pharmacotherapy of uti and std
DESCRIPTION
Dr.U.P.Rathnakarhttp://www.pharmacologyfordummies.blogspot.com/TRANSCRIPT
ANDSexually Transmitted Diseases
Sexually Transmitted Diseases
• “Disease transmitted most commonly and efficiently by sexual contact”
• Organisms easily inactivated• Suited to transmission by contact
of mucus membrane• Organisms: Bacteria, spirochetes,
chlamydia, viruses, protozoa, fungus
Diseases
• Gonorrhea• Syphilis• Chancroid• L.G.V• Granuloma ingiunale• Hepes virus,HIV, T.vaginitis• Scabies, louse, bacterial vaginosis• Shigellosis, hepatitis A,B,C,
cryptosporidiosis, salmonosis, etc.
SyphilisSyphilis
Primary Syphilis
Seconda-ry syphilis
Benzathine pen.2.4 M.U/i.m ORDox 100mg BD x 2 weeks ORT.C. 500 mg. QID x 2weeks ORCeftriaxone 1g.od im/iv x 10d ORAzithromycin 2 g.oral single dose
Same as above
Syphilis contdSyphilis contd…..…..LatentSyphilis
TertiarySyphilis
Neurosyphilis
•Benzathine pen. 2.4 MU x once a week x 3 weeks OR•Dox.100 mg.BID x 4 weeks OR•T.C. 500mg.BID x 4 weeks OR
Same as above
•Pen G 4 MU iv x 4h x 10-14 days OR•Pro pen.2.4MU.im OD x 10-14 days+ probenecid 500mg.QIDx10-14 days or•Ceftriaxone 2 g.im x 10-14 days
GonorrheaGonorrhea
Gonorrhea(Uncomp.)
Gonorrhea(Comp.)Salphingitis,Prostatitis, arthritis
•Ceftriaxone 125mg. Im single•Cefpodoxime 400 mg.oral single•Spectinomycin 1g. Im single dose
•Pen G 10MU iv daily x 5 days OR•Ceftriaxone 1 g. iv daily x 5 days•Cipro 500mg.BID x 5 days
Chancroid.,G.I.,L.G.VChancroid.,G.I.,L.G.V
Chancroid
G.I
LGV
•Azithromycin 1 g. oral single dose•OR Ceftriaxone 250 im single•OR Amox/Clav.500mg.TIDx7days•E.mycin 500mg.qidx7 days•OR Cipro 500mg OD x 3 days•E.mycin or T.C. 500mg.QID.3 weeks•Amp. 500mg.QIDx12 weeks•Dox. 100mg. BIDx3 weeks•E.Mycin 500mg.QIDx3weeks (pregnancy)
Urinary Tract InfectionsUrinary Tract Infections
• Classification• Risk factors• Patho-physiology• Host defenses• Organisms• Drugs• Pharmacotherapy• Chemoprophylaxis
Classification:• Urethritis. Cystitis. Pyelonephritis.
Prostatitis. Epidydymitis.
• Upper UTI and Lower UTI
Classification contd….Classification contd….
• Uncomplicated- Previously healthy, Lower risk of failure, Lower risk of complications
• Complicated: Metabolic, Functional, Structural abnormalities
Risk FactorsRisk Factors
• Children…Congenital anomalies• Healthy women..Sexual activity,
Barrier methods, AMA• Healthy men…Instrumentation,
Lack of circumcission, Anal intercourse,
• Elderly…Ut.prolapse, EP, DM, Bowel incont.
• All ages.. Catheter, Stone,Tumor, Stricture, CRF,Transplantation
Patho-PhysioPatho-Physio(Ascending-Descending)(Ascending-Descending)
•Ascending-Bowel…Perinium…Introitus…Vagina…Bladder…Host defence vs Virulence …Mucosal invasion …. Pyelonephritis
•Descending: Only 3%
Host DefenseHost Defense
• Mechanical not immunological-Neurogenic bladder, EP, Pregnancy.
• Antibact. sub in bladder• Prostate secretion• Dilute urine and Ph
• Immune system has no role in prevention. No higher incidence in immunocompromised. But severe
OrganismsOrganisms
G(-)ve…95%E.Coli (Uropathogen!)..80%Staphy SaprophyticusCoag.neg.StaphKlebsiellaProteusPseudomonasEnterococciEntero bacterCandida
DrugsDrugs• Bacteriostatic: Sulfanomides, T.C.• Bacteriocidal:
* Co-Trimox * Extended spectrum
penicillins * Aminoglycosides * Fluoroquinolones * Cephalosporins * Monobactams * Imipenem+Cilastatin * Teicoplanin
Drugs
• Urinary Antiseptics: NItrofurantoin Methenamine
Nalidixic acid
• Urinary Anaelgesics: Phenazopyridine
Urinary AntisepticsUrinary Antiseptics
•Toxic drugs•Produce adequate conc. in
urine•Not for systemic use•Only UTI( Local use)
NitrofurantoinNitrofurantoin
• Spectrum - Bacteriostatic, E.coli.• MOA: Nitrofurantoin reduced to
toxic sub-damages DNA• PK: Rapid absorption, 40% excreted
unchanged in urine• Colours urine brown• Ph less than 5.5• Antagonizes Nalidixic acid
Nitrofurantoin contd….Nitrofurantoin contd….
ADE:• GIT symptoms-Macrocrystalline prep.
Well tolerated• Hypersensitivity-Chills, rigors,
leukopenia, cholestatic jaundice,Hepatic damage
• Hemolysis(G6PD def)• Pneumonitis, Pulm.fibrosis• Neuropathy
Nitrofurantoin contd….Nitrofurantoin contd….
Uses:• Not routinely used• Dose-50-100 mg qid• Chemoprophylaxis( Recurrent
infection)
C.I.: Not more than 14 daysImpaired renal functionChildren<1 yr.
MethenamineMethenamine
Spectrum: All organisms, No resistanceMOA:• Breaks down in water in acidic Ph to
formaldehyde
• NH4(CH²)6+6H²O+4H+=4NH4+6HCHO
• Proteus raise Ph (Urea splitting)• Organism do not develop resistance• Methenamine+ Mandelic(Ascorbic,
Hippuric) acid , enteric coated tab.
MethenamineMethenamine
ADE:• GIT• Albuminurea, Hematuria• C.I. in renal insufficiency• False +ve test for catecholamine
metabolites Uses:• Not routinely used, only in resistant
infections
PhenazopyridinePhenazopyridine
• An azo dye• Not antiseptic• Urinary analgesic• Reduces-Dysurea,frequency,
burning,urgency• ADE: GIT, methemoglobinemia• Dose: 200mg tid
Nalidixic acid
PharmacotherapyPharmacotherapy
• Bactericidal• High sustained conc in tissues and
urine• Should eliminate pathogens from
vagina, bowel. Normal flora should not be affected
• Orally effective• Minimal ADE• Low cost
Treatment goalsTreatment goals• Microbiological cure• Clinical cure• Prevent morbidity and mortality• Pt compliance• Prevent recurrence and relapse.• Minimum secondary infection
Uncomplicated (women)
CystitisComplicated
• AcuteMild,Mod
UncomplicatedSevere
PyelonephritisMild,Mod
ComplicatedSevere
• Chronic
Condition Empirical Tt
AcuteUncomplicated cystitis in women
3 day regimenOral TMP-SMX,TMP,Quinolones
7 day regimenMacrocrystallineNitrofurantoin
Condition Circumstances Empirical Tt
Acute cystitiscomplicated
Men, Failure of 3 d. regimen, Children, Renal disease,DM
7 DayOral TMP-SMX, Quinolone
Pregnancy
7 day-Oral Amox., Nitro.,Cephalosporin,TMP-SMX
Condition Circumstance Empirical Tt
Acute uncomplicated pyelonephritis
•Mild-mod. illness•No nausea, vomiting•O.P.D.
•Oral quinolone7-14DOR•Single dose Ceftriaxone(1G)or•GM(3-5mg/kg)i.v
Followed by
•TMP-SMX 14 D
ConditionCircumstances
Empirical Tt
Acute uncomplicated pyelonephritis
Sever illness I.P
•Parenteral quinolone, GM,Ceftriaxone, Aztreonam, until defervescence•Followed byOral quinolone, cephalosporin or TMP-SMX for 14 Days
Condition Circumstances Empirical Tt
Complicated pyelo.acute(Catheterization, Urologic abnormalities, stones,Immunosuppre-ssion,Renal disease,DM)
Mild,ModerateOral quinolone 10-14 days
Sever
Parenteral amp., GM, quinolone, ceftriaxone, aztreonam, ticarcillin, imipenem
↓Oral quinolone or TMP/SMX 10-21D
Chronic PyelonephritisChronic Pyelonephritis
•Obstruction eliminated•If not possible
Long term therapy ( Indefinite) with TMP-SMX, TPM, Nitrofurantoin.
ChemoprophylaxisChemoprophylaxis
• Recurrence of uncomplicated cystitis, uncorrectable ab., inoperable EP, chronic indwelling catheter(Amp,TMP-SMX, Nitro)
• Infants-VUR• Post coital prophy: > than 3 per year
--Voiding after sex.intercourse--Cranberry juice or--Cipro 125mg single dose, or--TMP-SMX40/200, or--Cephelexin 250mg, or--Nitrofurantoin 50 mg. or
Asymptomatic BacteriuriaAsymptomatic Bacteriuria
• Elderly or with catheter- no Tt.• Pregnancy, neurotropic pts., recent
renal transplantation, young children- Require Tt.
• Sulfa, Betalactams, Nitrofurantoin.
Drug DosageDrug Dosage
• Cystitis: TMP-SMZ-160/800 mg.BID TMP 100mg. BID Cipro.-250mg. QID Nitrofurantoin- 100mg.QID Amox-250mg. TID Cefpodoxime proxetil-100mg.QID
Pyelonephritis: TMP-SMX-As above Cipro- 500mg.BID Cefpodoxime proxetil-200mg BID
ParenteralCipro 200-400mg.BIDGM-1mg/kg TIDAmpicillin-1g qidImipenem/cilastat-in-500mgTIDAztreonam-1g bid