys patterns forabnormal calcifi toevaluate Plain useful may radiographs abdominal be renal contour cations, &gas 5 colony forming units (cfu)/mL in midstream urine (MSU) sample or>10 colony (MSU) (cfu)/mL urine inmidstream units forming 3 , though may not be present w/ an obstructed urinary collecting system urinary , though present may w/anobstructed notbe © Urinary Tract InfectioninWomen -Complicated(4of13) 4 INDICATIONS FOR HOSPITAL ADMISSION 3 MIMS DIAGNOSIS B4 5 cfu/mL taken at least 24 taken at least cfu/mL hours apartw/ 4 cfu/mL instraight cfu/mL © MIMS 2020 UTI - COMPLICATED • • (SMZ)&Trimethoprim [Sulfamethoxazole (TM)] Co-trimoxazole • • • • • • • • Inhibitor Penicillin w/Beta-lactamase Antipseudomonal • • Inhibitor w/Beta-lactamase Aminopenicillin • • • Aminoglycosides • • TreatmentEmpiric • • Parenteral versus Oral erapy • • General Principles erapy susceptibility is known isknown susceptibility  considered if be can countries use oughmost have its highrates ofEcoli resistance toCo-trimoxazole, contraindications orconcerns fl regarding use uoroquinolone inthe outpatient used May be treatment ofpatientsmultidrug-resistant whohave risk infection w/low anaphylaxis systemic noprevious there hadbeen provided topatients given hypersensitivity w/penicillin stillbe Can - ofinitialempiric therapy failure incase 3rd or4th generation used mayIV be cephalosporins patients initialempiric therapy as inhospitalized 2ndor3rd generation used mayIV be cephalosporins UTI 2ndor3rd generation appropriate mayOral 1st, be forpatients cephalosporins w/mild-moderate complicated & carbapenems includeAntipseudomonal , (eg infection Ertapenem) foramultidrug-resistant orinpatients factors Gram-negative w/risk tractobstruction, patients w/urinary Appropriate empiric parenteral toinitialantibiotic patients therapy, torespond therapy whofail inhospitalized resistantor inpatients toother tobe agents inwhomthe isknown bacteria Appropriate empiric parenteral therapy patients to initial antibiotic to respond who in fail hospitalized therapy ofinitialempiric offailure cases therapy orforsevere incase used May be - therapy alone areAminopenicillins no longer sufficiently active against Effi- sp) (eg microorganisms Bstreptococci &Enterococcus group inGram-positive cacious alone agents more these activethan tobe inhibitorcauses Synergistic actionw/beta-lactamase Eff resistant microorganisms several against ective - analternative therapy as initialtherapy as orreserved used may be agent, etiologic onsuspected Depending One ofthe treatments of choice ifparenteral therapy isneeded ofanyuse antimicrobial tothe lead emergence will ofresistant microorganisms w/ replaced specifiShould immediately be c treatment once culture in urine pathogen since intense is detected antimicrobial w/ESBL coverage regimen Use abroad-spectrum - cost cases, patient in themicroorganism community tolerance, effi susceptibilities, documented & its & in some cacy  ofaspecifi eselection presentation, clinical c antimicrobial orsuspected upon the agent known isbased - resistant organisms forwhich oraltherapy isnotavailable suspected by oraninfection absorption Initial parenteral therapy instability, whohave: onlyforindividuals ispreferred Hemodynamic N/V, questionable Oral antibiotic instable therapy patients started may be Patients generally w/complicated require 7-14days ofantimicrobial UTIs therapy measures &adequate life-supporting of the orother underlying abnormalities diseases  e successful treatment considers of acomplicated eff UTI antimicrobialective therapy, coverage (eg & ) coverage &Cefoperazone) (eg Ceftazidime antipseudomonal &has administered notpreviously was Ensure that used 3rd generation tobe cephalosporin forempiric therapy used may be antimicrobial incombination aminopenicillins resistance onlocal w/aminoglycosides patterns, Depending initialtherapy) as used coverage pseudomonal is w/orwithout (many anaminopenicillin times combined w/beta-lactam May be tolerate can oralmedications they toappropriate improvement clinical Patients oraltherapy switched may 72hoursifshowing within be &if

© Urinary Tract InfectioninWomen -Complicated(5of13) Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing A MIMS PHARMACOLOGICAL THERAPY B5 & therefore should not be used as empiric Ecoli &therefore as used should not be optimal management © MIMS 2020 UTI - COMPLICATED • • • • • Transplant Renal in UTI Complicated Patients • • • w/DM Associated UTI Complicated • • • Patients Cord-Injured Spinal in UTI Complicated • • • • Stones w/Urinary Associated UTI Complicated • • • • • Catheter w/Indwelling Associated UTI Complicated Specific  erapy • Agents Other • • Q uinolones - Low-dose Co-trimoxazole antibiotic prophylaxis has been recommended for6months recommended posttransplant been antibiotic has prophylaxis Co-trimoxazole Low-dose - w/ treated that the bacteriuria occurs during fiAsymptomatic rst 6 months to be transplantation after may need often 10-14 days ofantibiotic treatment cases inmost isrequired tocomplete results culture 4-6weeks by &sensitivity tooralagents guided shifted May be Initially, antibiotics negative treat until culture w/parenteral urine becomes broad-spectrum & are ofrenal appropriately forthe failure level dose-adjusted Eff antibiotic therapyective theofantibiotics requires that therapeutic use concentration achieve inthe urine - routinely treated w/antibiotics shouldnotbe indiabetics bacteriuria Asymptomatic &renal radiograph Failure plainabdominal 48-72hoursrequires ultrasound within torespond - hospitalized shouldbe ofsepsis &symptoms &signs patientsDM whopresent w/UTI 7-14 days ofantimicrobial therapy isrecommended treated shouldnotbe bacteriuria Asymptomatic  of1agent ere ofantimicrobials isnosuperiority orclass another over - w/antimicrobials treated should be ofinfection Symptomatic episodes of patients toUTI  this group (anatomic &bladder orphysiologic) epresence outlet obstruction urine ofresidual predisposes If complete accomplished, antibiotic ofthe be therapy removal stonecannot long-term considered may be using astent therelieve obstruction ornephrostomy isfrequently tube necessary Eff intervention butearly to considered toremove the cleared once stoneshouldonlybe has orts the infection infection immediately inpatients antimicrobials that started shouldbe have of signs clinical Empiric broad-spectrum expectantly treated may be of infection evidence without obstruction Urinary Topical tothe applied catheter, shouldnotbe antiseptics urethra ormeatus Antibiotic forpreventing catheter-related isnotrecommended prophylaxis UTI catheter,long-term except tractprocedures incertain situations totraumatic prior eg urinary re treated shouldnotbe bacteriuria Asymptomatic days Replace orremove indwelling inplace antibiotics catheter ifindwelling >7 starting before been catheter has results onculture &sensitivity antibiotic based the removing catheterby &w/administration ofanarrow-spectrum in patientsSymptomatic occurring w/ a short-term indwelling complicated treated catheter should be UTIs , Plazomicin, Meropenem/, &parenteral Cefi Ceftazidime/, include Ceftolozane/, infections derocol, w/ Imipenem/cilastatin ofhighlyresistant Alternative agents formultidrug-resistant that cases organisms orselect used may be resistance is<10%&patient contraindications has foranaminoglycoside ora3rd generation cephalosporin Consider empiric treatment w/Ciprofl oxacin inwomen w/complicated iffl pyelonephritis uoroquinolone cases forsevere used may quinolones be IV - are Oralquinolones appropriate initialempiric therapy as inpatients w/mild-moderate complicated UTIs - anaphylactic beta-lactam reaction previous ifthe patient 6months, safelyin the ill&can last takeoraltherapy, isnotseverely orifthe patient hada has ofresistance, tohighlevels flDue used empiric treatment as notbeen ifithas used onlybe can uoroquinolones starting antibiotic bacteriuria starting treatment w/asymptomatic fordiabetics &other concomitant offebrile UTI considered on conditionsA history when tobe deciding are factors

© Urinary Tract InfectioninWomen -Complicated(6of13) Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not A Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing MIMS PHARMACOLOGICAL THERAPY (CONT’D) B6 gardless whether ornotthegardless patient short-term or has © MIMS 2020 UTI - COMPLICATED • • • • • • Women Pregnant in UTI Specific  (Cont’d) erapy • • • • - Most pregnant women will need hospitalization &parenteral hospitalization antibiotics need pregnant women will Most - w/caution aminoglycosides used may be are mainstays; inhibitor&cephalosporins abeta-lactamase w/orwithout aminopenicillins For pyelonephritis, are &Nitrofurantoin recommended cephalosporins , For cystitis, prenatal visits culture subsequent urine during torepeat culture 1st prenatalIf urine it is unnecessary during is negative, visit culture urine at prenatal each Repeat until visit delivery - culture urine completing 7-14days after Repeat antibiotic treatment Treat w/antibiotics bacteriuria symptomatic&asymptomatic both - confi Ifpositive, throughrm a2ndculture - culture treatment forurine starting before Obtainspecimen - ofgestation at ideally 16weeks prenatal visit, through bacteriuria aquantitative forasymptomatic culture urine at screened fiPregnant women shouldbe rst women is signifi topyelonephritis bacteriuria & asymptomatic of cystitis Progression inpregnant cantly increased Further follow-up to identify & correct anatomical, functional or metabolic abnormalities as indicated as abnormalities ormetabolic anatomical, &correct functional toidentify Further follow-up therapy after recurrence Early ofinfection - toappropriate orincomplete Delayed antimicrobial response therapy - of: madeincases Further investigation shouldbe genitourinary done completing 1-2 culture after may be A urine therapy obtained indicated also clinically weeks &thereafter as toensurePerform analysis that urine causative eradicated agent been has

© Urinary Tract InfectioninWomen -Complicated(7of13) Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not A Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing PHARMACOLOGICAL THERAPY (CONT’D) B MIMS FOLLOW-UP B7 © MIMS 2020 UTI - COMPLICATED Bekanamycin 400-600 mg/day IM divided 400-600mg/day IMdivided Bekanamycin (TM)] Trimethoprim & (SMZ) xazole [Sulfametho- Co-trimoxazole 4-6mg/kg/day IM/IV Sisomicin 15mg/kg/day IM/IV Netilmicin 3-5mg/kg/day IM/IV Kanamycin Gentamicin Amikacin All dosage recommendations are for non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults non-elderly for are recommendations dosage All Drug Drug Products listed above may not be mentioned in the disease management chart but have been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed Urinary Tract InfectioninWomen -Complicated(8of13)

© 12hrly IV 800 mgSMZ/160TM or 12hrly PO 800 mgSMZ/160TM 12 hrly divided 2 mg/kg/day IM/IV 24 hrly 8hrly,divided 12hrly, or 1.5g/day dose: Max 8-12hrly divided 8-12hrly divided 8-12 hrly 1.5g/day dose: Max 12hrly 250 mgIM/IV 8-12hrly or divided 15 mg/kg/day IM/IV Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Dosage Dosage ANTIBACTERIAL COMBINATION Dosage Guidelines AMINOGLYCOSIDES • • • • • Instruction Special MIMS• • Reactions Adverse • Instructions Special • Reactions Adverse B8 cochlear impairment or vestibular patients renal dysfunction, w/preexisting Parkinson’s), (egmuscle myasthenia weakness gravis, w/ Use w/caution inpatients w/conditions associated defi (may considerciency administration ofFolinic acid) &w/ caution inpatients w/folate hepatic dysfunction Use w/ caution inpatients w/renal impairment orsevere anemia duetofolicaciddeficiency megaloblastic disorders especially hematological Use w/ extreme caution ornotat allinpatients w/ inpatientsContraindicated allergic tosulfonamides Maintain adequate fluid intake eff renal effects, occurred has meningitis aseptic ects; rarely hepatic orw/highdoses; forlongperiods if given Rarely hematologic eff which more may common be ects syndrome); (eg Stevens-Johnson to severe/life-threatening glossitis); diarrhea/colitis, antibiotic-associated GI eff (N/V, ects rarely diarrhea, anorexia, concentrations ofserum Consider monitoring &/or - otherreceived ototoxic/nephrotoxic drugs receiving orhave orwhoare also or forlongperiods impairment, inpatients whoare receiving highdoses w/renal dehydrated those geriatric, patients, &nephrotoxicity likely areOtotoxicity most in reactions Hypersensitivity & muscular paralysis); depression inresp resulting (neuromuscular blockade N administered); been also usuallywhen have other nephrotoxic drugs reported nephrotoxicity,(reversible been acuterenal has failure vertigo); R dizziness, loss, hearing effOtotoxic ototoxicity in resulting (irreversible ects H D ermatologic effermatologic photosensitivity); pruritus, (rash, ects ypersensitivity reactions can range from mild (eg rash) range mild(eg from can reactions rash) ypersensitivity concentration ratio patients inthese (MIC) concentrations/minimum serum peak inhibitory U rogenital eff inthe urine) (crystallization ect Remarks Remarks euromuscular eff ects enal eff ects © MIMS 2020 UTI - COMPLICATED Ceftriaxone 1-2 g IM/IV 24hrly 1-2gIM/IV divided 500mg-2g/day IM/IV 24hrly 400mgPO Ceftriaxone 12hrly 250mg-1gIM/IV 12hrly 100mgPO Ceftazidime 8-12hrly 1-2gIM/IV 12hrly 1-2gIM/IV 8hrly or 100mgPO Cefoperazone Cefi xime 12hrly or 125-250mgPO  Generation ird 8hrly 1gIM/IV Generation Second (Cephradine) 12hrly 24hrly ordivided 1-2gPO (Cephalexin) First Generation All dosage recommendations are for non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults non-elderly for are recommendations dosage All Drug Products listed above may not be mentioned in the disease management chart but have been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed Urinary Tract InfectioninWomen -Complicated(9of13)

© 4g/day dose: Max 6-12 hrly 12g/day dose: Max 16g/day dose: Max 24hrly 400-500 mgPO 12hrly 200 mgPO 24hrly 600 mgPO 12hrly or 300 mgPO 6-8hrly 750 mg-1.5gIM/IV 8-12hrly 1 gIM/IV 6-12hrly divided 0.5-2 g/day IM/IV 4g/day dose: Max 24hrly 500 mgPO 12hrly or 375 mgPO 8hrly or 250-500 mgPO 4g/day dose: Max 6hrly 500 mgIM/IV or 12hrly 6hrly or1gPO 500 mgPO 12hrly 1 gIV 6-12hrly divided 1-2 g/day PO Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Dosage Dosage Guidelines MIMS CEPHALOSPORINS B9 • • Instructions Special • • • • Reactions Adverse impairment &renal orother penicillins drugs tocephalosporins, reactions hypersensitivity Use w/caution inpatients w/non-severe distress gastric todecrease taken w/food May be chain-containing cephalosporins N-methylthiotetrazole side (NMTT) frequently& occur most w/ reported have been bleeding) (w/ orwithout &/orhypoprothrombinemia time (APTT), thromboplastin partial activated prolonged prothrombinProlonged time(PT), have occurred hematologic eff hepatic &renal effects; ects eff (encephalopathy,ects convulsions); rarely w/CNS associated may be High doses or inflammation pain&/ including reactions phlebitis, Local ALT/AST) increased dizziness, Other eff headache, (candidal infections, ects diarrhea/colitis); rarely antibiotic-associated GIeffanaphylaxis); N/V, (diarrhea, ects eg reactions severe rash, pruritus, (urticaria, reactions Hypersensitivity Remarks © MIMS 2020 UTI - COMPLICATED 1 Combination w/ Arginine is available. Please see the forspecifi latest MIMS see Combination w/Arginine isavailable. Please information. c prescribing sulbactam Ceftriaxone/ tazobactam Ceftolozane/ divided 2-4g/day IM/IV avibactam Ceftazidime/ Cefoperazone/sulbactam tazobactam / Inhibitors w/β-lactamase Cephalosporins /sulbactam) (: of Pro-drug Ampicillin/sulbactam Ampicillin /sulbactam Co-amoxiclav) (Amoxicillin/clavulanate, 12hrly divided 1500-2000mg/day PO Amoxicillin/ Amoxicillin (Amoxycillin) Inhibitors β-Lactamase w/orwithout Aminopenicillins Cefepime Fourth Generation All dosage recommendations are for non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults non-elderly for are recommendations dosage All 1 Drug Drug Products listed above may not be mentioned in the disease management chart but have been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed © Urinary Tract InfectioninWomen -Complicated(10of13) Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Max dose: 4g/day dose: Max 12hrly doses divided equally 24hrly orin 1-2 gIM/IV 8 hrly for 7days infusion 1.5 gfor1-hrIV bacteremia) 14 days inpatients w/ 8 hrly for 5-10days (upto 120min of 100mLover inavol infusion 2.5 gIV 12 hrly (1:1 ratio) 12 hrly for 10days 2gIV infection: Severe IM 12hrly for7-10days 500mg-1gIV/ infection: tomoderate Mild 12hrly 1-2 gIV 1.5-3 g IM/IV 6-8hrly 1.5-3 gIM/IV 12hrly or 375-750 mgPO 4-6hrly 500 mg-1gIM/IV 6-8hrly or 250-500 mgPO 8 gAmoxicillin 24hrly 4gSulbactam/ dose: Max infections in severe upto150mg/kg/day increased May be 8hrly infusion IM/IV/IV 1.5-3gdeep Inj TabFC 8hrly 500mgPO 12 hrly 8hrly or625mg-1gPO 375-625 mgPO 2 g IM/IV 12hrly 2 gIM/IV CEPHALOSPORINS (CONT’D) Dosage Guidelines Dosage PENICILLINS Dosage

B10 MIMS • • Instructions Special • • • • Reactions Adverse penicillins or other drugs &renal orother impairmentpenicillins drugs tocephalosporins, reactions hypersensitivity Use w/caution inpatients w/non-severe distress gastric todecrease taken w/food May be chain-containing cephalosporins frequentlyoccur most side w/NMTT & reported have been bleeding) without PT, &/orhypoprothrombinemia (w/or APTT have occurred hematologic eff &renalHepatic effects; ects (encephalopathy, convulsions);Rarely eff w/CNS associated may be High doses ects inflammation pain&/or including reactions phlebitis, Local ALT/AST) increased dizziness, eff headache, (candidal infections, ects diarrhea/colitis); Other antibiotic-associated occur); GIeff N/V, (diarrhea, ects rarely can anaphylaxis eg reactions severe rash, pruritus, (urticaria, reactions Hypersensitivity • • Instructions Special • • Reactions Adverse renal impairment Use w/caution inpatients w/ allergy Avoid inpatients w/Penicillin (encephalopathy, convulsions) eff w/CNS associated ects may be doses High occurred; Rarely hematologic eff ects; infections) colitis); effOther (candidalect diarrhea/ antibiotic-associated N/V,(diarrhea, rarely occur); GIeffcan ects anaphylaxis eg reactions severe pruritus, urticaria, (rash, reactions Hypersensitivity Renal &hepatic eff have ects Remarks Remarks © MIMS 2020 UTI - COMPLICATED Sitafl oxacin hydrate 50 mg PO 12hrly x7-14days 50mgPO Sitafloxacin hydrate Rufl oxacin Prulifl oxacin acid Pipemidic Pefl oxacin Ofl oxacin Norfl oxacin Lomefl oxacin Levofl oxacin Ciprofl oxacin Penicillin Other (/clavulanate) 6-8hrly 2.25-4.5gIM/IV Ticarcillin/clavulanic acid /tazobactam Inhibitors Penicillins w/β-Lactamase Antipseudomonal All dosage recommendations are for non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults non-elderly for are recommendations dosage All Drug Drug Products listed above may not be mentioned in the disease management chart but have been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed © Urinary Tract InfectioninWomen -Complicated(11of13) Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing 100 mg PO 12hrly 100mgPO dose: Max 24hrly x5days 200mgPO by x1day followed 400 mgPO 24hrly 600 mgPO 12hrly 400 mgPO 12hrly 8 mg/kg/day IV 12hrly 200-400 mgIV 12hrly or divided 24hrly or 200-400 mgPO 12hrly 400 mgPO 24hrly 400 mgPO 24hrly x5days IV slow or x 10days or750mgPO 24hrly IV orslow 250 mgPO 24hrly 500-1000 mgPO Extended-release: 12hrly 100-400 mgIV 12hrly or 250-750 mgPO 6-12hrly divided 2-4 gIM/IV 4-6hrly 3.2 gIM/IV PENICILLINS (CONT’D) Dosage Guidelines Dosage Dosage QUINOLONES

B11 MIMS • • • Instructions Special • • • Reactions Adverse • • Instructions Special • • Reactions Adverse those w/G6PDdefithose ciency impaired &in renal orhepatic function inpatients w/ disorders, ofCNS history or Use w/ caution inpatients w/epilepsy tanning beds Avoid tostrong sunlight exposure or buff preparations Didanosine ered orFesupplements containing or Zn Al- orMg-containing dietary antacids, or3hrafter 2hr before Administer at least prolong the QT interval have quinolones Some the potential to s t c ff e e Rarely hematologic eff hepatic &renal ects; syndrome) life-threatening (eg Stevens-Johnson range mild(eg tosevere/ from can rash) reactions Hypersensitivity photosensitivity); effDermatologic pruritus, (rash, ects drowsiness); restlessness, disorders, eff sleep dizziness, (headache, ects diarrhea/colitis); CNS antibiotic-associated rarely diarrhea, dyspepsia, GI eff (N/V,ects pain, abdominal diarrhea, impairment Use w/caution inpatients w/renal Avoid in patients w/Penicillin allergy convulsions) eff w/CNS associated (encephalopathy,ects eff may be doses High have occurred; ects Rarely hematologic effRenal &hepatic ects; diarrhea/colitis); antibiotic-associated occur); GIeffcan N/V, (diarrhea, ects rarely anaphylaxis eg reactions severe pruritus, urticaria, (rash, reactions Hypersensitivity Other effOther (candidal ect infections) Remarks Remarks © MIMS 2020 UTI - COMPLICATED Nitrofurantoin 50-100 mg PO 6hrly 50-100mgPO Nitrofurantoin Nitrofuran 12hrly or 100mgPO Trimethoprim Diaminopyrimidine All dosage recommendations are for non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults non-elderly for are recommendations dosage All Drug Products listed above may not be mentioned in the disease management chart but have been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed © Urinary Tract InfectioninWomen -Complicated(12of13) 100 mg PO 12hrly 100 mgPO Extended-release: 24hrly 200-300 mgPO Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Dosage Dosage Guidelines OTHER ANTIBIOTICS

B12 MIMS • • • Instructions Special • Reactions Adverse • • Instructions Special • • Reactions Adverse Withdraw neuropathy ofperipheral ifsigns - neuropathyperipheral Bdefivit to which may predispose ciency) imbalance, electrolyte debility DM, or anemia, allergic w/conditions disorders &inthose (eg or pulmonary, neurological preexisting hepatic, Use w/ caution inthe elderly &inpatients w/ w/ G6PDdeficiency Avoid inpatients w/renal impairment, patients Maintain adequate hydration (2-3 L/day of - Take GIeff todecrease w/food ects optic neuritis) effOcular weakness); nystagmus, (amblyopia, ects paresthesia, numbness, (arthralgia, have occurred eff ects; Hematologic fiincluding pulmonary brosis); have reactions occurred sensitivity pulmonary pancreatitis); eff Resp dermatitis, (acute ect exfoliative syndrome, Stevens-Johnson angioedema, (rash, reactions Hypersensitivity polyneuropathy); peripheral rarely irreversible eff headache, fatigue, drowsiness, (dizziness, ects rarely C diffi diarrhea/colitis); CNS cile-associated GI (N/V, anorexia, pain,diarrhea, abdominal administration ofFolinic acid) patients w/folate defi (may considerciency &w/caution in hepatic dysfunction or severe Use w/caution inpatients w/renal impairment anemia duetoFolicmegaloblastic aciddeficiency disorders especially w/ hematological Use w/extreme caution ornotat allinpatients eff BUN &Cr) (increased ects metabolism); oftimeduetointerference long periods offolicacid or inhighdoses occur ifgiven can hematopoiesis effHematologic occurred); (depression of ect eff CNS necrolysis; has meningitis (aseptic ect toxic epidermal syndrome, Stevens-Johnson Rarely, multiforme, exfoliative dermatitis, erythema glossitis) distress, epigastric GIeff occurred); has photosensitivity (N/V,ects effDermatologic pruritus, (rash, ects develop fl fl torestrict instructed uids) unless uid intake Hepatic effHepatic effNeuromuscular ects; ects H epatic eff R rarely occur; ects Remarks enal enal © MIMS 2020 UTI - COMPLICATED tartaric acid tartaric acid/ citric Na citrate/ Na bicarbonate/ Carbapenems Aztreonam Meropenem cilastatin Imipenem/ Ertapenem Doripenem All dosage recommendations are for non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults non-elderly for are recommendations dosage All Drug Drug OTHER DRUGS ACTING ON THE GENITO-URINARY SYSTEM OTHER DRUGSACTINGONTHEGENITO-URINARY Products listed above may not be mentioned in the disease management chart but have been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed © Urinary Tract InfectioninWomen -Complicated(13of13) 5 days therapy: of duration Max 6-8 hrly water then takePO 4-8g in coldDissolve alkalinization: Urinary Max dose: 1.2g/day dose: Max 12 hrly divided infusion drip 1.2 g/day IV min 20-60 over infusion 3-5minorIV over inj IV IM inj, slow 0.5-1 g8-12hrly deep 8hrly 500 mg-1gIV 6hrly 500 mgIV 24hrly 1 gIM/IV 8hrly 500 mgIV Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Please see the end of this section for the reference list. reference the for section this of end the see Please Dosage Dosage OTHER BETA-LACTAMS Dosage Guidelines • Instructions Special • • Reactions Adverse • Instructions Special • Reactions Adverse • • Instructions Special • Reactions Adverse renal impairment & CNS disorders (egrenal impairment epilepsy) &CNS &inpatients orother w/ beta-lactams cephalosporins Use w/caution inpatients allergic topenicillins, rarely hepatic effects etc); syndrome, Stevens-Johnson exfoliative dermatitis, (eg reactions dermatologic rarely severe dysfunction); &/orrenal lesions ofCNS inpatients w/history especially &convulsions reported Seizures havecilastatin: been effCNS (mental Imipenem/ confusion; disturbances, ects infections) Other eff (eg occur; can anaphylaxis) severe (candidalect mild(eg to from rash) ranging reactions hypersensitivity discoloration, taste); tongue/tooth altered colitis, GI eff N/V, (diarrhea, ects diarrhea/ antibiotic-associated hypersensitivity, renal &hepatic impairment ofbeta-lactam Use w/caution inpatients w/history pruritus) site,skinrash, at reactions infusion local Other effliver enzymes); prolongation, &PTT (PT ects Hepatic effbleeding); increased (jaundice,ects hepatitis, GI eff (N/V, GI ects colitis, pseudomembranous diarrhea, alkalinizers &quinolonealkalinizers antibiotics concomitanthippurate therapy; ofurinary use conjunction mandelate w/hexamine orhexamine Avoid inpatients in w/renal orhypernatremia; failure &preeclampsia edema pulmonary & HTN,failure, peripheral impaired renal function, w/cardiac Use w/ caution inpatients Nadiet, onlow hypernatremia) alkalosis/ GI eff Other eff (mildlaxative); ect (systemic ects

B13 MIMS Remarks Remarks © MIMS 2020

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