Skin and Soft Tissue/UTI Discussion Essay

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Skin and Soft Tissue/UTI Discussion Essay

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Often infections have several treatment possibilities, depending on both patient specific and disease specific characteristics.  Below is a very short case, and I want you as a class to compare and contrast the listed treatment options.  The focus will be on safety and efficacy of the regimens, all considered possible choices by the Infectious Disease Society of America’s treatment guidelines for Acute Uncomplicated Cystitis. Skin and Soft Tissue/UTI Discussion Essay

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HT is a 31 year old female with acute, uncomplicated cystitis and no known drug allergies.  She has no significant PMH or medications.  Her urine culture shows a susceptible E. coli (susceptible to all treatments listed below).  Please compare the safety and efficacy of the following options.  What would make you choose one over another?

  1. nitrofurantoin 100 mg po BID x 7 days
  2. TMP/SMX DS (160 mg/800 mg) po BID x 3 days
  3. levofloxacin 250 mg po daily x 3 days
  4. cephalexin 500 mg po q12hrs x 7-14 days

I want you all to discuss and add to or dispute each other’s thoughts and ideas.

Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight.  Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced.  A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section.  Skin and Soft Tissue/UTI Discussion Essay

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    • Pharmacology Discussion 8
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    • Dianne Cohen posted Oct 21, 2020 10:46 PM
    •                                          Pharmacology Discussion 8
      nitrofurantoin

      100 mg po BID x 7 days

      		 TMP/SMX DS 160 mg/800 mg) po BID x 3 days levofloxacin 250 mg

      po daily x 3 days

      		 cephalexin

      500 mg po q12hrs x 7-14 days
      Safety Not recommended in: liver failure or kidney disease with creatinine/clearance <60ml/min, and in late pregnency>

      38wks, breastfeeding

      Side effects: nausea, vomiting, diarrhea

      		 Not recommended in:

      sulfonamide hypersensitivity,

      liver disease, kidney disease, anemia, pregnant, breastfeeding, Colitis

      Side effects: nausea, vomiting, diarrhea

      		 Black Box Warning: tendonitis, >age 60 increase risk tendon rupture, not recommended: Myasthenia Gravis, cardiac arrhythmias, CNS, corticosteroids, arteriosclerosis, pregnant/breastfeeding, can increase/decrease blood sugar in diabetes, possible interaction with antipsychotics

      Side effects: Headache, dizziness, delirium, confusion, diarrhea, constipation, dysgeusia, visual impairment  not tolerated in children and elderly

      		 Not recommended in cephalosporin or penicillin hypersensitivity, renal failure, or colitis

      Side effects: stomach pain, fatigue, light-headed
      Efficacy First-line treatment, lowest resistance, high sensitivity, where local E-coli

      resistance rate <20%

      		 First-line treatment, lowest resistance, high sensitivity where local E-coli resistance rate <20% Skin and Soft Tissue/UTI Discussion Essay An alternative to first-line, increased risk of resistance to antibiotics A possible alternative, more data needed to support improved effectiveness

      Chisholm-Burns, M., Schwinghammer, T., Malone, P., Kolesar, J., Lee, K. C., & Bookstaver, P.  B. (2019). Pharmacotherapy principles and practice, fifth edition (5th ed.). McGraw-Hill  Education / Medical. https://doi.org/10.1038/nrmicro3432 Kranz, J., Schmidt, S., Lebert, C., Schneidewind, L., Schmiemann, G., & Wagenlehner, F.  (2017). Uncomplicated bacterial community-acquired urinary tract infection in adults. Robinson, T. F., Barsoumian, A. E., Aden, J. K., & Giancola, S. E. (2020). Evaluation of the trends and appropriateness of fluoroquinolone use in the outpatient treatment of acute uncomplicated cystitis at five family practice clinics. Journal of Clinical Pharmacy & Therapeutics, 45(3), 513–519. https://docs.google.com/document/d/1KlN8vH0w2HnUo-s142c5v6yoNGergEaXfLOSn3ERHtQ/edit?usp=sharingless0 UnreadUnread

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    • View profile card for Kelly Miskovsky
    • Last post Oct 26, 2020 10:14 AM by Kelly Miskovsky
    • https://doi-org.ezproxy.fau.edu/10.1111/jcpt.13099
    •     https://doi.org/10.3238/arztebl.2017.0866
    • Kim, D. K., Kim, J. H., Lee, J. Y., Ku, N. S., Lee, H. S., Park, J.-Y., Kim, J. W., Kim, K. J., & Cho, K. S. (2020). Reappraisal of the treatment duration of antibiotic regimens for acute uncomplicated cystitis in adult women: a systematic review and network meta-analysis of 61 randomized clinical trials. Lancet Infectious Diseases, 20(9), 1080–1088.
    • Flores-Mireles, A. L., Walker, J. N., Caparon, M., & Hultgren, S. J. (2015). Urinary tract infections: Epidemiology, mechanisms of infection and treatment options. Nature  Reviews Microbiology, 13(5), 269–284.
    •                                                              References
    • The treatment of uncomplicated cystitis is based on physical symptoms and laboratory findings. Also, patients may or may not present with urinary frequency, urgency, dysuria, nocturia, and suprapubic heaviness (Chisholm-Burns et al., 2019). Furthermore, risk factors include female sex, prior UTI, sexual activity, vaginal infection, diabetes, obesity, and genetic susceptibility (Flores-Mireles et al., 2015). Accordingly, the primary care provider must decide which antibiotic is appropriate to avoid serious sequelae. Complications may include frequent recurrences, pyelonephritis with sepsis, renal damage in young children, pre-term birth. Equally important, regular antimicrobial use may cause resistance and clostridium difficile colitis  (Flores-Mireles et al., 2015). Consequently, local resistance patterns, current medication use, contraindications, allergies, and cost should determine antibiotic choice (Kranz et al., 2017). According to data from the Infectious Disease Society of America (IDSA), nitrofurantoin, and trimethoprim‐sulfamethoxazole are first-line treatments with the highest sensitivity rates (Kim, et al. 2020). However, due to fewer contraindications, few side effects, and high sensitivity, I recommend nitrofurantoin 100mg BID x 7 days for uncomplicated cystitis treatment. Levofloxacin is an alternative to first-line therapy but has potentially severe side effects and is known to increases antibiotic resistance rates (Robinson et al., 2020). Lastly, cephalexin is another alternative; however, it lacks robust data proving its efficacy (Kim et al., 2020). Skin and Soft Tissue/UTI Discussion Essay
    • Karen Halter
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    • Karen Halter posted Oct 21, 2020 1:25 PM
    • Module 8 PharmTreatment of Uncomplicated Cystitis
       Class/drug  Dose/length of treatment  Efficacy  Safety
      Miscellaneous/Nitrofurantoin  100mg BID/7 days  Considered first line treatment  Minimal collateral damage or increase in resistance
       Miscellaneous/Trimethoprim-sulfamethoxazole  DS BID/ 3 days  Proven efficacy  Do not use of resistance is above 20%
       Flouroquinolones/Levofloxacin 250 mg QD/3 days  Highly effective  Higher risk of collateral damage
       B-lactan/cephalexin 500mg q 12/7-14 days  Inferior efficacy  More adverse reaction

      Based on the above for HT I would prescribe Nitrofurantoin 100mg BID for 7 days based on the present guidelines for first line treatment for uncomplicated cystitis. It is important as clinicians to prevent resistance and only utilize medications with low collateral damage, and although the cost per day of Nitrofurantoin ($17.13) is higher than Trimethoprim-sulfamethoxazole ($3.88) preventing resistance to commonly used medication is imperative. (Mehnert-Kay, 2005)ReferencesInternational clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the infectious diseases society of america and the european society for microbiology and infectious diseases. (2011). OUP Academic. https://academic.oup.com/cid/article/52/5/e103/388285less0 UnreadUnread Skin and Soft Tissue/UTI Discussion Essay

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    • View profile card for Kelly Miskovsky
    • Last post Oct 26, 2020 10:11 AM by Kelly Miskovsky
    • Mehnert-Kay, S. A. (2005). Diagnosis and management of uncomplicated urinary tract infections. https://www.aafp.org/afp/2005/0801/p451.html
    • Chisholm-burns, M. A., Schwinghammer, T. L., Malone, P. M., Kolesar, J. M., Lee, K. C., & Bookstaver, P. B. (2019). In Pharmacotherapy principles and practice, fifth edition (5th ed., pp. 1197–1199). Mcgraw-hill Education / Medical.
    • Uncomplicated infections of the lower urinary tract are most commonly caused by E. coli and present with symptoms of increased frequency, dysuria, and nocturia. (Chisholm-burns et al., 2019) Treatment of UTI’s accounts for a large amount of prescriptions for antibiotics, so as clinicians it is imperative to carefully order the most effective and safest treatment without increasing the risk of drug resistance.(Chisholm-burns et al., 2019)  Below is a chart of four possible treatments for HT including data on efficacy and safety. (International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: a 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases, 2011) Skin and Soft Tissue/UTI Discussion Essay
    • Module 8: UTI
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    • Jessica Faltinowski posted Oct 19, 2020 2:56 PM
    • Module 8: UTITreatment of cystitis is commonly empirical, as the urine culture can take a few days to be completed and treatment of symptomatic patients needs to begin right away.  In the case study, HT, a 31-year-old female is endorsing signs and symptoms consistent with a lower urinary tract infection.  As the microbiological agent is confirmed as E. Coli and the patient does not have any significant medical history, she will be treated for uncomplicated cystitis.  There are many antimicrobials able to effectively treat the bacterial infection and selecting one is a practitioner’s discretion based upon patient allergies and tolerance, affordability, ease of administration, and side effect profile.Another commonly used anti-microbial for uncomplicated cystitis is TMP/SMX (Bactrim or Septra).  TMP/SMX would be a first-line choice if the resistance rate in the area was less than 20%, as many bacterial infections have developed resistance over the last five years (Heytens et al., 2016).  This resistance is even higher in other countries leading the European Association of Urology to no longer recommend this antimicrobial as a first line treatment for UTI (Gupta et al., 2011). Finally, cephalexin, a cephalosporin beta lactam, is considered.  Cephalexin would be a good choice as a prophylactic treatment, but is not considered a first-line treatment for uncomplicated cystitis, as it does not have the demonstrated efficacy (Grigoryan et al., 2014). Cephalexin would be second or third tier therapy for UTI, as it also has more side effects than nitrofurantoin or TMP/SMX (Kang et al., 2018).  Grigoryan, L., Trautner, B. W., & Gupta, K. (2014). Diagnosis and management of urinary tract infections in the outpatient setting. JAMA, 312(16), 1677. https://doi.org/10.1001/jama.2014.12842Heytens, S., Boelens, J., Claeys, G., DeSutter, A., & Christiaens, T. (2016). Uropathogen distribution and antimicrobial susceptibility in uncomplicated cystitis in belgium, a high antibiotics prescribing country: 20-year surveillance. European Journal of Clinical Microbiology & Infectious Diseases, 36(1), 105–113. https://doi.org/10.1007/s10096-016-2776-8Markowitz, M. A., Wood, L. N., Raz, S., Miller, L. G., Haake, D. A., & Kim, J.-H. (2018). Lack of uniformity among united states recommendations for diagnosis and management of acute, uncomplicated cystitis. International Urogynecology Journal, 30(7), 1187–1194. https://doi.org/10.1007/s00192-018-3750-zless0 UnreadUnread
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    • View profile card for Kelly Miskovsky
    • Last post Oct 26, 2020 10:11 AM by Kelly Miskovsky
    • Kang, C.-I., Kim, J., Park, D., Kim, B.-N., Ha, U.-S., Lee, S.-J., Yeo, J., Min, S., Lee, H., & Wie, S.-H. (2018). Clinical practice guidelines for the antibiotic treatment of community-acquired urinary tract infections. Infection & Chemotherapy, 50(1), 67. https://doi.org/10.3947/ic.2018.50.1.67
    • Gupta, K., Hooton, T. M., Naber, K. G., Wullt, B., Colgan, R., Miller, L. G., Moran, G. J., Nicolle, L. E., Raz, R., Schaeffer, A. J., & Soper, D. E. (2011). International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the infectious diseases society of america and the european society for microbiology and infectious diseases. Clinical Infectious Diseases, 52(5), e103–e120. https://doi.org/10.1093/cid/ciq257
  • References
    • HT could be started on nitrofurantoin or TMP/SMX and achieve therapeutic benefits.  However, the choice would depend upon the area susceptibility to TPM/SMX and erring on the side of caution, nitrofurantoin would be the most appropriate choice for therapy.  Additionally, this medication has demonstrated to be as effective as a 5-day regimen as a 7-day regimen which make adherence more likely (Kang et al., 2018).
    • Next is levofloxacin, a fluoroquinolone, with broad-spectrum antimicrobial properties.  While this antibiotic would effectively treat the bacteria, it is not recommended for uncomplicated urinary tract infections, as fluoroquinolone use has been attributed to the rising rate of methicillin-resistant-staphylococcus aureus, which is indicative of collateral damage (Gupta et al., 2011).  Fluoroquinolones also have more adverse side effects, such as central nervous effect and Clostridium difficile (Markowitz et al., 2018).   As such, this antibiotic should be reserved for larger infections.
    • The bacteria is susceptible to nitrofurantoin, which is a first line broad spectrum antibiotic commonly used to treat uncomplicated urinary tract infections, but is not effective for treating pyelonephritis, as it has poor tissue penetration (Markowitz et al., 2018).  Nitrofurantoin is commonly prescribed as it has minimal resistance to E. Coli (Gupta et al., 2011).  This antibiotic also has few side effects, making it a first line choice. Skin and Soft Tissue/UTI Discussion Essay
    • Cystitis is a type of urinary tract infections that infects the bladder.  Classification of cystitis is as either complicated or uncomplicated.  Women who are of child-bearing age usually have uncomplicated infections, while complicated infections are more often related to patients with structural abnormalities.  The most common microbiological agent of cystitis is Escherichia coli, which is the etiologic agent in 72%of the cases (Markowitz et al., 2018).
    • Nitrofurantoin
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    • Anna McMullen posted Oct 19, 2020 4:30 PM
    • The presenting patient is a 31-year-old female with acute, uncomplicated cystitis, NKDA, no significant PMH, and no current medications. The patient’s urine culture presents with Escherichia coli, which is the most common pathogen found in UTIs and seen in approximately 86% of cases (Lala & Minter, 2020). UTI’s are the most common bacterial infection in women and age plays an important factor; as estrogen diminishes, pH in the vagina increases, which promotes colonization of gram-negative organisms, such as E. coli (Lala & Minter, 2020). Gupta et. al (2011) discuss clinical practice guidelines for women with acute uncomplicated cystitis, with particular attention paid to collateral damage of antimicrobials. The term “collateral damage” refers to ecological adverse effects of antimicrobial therapy and how drug-resistant organisms and colonization have been associated with certain antimicrobials, most particularly broad spectrum cephalosporins and fluoroquinolones, that have been linked to subsequent infection with drug-resistant organisms (Gupta et al., 2011). Minimal risk of progression to tissue invasion or sepsis as well as uncomplicated UTI being one of the most common reasons for antimicrobial exposure in an otherwise healthy population are two main reasons Gupta et al. (2011) indicate that collateral damage should be considered when determining treatment recommendations for uncomplicated UTIs. Due to the potential antimicrobial resistance that these medications can cause, I would not recommend that this patient be started with levofloxacin or cephalexin. Fluoroquinolones, such as levofloxacin, though highly efficacious, have a propensity for collateral damage and should be reserved for more serious illnesses other than acute cystitis (Gupta et al., 2011). Beta-lactams, such as the cephalosporin, cephalexin, are not listed as preferred first-line therapy. These medications generally have inferior efficacy and more adverse effects compared to preferred agents and should only be used when other agents are contraindicated (Gupta et al., 2011).ReferencesGupta, K., Hooton, T. M., Naber, K. G., Wullt, B., Colgan, R., Miller, L. G., Moran, G. J., Nicolle, L. E., Raz, R., Schaeffer, A. J., & Soper, D. E. (2011). International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the infectious diseases society of America and the European society for microbiology and infectious diseases. Clinical Infectious Diseases, 52(5), e103–e120. https://doi.org/10.1093/cid/ciq25A less0 UnreadUnread  Skin and Soft Tissue/UTI Discussion Essay