Pharmacotherapy Of Uti And Std

AND Sexually 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.

Syphilis Primary Syphilis

Seconda -ry syphilis

Benzathine pen.2.4 M.U/i.m OR Dox 100mg BD x 2 weeks OR T.C. 500 mg. QID x 2weeks OR Ceftriaxone 1g.od im/iv x 10d OR Azithromycin 2 g.oral single dose

Same as above

Syphilis contd….. Latent •Benzathine pen. 2.4 MU x once a OR Syphilis week x 3 weeks •Dox.100 mg.BID x 4 weeks OR •T.C. 500mg.BID x 4 weeks OR Tertiary Syphilis

Same as above

Neuro •Pen G 4 MU iv x 4h x 10-14 days OR syphilis •Pro pen.2.4MU.im OD x 10-14 days+ probenecid 500mg.QIDx10-14 days or •Ceftriaxone 2 g.im x 10-14 days

Gonorrhea Gonorrhea •Ceftriaxone 125mg. Im single (Uncomp.) •Cefpodoxime 400 mg.oral single •Spectinomycin 1g. Im single dose Gonorrhea •Pen G 10MU iv daily x 5 days OR (Comp.) Salphingitis, •Ceftriaxone 1 g. iv daily x 5 days Prostatitis, •Cipro 500mg.BID x 5 days arthritis

Chancroid.,G.I.,L.G.V Chancroid •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 G.I •E.mycin or T.C. 500mg.QID.3 weeks •Amp. 500mg.QIDx12 weeks •Dox. 100mg. BIDx3 weeks •E.Mycin 500mg.QIDx3weeks LGV (pregnancy)

Urinary 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…. • UncomplicatedPreviously healthy, Lower risk of failure, Lower risk of complications

• Complicated: Metabolic, Functional, Structural abnormalities

Risk 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-Physio (Ascending-Descending)

• Ascending-Bowel…Perinium… Introitus…Vagina…Bladder…Host defence vs Virulence …Mucosal invasion …. Pyelonephritis

• Descending: Only 3%

Host Defense

• Mechanical not immunologicalNeurogenic 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

Organisms G(-)ve…95% E.Coli (Uropathogen!)..80% Staphy Saprophyticus Coag.neg.Staph Klebsiella Proteus Pseudomonas Enterococci Entero bacter Candida

Drugs • 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 Antiseptics

• Toxic drugs • Produce adequate conc. in urine • Not for systemic use • Only UTI( Local use)

Nitrofurantoin

• 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….

ADE: • GIT symptoms-Macrocrystalline prep. Well tolerated • Hypersensitivity-Chills, rigors, leukopenia, cholestatic jaundice,Hepatic damage • Hemolysis(G6PD def) • Pneumonitis, Pulm.fibrosis • Neuropathy

Nitrofurantoin contd….

Uses: • Not routinely used • Dose-50-100 mg qid • Chemoprophylaxis( Recurrent infection) C.I.: Not more than 14 days Impaired renal function Children<1 yr.

Methenamine

Spectrum: All organisms, No resistance MOA: • 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.

Methenamine ADE: • GIT • Albuminurea, Hematuria • C.I. in renal insufficiency • False +ve test for catecholamine metabolites Uses: • Not routinely used, only in resistant infections

Phenazopyridine

• An azo dye • Not antiseptic • Urinary analgesic • Reduces-Dysurea,frequency, burning,urgency • ADE: GIT, methemoglobinemia • Dose: 200mg tid Nalidixic acid

Pharmacotherapy

• 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 goals • Microbiological cure • Clinical cure • Prevent morbidity and mortality • Pt compliance • Prevent recurrence and relapse. • Minimum secondary infection

Uncomplicated (women) Cystitis Complicated • Acute

Mild,Mod Uncomplicated Severe

Pyelonephritis

Mild,Mod Complicated Severe

• Chronic

Condition

Acute Uncomplicated cystitis in women

Empirical Tt 3 day regimen Oral TMP-SMX,TMP, Quinolones

7 day regimen Macrocrystalline Nitrofurantoin

Condition

Acute cystitis complicated

Circumstances Empirical Tt Men, Failure of 7 Day 3 d. regimen, Oral TMP-SMX, Children, Quinolone Renal disease,DM

Pregnancy

7 day-Oral Amox., Nitro., Cephalosporin, TMP-SMX

Condition

Circumstance Empirical Tt

•Mild-mod. illness •No nausea, Acute uncomplicated vomiting pyelonephritis •O.P.D.

•Oral quinolone714D OR •Single dose Ceftriaxone(1G) or •GM(3-5mg/kg)i.v Followed by •TMP-SMX 14 D

Circumstances Condition

Acute

uncomplicated

Sever illness pyelonephritis I.P

Empirical Tt •Parenteral quinolone, GM, Ceftriaxone, Aztreonam, until defervescence •Followed by Oral quinolone, cephalosporin or TMP-SMX for 14 Days

Condition

Circumstances Empirical Tt

Complicated pyelo.acute Mild,Moderate (Catheterization, Urologic abnormalities, stones, Sever Immunosuppre -ssion, Renal disease,DM)

Oral quinolone 10-14 days Parenteral amp., GM, quinolone, ceftriaxone, aztreonam, ticarcillin, imipenem

↓ Oral quinolone or

Chronic Pyelonephritis

• Obstruction eliminated • If not possible  Long term therapy ( Indefinite) with TMP-SMX, TPM, Nitrofurantoin.

Chemoprophylaxis • 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 Bacteriuria

• Elderly or with catheter- no Tt. • Pregnancy, neurotropic pts., recent renal transplantation, young childrenRequire Tt. • Sulfa, Betalactams, Nitrofurantoin.

Drug Dosage

Parenteral • Cystitis:  TMP-SMZ-160/800 mg.BID Cipro 200 TMP 100mg. BID 400mg.BID  Cipro.-250mg. QID GM-1mg/kg TID  Nitrofurantoin- 100mg.QID Ampicillin-1g qid  Amox-250mg. TID Imipenem/cilastat  Cefpodoxime proxetil-in-500mgTID 100mg.QID Aztreonam-1g bid

 Pyelonephritis:  TMP-SMX-As above  Cipro- 500mg.BID  Cefpodoxime proxetil-200mg BID