Urinary tract infections

Facts Behind the Fact Card Pharmacist CPE Urinary tract infections by Lynn Gould Urinary tract infections (UTIs) are very common, affecting about 250,000 people in Australia each year. 1 Many people go to a pharmacy seeking medications to self-treat their symptoms. UTIs are rarely serious when they occur in otherwise healthy adults, but they do have the potential to cause permanent kidney damage or life-threatening infection if they are not treated promptly, especially in people who have medical conditions that may complicate the infection. 2 Pharmacists can give advice about the need for appropriate treatment and about strategies to prevent and manage the discomfort of UTIs. Who is at risk for urinary tract infections? 3-7 Babies and children among infants, boys are more likely to develop UTIs; after infancy, UTIs are more common in girls. Uncircumcised infant boys and young children with severe constipation are more prone to UTIs. Developmental abnormalities such as vesicoureteral reflux (a bladder valve abnormality which allows a backflow of urine from the bladder to the ureter) and conditions that produce obstruction to the flow of urine are present in up to 50% of infants and in 20 to 30% of school-aged children with a UTI. If the kidneys are infected this can result in scarring, contributing to high blood pressure and poor kidney function in adulthood. Women up to the age of 50 years, UTIs are about 50 times more common in women than in men; a woman s urethral opening is near sources of bacteria from the anus and vagina and a woman s urethra is relatively short, allowing bacteria quick access to the bladder. In men, antibacterial prostatic secretions discourage pathogen growth. After 50 years of age, the incidence of UTI is almost as high in men as in women due to the increased frequency of prostate disease. Elderly people often have a number of risk factors for UTI, including alterations in urinary tract structure such as uterine prolapse and benign prostatic hyperplasia, and limited functional status impairing mobility, hygiene, and toileting. Other risk factors for UTI include: Pregnancy pregnancy-related changes in the urinary tract, such as pressure on the bladder and ureters from an expanding uterus, contribute to urinary reflux. 6 An obstruction blocking the passage of urine, such as a tumour, kidney stone, or enlarged prostate. 7 Conditions that affect the bladder s nerve supply, such as multiple sclerosis and spinal-cord injuries, or the immune system, such as diabetes and HIV. Catheterisation even with optimal care, catheter use for one month or longer will eventually result in bladder infection. Constipation has been shown to contribute to bladder instability. There is increasing evidence that genetic factors may influence susceptibility to recurrent UTI. It is thought that epithelial 6

Facts Behind the Fact Card Urinary tract infections cells from susceptible women may possess specific types or greater numbers of receptors to which E. coli can bind, thereby facilitating colonisation. Types of UTI 5 Urinary tract infections may be acute, recurrent or chronic, simple or complicated. Lower UTIs are urethritis (infection of the urethra) and cystitis (infection of the bladder). Upper UTIs are ureteritis (infection of the ureters) and pyelonephritis (infections of the kidneys). Causes 1,3,4,7,8 Urine is normally sterile. A UTI occurs when a micro-organism enters the urinary system, usually via the urethra or, rarely, from the bloodstream. The most common infecting organism is E. coli, which may be spread through contamination from the gastrointestinal tract. Other causative bacteria include Staphylococcus saprophyticus, Neisseria gonorrhoeae, and Proteus, Klebsiella and Enterococcus species. An increasing number of bladder infections in men and women have been linked to two sexually transmitted organisms Chlamydia trachomatis and mycoplasma. Infection via the bloodstream is usually due to relatively virulent organisms, such as Salmonella and Staph. aureus. The Herpes simplex virus type two may cause urethritis, and certain fungi or yeasts can cause a UTI. The most common fungal agent is Candida, which frequently infects people who are catheterised or who have an impaired immune system. Rarely, other types of fungi, such as Blastomyces or Coccidioides, may infect the urinary tract. 5 An infection is usually prevented from moving up through the urinary tract by the flow of urine flushing out organisms and by closure of the ureteral sphincters. However, any physical obstruction to the urine flow, or the reflux of urine from the bladder into the ureters, increases the likelihood of a UTI. 1,3,5 Symptoms The clinical symptoms of UTIs do not always correlate with the site of infection or with the degree of bacteriuria. 9 The symptoms of cystitis include 5,9 Dysuria (painful, burning urination) Urinary frequency and urgency Nocturia Suprapubic or back pain Cloudy, unpleasant smelling or bloody urine. A person whose bladder is malfunctioning because of nerve damage or who has a permanent catheter may have asymptomatic cystitis until the infection progresses to pyelonephritis Urethritis generally causes dysuria without symptoms of suprapubic pain or urinary frequency. In men, urethritis usually begins with a discharge containing yellowish-green pus when N. gonorrhoeae is involved or clear mucus when other organisms are involved. 5,10 Pyelonephritis symptoms often begin suddenly with chills, fever, pain and tenderness in the lower back, nausea and vomiting, Symptoms of cystitis may also be present. In chronic pyelonephritis the pain may be vague, and fever may be intermittent or not occur at all. Chronic pyelonephritis occurs only in people who have major underlying abnormalities, such as a urinary tract obstruction, large kidney stones or urinary reflux. 5 Babies, children and elderly people may not have typical symptoms of a UTI. Their symptoms may include: 5,9,11-13 Neonates fever or hypothermia, poor feeding, jaundice Infants vomiting, diarrhoea, fever, poor feeding, failure to thrive Children irritability, loss of appetite, diarrhoea, change in urination pattern, persistent fever (an infant or young child with an unexplained fever for more than three days should have a urine specimen tested for infection) Elderly people fever or hypothermia, poor appetite, lethargy, changes in mental status e.g., confusion, agitation. Diagnosis It is important for a person who suspects they have a UTI to see a doctor for diagnosis. Early treatment will lead to quicker recovery and, if the infection is in the kidney, permanent damage can occur if it is left untreated. 1 Practice Points Practice Point 1 The role of lactobacilli in protecting against UTIs 6,22,-24 Lactobacilli are a normal component of the periurethral flora. They produce hydrogen peroxide and lactic acid which are toxic to uropathogens and provide the periurethral area and vagina with a ph that inhibits bacterial growth and blocks potential sites of attachment. Women who are exposed to the spermicide nonoxynol-9 are at increased risk of UTI, possibly due to the reduction of lactobacilli by the antibacterial spermicide. Antibiotic use potentially increases UTI risk by the same mechanism. The replenishment of urogenital microflora with probiotics taken orally in capsules, drinks or yogurt, or applied via vaginal douche, is gaining popularity. Results from studies using a combination of L. rhamnosus GR-1 and L. fermentum B-54 (recently replaced by RC-14) indicate that the recurrence rate of UTI can be significantly reduced using one or two capsules vaginally per week for one year, with no side effects or yeast infections. Although these results are promising, further large clinical studies are needed to define the role of lactobacillus as a probiotic in the prevention of UTI. Practice Point 2 Cranberry 26,29-31 It has been shown that cranberries prevent bacteria (particularly E. coli) from adhering to epithelial cells lining the wall of the bladder. There is evidence from two RCTs that cranberry juice may decrease the number of symptomatic UTIs over a 12-month period in women, but there is as yet no clear evidence for other groups such as children, men and the elderly. The dosages used in the trials varied from 300ml daily to 250ml three times a day and the optimum dosage and concentration of cranberry juice remains to be scientifically determined. Adverse effects included nausea, gastric reflux and diarrhoea. There have been reports of serious side effects and death in older patients taking cranberry concurrently with warfarin; however currently there is no reliable evidence documenting this effect. The large number of dropouts/withdrawals from trials indicates that drinking large amounts of cranberry juice over long periods of time may not be acceptable. Tablets or capsules have been used at doses up to 10g daily for prevention and may be more acceptable. Further properly designed trials of the various cranberry dosage forms are needed before definitive recommendations can be made. in 7 PHARMation 7

Practice Points Practice Point 3 Management and prevention of UTIs 1,3,12,20,25-27 Strategies which may help to reduce the discomfort of UTIs include: An analgesic such as paracetamol may be taken to relieve the pain associated with a UTI. A warm bath or a hot water bottle or heating pad on the suprapubic area or lower back may help to ease the pain. Drink plenty of water to help flush out the urinary system (the evidence for this is unclear and some people believe that it may do little to clear bacteria from an inflamed bladder while the pain of frequent urination may be distressing). Avoid coffee, alcohol and spicy foods, which irritate the bladder. Smokers should stop smoking as smoking irritates the bladder. Urinary alkalinisers such as Ural, Citravescent and Citralite, may be used to reduce symptoms of dysuria and/or frequency; however, there is evidence that casts doubt on the effectiveness of this strategy. They should not be used with quinolone antibiotics (e.g., ciprofloxacin, norfloxacin) as crystalluria may occur. Alkalinisation of the urine may reduce the effect of tetracyclines, lithium and salicylates and increase the effect of amphetamines and pseudoephedrine. Concomitant use with antacids may result in systemic alkalosis, hypernatraemia or aluminium toxicity and use with laxatives may have an additive effect. They should be used with caution in patients with cardiac failure, hypertension and renal impairment. Longterm use may result in hypernatraemia and alkalosis. Strategies which may help to prevent UTIs include: Drink plenty of fluids. Avoid delaying urinating and ensure the bladder is as empty as possible. Women should wipe from the front to the back after urinating. Empty the bladder immediately after sexual intercourse. Wash hands well after going to the toilet. Wear cotton underwear and do not wear tight fitting trousers or tights. Non-English speaking patients can find information in several languages on the following website: http://www.mhcs.health. nsw.gov.au/health-public-affairs/mhcs/ publications/5460.html Facts Behind the Fact Card Urinary tract infections Table 1. When urine culture is necessary 16 When symptoms of infection are present in children patients with an indwelling catheter men patients with a known genito-urinary abnormality elderly patients immunocompromised or diabetic patients pregnant women Or where there are/is three or more episodes relapse or treatment failure per year The two main diagnostic tests for UTI are urinalysis and urine culture. Urinalysis is used to provide quick information to support the diagnosis of a UTI. It may be done at the doctor s surgery using a dipstick to test a sample of urine for the presence of leukocyte esterase (released from white blood cells secondary to bacterial invasion) and nitrites (produced by the bacterial breakdown of dietary nitrate). Urine culture is the only absolute way to make a diagnosis of UTI. A clean-catch midstream urine specimen (collected from the middle portion of the flow of urine after the external genitalia have been carefully cleaned) is cultured and studied under a microscope to identify pathogenic bacteria. In patients who cannot produce a cleancatch urine specimen, alternative methods to obtain an uncontaminated specimen include suprapubic aspiration (SPA) and transurethral catheterisation. 5,9,12,14,15 Imaging tests may sometime be necessary, especially in children younger than five years of age, in men at any age, and in women with frequently recurring infections (three or more per year), in order to detect any underlying problems in the urinary tract. These tests include ultrasound, intravenous pyelography (IVP) a series of x-rays using a contrast dye and CT scans, which give a detailed three-dimensional picture of the urinary tract. 5,9,12 Complications Underlying conditions that impair the normal urinary flow (such as kidney stones, prostatic hyperplasia, or neurogenic bladder weakness) can lead to more complicated UTIs, with persistent infection, recurrent infections or treatment failure. The underlying problem must be corrected or the patient is at risk of kidney damage. 3 Other potential causes of complicated UTIs are catheterisation and resistant bacteria. 10 The clinical manifestations of complicated UTIs range from cystitis to urosepsis with septic shock. 10 Factors associated with poor outcome or death from complicated UTI include old age, general disability, kidney stones, recent hospitalisation, diabetes, sickle cell disease, cancer and chronic renal disease. 12 A gonorrheal infection of the urethra that is inadequately treated can cause a narrowing of the urethra, which increases the risk of developing cystitis or pyelonephritis. Untreated gonorrhea occasionally leads to an abscess around the urethra which can produce urethral diverticula, which can also become infected. If the abscess perforates the skin, urine may flow through a newly created abnormal connection (urethral fistula). 5 Prevention of cystitis Bowel Bladder Wiping from back to front after a bowel movement may force germs into urethra 8

Facts Behind the Fact Card Urinary tract infections Male urinary tract Practice Points Practice Point 4 Treatment 12,17,18 The usual treatment for both simple and complicated UTIs is antibiotics. Recommended antibiotic regimens vary according to the individual patient and the site, duration and severity of infection. In acute cystitis, recommended oral antibiotics are: trimethoprim 300mg (child 6mg/kg) once daily; or cephalexin 500mg (child - 12.5mg/kg) 12 hourly; or amoxycillin + clavulanate 500+125mg (child 12.5+3.1mg/kg) 12 hourly or nitrofurantoin 50mg six hourly (not recommended for children). Children may also be prescribed trimethoprim +sulphamethoxazole 4+20mg/kg 12 hourly. If resistance to all the above drugs is proven, a suitable alternative is norfloxacin 400mg 12 hourly for three days. Fluoroquinolones should not be used as first-line drugs as they are the only orally active drugs available for infections due to multiresistant bacteria. Duration of treatment varies from three to five days for a non-pregnant woman or child to 10 days for a pregnant woman and 14 days for a man. Elderly women should be treated for a minimum of seven days if the infection is acquired in a hospital or aged care facility or is associated with incontinence, diabetes Kidney Renal pelvis Ureter Urinary bladder Urethra or immunosuppression. For an episode of recurrent urinary tract infection, treatment should be continued for 10 days; selected patients may be permitted to self-initiate treatment. Single-dose therapy is not as reliable as multiple dose therapy in preventing relapse. However, in remote communities treatment with nitrofurantoin 200mg orally as a single dose has been found useful. Mild cases of acute pyelonephritis may be treated orally with: cephalexin 500mg (child 12.5mg/kg) six hourly; or amoxycillin + clavulanate 875+125mg (child 22.5+3.2mg/kg) 12 hourly; or trimethoprim 300mg (child 6mg/kg) daily. If resistance to all the above drugs is proven or the causative organism is Pseudomonas aeruginosa, ciprofloxacin 500mg 12 hourly may be used (ciprofloxacin should, as far as possible, be avoided in children). Treatment should be continued for a total of 10 days. A follow-up urine culture after the conclusion of therapy is advised. Severe cases of acute pyelonephritis with vomiting or suspected sepsis should initially be treated parenterally and oral therapy substituted as soon as possible, guided by antibiotic sensitivity results: amoxy/ampicillin 1g (child 25mg/kg) IV six hourly plus gentamycin 4-6mg/kg (child <10 Recurrent UTIs 17,18,26,28,29 Recurrent UTI may result from an abnormality of the urinary tract. In men, chronic prostatitis is the most common cause of recurrent UTI, while changes related to decreased oestrogen levels are thought to contribute to recurrent UTI in post-menopausal women. In elderly women, recurrent infection may be due to poor urethral function, incontinence, atrophic changes, diabetes or vaginal colonisation by bowel flora. In patients with recurrent symptomatic UTIs (three or more infections per year) antibiotic prophylaxis of three months or longer is recommended. Recommended antibiotics for prophylaxis are: nitrofurantoin 50 mg at night or, in women, within two hours of sexual intercourse; or cephalexin 250 mg at night; or trimethoprim 150 mg at night. Night-time dosing is recommended to maximise urinary concentrations. A systematic review of studies in women concluded that infection rates quickly return to their previous level on withdrawal of antibiotics. There is not enough evidence to conclusively support the use of hexamine hippurate (Hiprex) for urinary prophylaxis. Two trials of topical oestrogen in postmenopausal women showed a significant reduction in the incidence of UTIs. However, a more recent trial of oestriol vaginal pessaries found that the preventive effect was inferior to prophylaxis with nitrofurantoin. There is no good evidence to support prescribing oral oestrogens for this purpose. Relevant fact cards Below is a list of fact cards relevant to the topic of this month s. PSC suggests pharmacists and their staff familiarise themselves with these cards and use them while counselling customers. Urinary Tract Infection Bladder and Urine Control Menopause Prostate Problems Antibiotics 9

Practice Points Facts Behind the Fact Card Urinary tract infections Practice Point 5 UTIs and pregnancy 4,6,17,32 UTI in pregnant women is a significant risk factor for low-birthweight infants and prematurity. Asymptomatic bacteriuria occurs in 5% to 9% of both non-pregnant and pregnant women. If left untreated in pregnancy, progression to symptomatic UTI including acute cystitis and pyelonephritis occurs four times more frequently than in non-pregnant women. Therefore, a urine culture should be obtained from all women early in pregnancy, even in the absence of UTI symptoms. Treatment of asymptomatic bacteriuria with a course of antibiotics reduces the risk of developing symptomatic UTI by 80-90%. Recommended drug regimens are: cephalexin 500mg 12 hourly (category A); or nitrofurantoin 50mg six hourly (category A see below); or amoxicillin + clavulanate 500 + 125mg 12 hourly (category B1). Treatment should be continued for 10 days, after which the urine culture should be repeated. Trimethoprim is not recommended in pregnancy due to lack of safety data and the potential risks associated with folic acid antagonism. Fluoroquinolones should be avoided because of possible adverse effects on foetal cartilage development. Nitrofurantoin should be avoided after the 36th week of gestation due to the potential risk of producing haemolytic anaemia in an infant with glucose-6-phosphate dehydrogenase deficiency. Prophylaxis for pregnant women should be considered in patients who have had acute pyelonephritis during pregnancy, patients with recurrent bacteriuria during pregnancy and patients who had recurrent UTI requiring prophylaxis before pregnancy. Recommended drugs are: nitrofurantoin 50mg at night or within two hours of sexual intercourse or cephalexin 250mg at night. Relevant shelf talkers Below is a list of shelf talkers relevant to the topic of this month s. PSC suggests pharmacists and their staff familiarise themselves with these shelf talkers and use them while counselling customers. Paracetamol Cranberry Laxatives years 7.5mg/kg ; >=10 years 6mg/kg) IV daily (adjust dose for renal function). Where the use of an aminoglycoside is undesirable e.g., in the elderly or pregnant, in the presence of significant renal failure or following a previous adverse reaction use, as a single drug, cefotaxime 1g (child 50mg/ kg) IV eight hourly or ceftriaxone 1g (child 50mg/kg) IV daily. Treatment should be continued for 10 to 14 days, the greater part of which may be oral or in an established outpatient IV antibiotic therapy program. A follow-up urine culture at the conclusion of therapy is advised. The presence of Candida in the urine is common, particularly in association with indwelling urinary catheters, and does not necessarily indicate a UTI. Antifungal therapy is not usually indicated. If candiduria occurs in association with an upper UTI, systemic treatment with antifungal drugs is recommended. Nitrofurantoin should not be taken with a urinary alkaliniser because alkalinising drugs increase its rate of excretion, thus potentially reducing its antibacterial effect. Macrodantin is a macrocrystalline form of nitrofurantoin. It is less likely to cause nausea, vomiting and diarrhoea, which are the most common adverse effects of nitrofurantoin. To further minimise these effects it should be taken with food or milk. Rare but serious adverse effects include: Polyneuropathy leading to degeneration of motor and sensory nerves and muscle atrophy. This is more likely to occur in patients with renal impairment (patients on long-term therapy should have their renal function monitored regularly), diabetes, electrolyte imbalance, anaemia or vitamin B deficiency. If a patient on nitrofurantoin experiences any numbness or tingling, they should see their doctor. Hepatotoxicity which may manifest as hepatitis, cholestatic jaundice or hepatic necrosis. Patients on long-term therapy should have their liver function monitored every month for the first three months, and then every three months. Pulmonary hypersensitivity, which may cause permanent pulmonary damage or even death. Symptoms such as cough, chest pain or difficulty breathing should immediately be reported to the doctor. Pulmonary function should be monitored at least six-monthly during long-term treatment. 17,19,20,21 Trimethoprim causes potassium retention which may potentially result in hyperkalaemia, especially with high doses, concomitant use of other potassium-sparing drugs, or in renal impairment. It may potentiate the effects of warfarin, digoxin and phenytoin, and concomitant use with other folate inhibitors such as methotrexate increases the risk of megaloblastic anaemia. During prolonged use, patients should have their complete blood picture and folate status regularly monitored. 20,21 References 1. Urinary tract infections, Better Health Channel; www.betterhealth.vic.gov.au (accessed 13 Feb 2006). 2. Urinary Tract Infections in Teens and Adults, WebMD; www.webmd.com/hw/infection/hw57228. asp (accessed 13 Feb 2006). 3. Urinary tract infection in adults, MedicineNet; www.medicinenet.com/urine_infection/article.htm (accessed 13 Feb 2006). 4. Urinary tract infections, ACP Medicine; www.medscape.com/viewarticle/505095_2 (accessed 13 Feb 2006). 5. Urinary tract infections, Merck Manual Home Edition; www.merck.com/mmhe/sec23/ch272/ ch272i.html (accessed 13 Feb 2006). 6. Clinical update: Urinary Tract Infection: Providing the Best Care; Medscape, 24 June 2003 www.medscape.com/viewarticle/436592_4 7. Understanding UTIs The Basics, WebMDHealth; www.medscape.com/viewarticle/513000 (accessed 14 Feb 2006). 8. Urinary Tract Infections, the Merck Manual of Diagnosis and Therapy; www.merck.com (accessed 14 Feb 2006). 9. Gupta K, Stamm W, Urinary Tract Infection; ACP Medicine Sept 2004 www.medscape.com/viewarticle/ 484580?src=search 10. Orenstein R, Wong ES, Urinary Tract Infections in Adults; American Family Physician Vol. 59 No. 5, March 1999 www.aafp.org/afp/990301ap/1225.html 11. Hellerstein S, Urinary Tract Infection; emedicine www.emedicine.com/ped/topic2366.htm (accessed 15 Feb 2006). 12. Di Leo Thomas LA et al, Urinary Tract Infections Overview, emedicine www.emedicinehealth.com/ fulltext/24812.htm (accessed 13 Feb 2006) 13. Midthun SJ, Criteria for Urinary Tract Infection in the Elderly: Variables That Challenge Nursing Assessment; Urologic Nursing, 25 June 2004 www.medscape.com/viewarticle/481627 14. Dulczak S, Kirk J, Overview of the Evaluation, Diagnosis, & Management of UTIs in Infants and Children; Urol Nurs 2005;25(3):185-192. www.medscape.com/viewarticle/507162_1 15. Mosby s Dictionary of Medicine, Nursing & Health Professions, Australia & New Zealand edition, 2006. 10

Facts Behind the Fact Card Urinary tract infections 16. NPS Prescribing Practice Review 30: Antibiotics in primary care, June 2005 www.nps.org.au 17. etherapeutic Guidelines; Antibiotic, 2003 18. Australian Medicines Handbook Drug Choice Companion: Aged Care, 2003 19. Goodman & Gilman s The Pharmacological Basis of Therapeutics 11th edition, 2006. 20. E- MIMS 2006 21. Australian Medicines Handbook 2006. 22. Reid G, Bruce A W, Urogenital infections in women: can probiotics help? Postgraduate Medical Journal 2003;79:428-432 www.pmj.bmjjournals.com/cgi/ content/full/79/934/428 23. Reid G, The Rationale for Probiotics in Female Urogenital Healthcare; Medscape General Medicine, 2004;6(1):e38 www.medscape.com/ viewarticle/470468_ 24. Andreu A, Lactobacillus as a probiotic for preventing urogenital infections. Reviews in Medical Microbiology. 15(1):1-6, January 2004. www.revmedmicrobiol.com 25. PRODIGY Guidance - Urology, UK Dept. of Health; April 2002 (revised July 2005). www.prodigy.nhs.uk (accessed 22 Feb 2006). 26. Clinical Information Sheet 14, North West Melbourne Division of General Practice www.nwmdgp.org.au/ pages/after_hours/gprac-cis-14.html (accessed 21 Feb 2006) 27. Cystitis, NSW Multicultural Health Communication Service www.mhcs.health.nsw.gov.au/health-publicaffairs/mhcs/publications/5460.html (accessed 1 March 2006). 28. Methenamine hippurate for preventing urinary tract infections. The Cochrane Database of Systematic Reviews 2006, Issue 1 http://www.mrw.interscience.wiley.com/cochrane/ clsysrev/articles/cd003265/frame.html 29. NPS News 40, June 2005 www.nps.org.au 30. Jepson RG, Mihaljevic L, Craig J. Cranberries for preventing urinary tract infections. The Cochrane Database of Systematic Reviews, Issue 2, April 2004 31. Braun L, Herbs & Natural Supplements - An evidence-based guide, 2005 32. Drugs and Pregnancy, Pharmacy Dept., The Royal Women s Hospital Melbourne, 2001 Facts Behind The Fact Card assessment For Pharmacy Self Care members only Questions Select one correct answer from each of the following questions. Answers due 31 May 2006 Submit answers online To submit your response to these questions online, go to www.psa.org.au and follow the link on the front page or in the PSC section (via the Navigate button). Please answer the following multiple choice questions using the information in Facts Behind the Fact Card and Practice Points. This activity is recognised under the PSA CPD & PI Program. ONE credit point will be awarded to pharmacists with five out of six answers correct. To receive your credit remove the answer card provided. Complete the contact details section and your answers and fax the card to 02 6285 2869. 1. Urinary tract infections: a) do not commonly occur in post-menopausal women; b) usually originate in the kidneys, via the blood; c) in elderly people may present with changes in mental status; d) can be specifically diagnosed by urinalysis. 2. In the treatment of UTI: a) Antibiotics are usually reserved for severe infections involving the kidneys. b) Cranberry juice is first-line treatment for uncomplicated cystitis. c) Pregnant women should only be treated if they have symptomatic UTI. d) Fluoroquinolone antibiotics should not be used as first-line treatment. 3. In the diagnosis of UTI: a) Cystitis should be suspected if a pre-menopausal woman presents with a sudden fever and back pain. b) Pregnant women should routinely have a urine culture to test for the presence of asymptomatic bacteriuria. c) A pre-menopausal woman presenting with symptoms of cystitis should routinely have a urine culture to confirm the diagnosis. d) Imaging tests such as ultrasound are usually recommended for post-menopausal women with symptoms of pyelonephritis. 4. Which of the following statements is TRUE? a) The concomitant use of trimethoprim and enalapril may increase the risk of hyperkalaemia. b) The therapeutic effect of nitrofurantoin may be enhanced if it is taken with a urinary alkaliniser. c) Circumcision may increase the risk of UTI in infant boys. d) The most common fungal agent implicated in UTI is Blastomyces. 5. With regard to antibiotic therapy in UTI: a) A mild case of pyelonephritis in a non-pregnant woman should be treated for three to five days. b) Nitrofurantoin is the antibiotic of choice for cystitis in children. c) In IV therapy for severe pyelonephritis where gentamycin is contraindicated, ceftriaxone may be used in combination with amoxycillin. d) Ciprofloxacin should be avoided during pregnancy due to the possibility of damage to foetal cartilage. 6. Which of the following statements is FALSE? a) In men, chronic prostatitis is the most common cause of recurrent UTI. b) Structural and functional abnormalities of the urinary tract are a significant cause of UTIs in babies. c) The optimum dose of cranberry juice for UTI prevention has been proven to be 250ml three times a day. d) Patients on long-term nitrofurantoin therapy should have their lung and liver function regularly monitored. Pharmacist CPE answers Baby care (the first six months) (December 2005) 1. c 2. b 3. d 4. c 5. a 6. d 11