uti -for_non-urologists-uncomplicated and complicated

Urinary Tract Infection

Urinary Tract Infection (UTI)

• UTI is the 2nd most common infectious presentation in community practices

• World wide, about 150 million people are diagnosed with UTI each year

Ann Clin Micr Anti 2007;6:4-12

UTI is an inflammatory response of the urothelium to bacterial invasion

Campbells Urology 2007; 9th Ed

Urinary Tract Infection (UTI)

UTI can occur in females and males, in all age groups

Prevalence

35% of healthy women suffer symptoms of UTI at some time in their life

Common in women

Medicine 2007;35:423-427

Why greater susceptibility of UTI in women?

The female urethra

• short length (~4cm)• proximity to anus

Urethra is prone to colonization with bacteria (Fecal bacteria)

Medicine 2007;35:423-427

Prevalence

• Rare in Males• Anatomical or functional abnormality of the urinary tract

8% of girls and 2% of boys will have UTI in childhood

• Increases in elderly• 21% of women and 12% of men over 65 yrs of age have UTI

Medicine 2007;35:423-427

BMJ 1999;319:1173-1175

Pathogenesis

Most UTI occur in women who are healthy

Interaction between the bacterial virulence and host defence

Increase in virulence

Decrease in host defence

Infection+

Medicine 2007;35:423-427

Routes of Infection

Common route – Ascending through urethra

Other route – Blood and lymphatic

EAU Guidelines 2006

Community acquired UTI

NosocomialUTI

UTI - Classification

EAU Guidelines 2006

Uncomplicated UTIs Complicated UTIsInfection involving normal

urinary tractPresence of metabolic,anatomic and functional

abnormalities

EAU Guidelines 2006

Healthy non-pregnant women • Pregnancy• Catheterization• Diabetes• Infection stones

Site of origin

Epididymitis

Prostatitis

Pyelonephritis

Cystitis

Urethritis

Orchitis

EAU Guidelines 2006

Risk factors associated with UTIs

Uncomplicated Complicated

• Sexual intercourse• Spermicide creams• Diaphragm• Previous UTI

• Pregnancy• Catheterization• Diabetes• Infection stones• Male• Elderly

Medicine.2007;35:423-427

Clinical presentation of Uncomplicated UTI

Common symptomatic infection in young non-pregnant women is uncomplicated

cystitis

• Asymptomatic bacteriuria• Acute Cystitis• Acute Pyelonephritis

EAU Guidelines 2006

Causative organisms

Acute Uncomplicated cystitis

E.Coli : 70- 95%Staphylococcus.saprophyticus :10-15%Klebsiella species Proteus mirabilis

Arch Intern Med.2007;167:2207-12

Causative organisms

Acute Uncomplicated pyelonephritis

E.Coli – 80%Klebsiella species Proteus mirabilisOther enterobacteriaStaphylococcus aureus

Prim Care Clin Office Pract 2008;35:345-367

Symptoms of Uncomplicated cystitis

If both dysuria and frequency present in the absence of vaginal

discharge, the chance of UTI is ~90%

• Dysuria• Frequency• Urgency • Hematuria• Suprapubic pain

Symptoms of Uncomplicated pyelonephritis

• Fever • Flank pain• Nausea• Vomiting • Abdominal pain

The patient may or may not have symptoms of cystitis

Diagnosis

History

• Symptoms of UTI• Other History (eg. Vaginal discharge)

Examination

Pelvic examination to rule out other causes like urethritis and vaginitis

EAU Guidelines 2006

Diagnosis

Urine Analysis

-Dipstick method

• Nitrite• Leukocyte esterase

- Microscopic analysis

• Bacteriuria• Pyuria• Hematuria

EAU Guidelines 2006

Diagnosis

Urine Culture

Not recommended in case of cystitis but doneif pyelonephritis suspected or complicated UTI

Ultrasonography

CT scan

EAU Guidelines 2006

Treatment for Uncomplicated Cystitis

Short term antibiotics( EAU recommendation - Drugs of first choice)

Drug Dose DurationNitrofurantoinNitrofurantoin

macrocrystalsmacrocrystals

100mg, bid100mg, bid 5-7days5-7days

Fosfomycin trometamol°

3 g SD 1day1day

Pivmecillinam

400 mg bid

200 mg bid

3 days

7 days

EAU Guidelines 2010

Ciprofloxacin 250 mg bid 3 days (CIPLOX) Levofloxacin 250 mg qd 3 days (LEVOFLOX) Norfloxacin 400 mg bib 3 days (NORFLOX) Ofloxacin 200 mg bid 3 days Cefpodoxime proxetil 100 mg bid 3 days (CEFOPROX)

If local resistance pattern is known (E. coli resistance < 20%):

Trimethoprim–sulphamethoxazole 160/800 mg bid 3 days Trimethoprim 200 mg bid 5 days

Treatment for Uncomplicated Cystitis (Alternatives)

EAU Guidelines 2010

Oral therapy in mild and moderate cases Ciprofloxacin 500–750 mg bid 7–10 days Levofloxacin 250–500 mg qd 7–10 days Levofloxacin 750 mg qd 5 days

Alternatives (clinical but not microbiological equivalent efficacy compared with fluoroquinolones):

Cefpodoxime proxetil 200 mg bid 10 days Ceftibuten 400 mg qd 10 days

Only if the pathogen is known to be susceptible (not for initial empirical therapy):

o Trimethoprim–sulphamethoxazole 160/800 mg bid 14 days o Co-amoxiclav 0.5/0.125 g tid 14 days

Treatment for Uncomplicated Pyelonephritis

Recommendations as per EAU guidelines

EAU Guidelines 2010

Treatment for Uncomplicated Pyelonephritis

In severe cases of pyelonephritis

• Hospitalization• Parenteral antibiotics (Quinolones and beta lactamase inhibitor)• With improvement switch to oral therapy to complete the course

EAU Guidelines 2006

Choice of antibiotics should take into account not only the spectrum of activity

but also resistance

Susceptibility Patterns of Susceptibility Patterns of E.ColiE.Coli from 2003-2007 from 2003-2007 International dataInternational data

E.coli-2003 E.Coli-2004 E.Coli-2005 E.Coli-2006 E.Coli-2007 Average

TMP/Sulfa

Ciprofloxacin

Levofloxacin

Nitrofurantoin

J Urol 2008;178:84

E.coli has highest susceptibility for Nitrofurantoin

Susceptibility patterns of E.coli to variousantibiotics : Indian data

0102030405060708090

T/S A Nx Cf G Ce Ci Nf

T/S- Trimethoprim/Sulfamethoxazole; A- Ampicillin; Nx-Norfloxacin; Cf-Ciprofloxacin; G-Gentamicin; Ce-Cefotaxime; Ci-Ceftriaxone; Nf-Nitrofurantoin

Indian J Med Sci 2006;60:53-58

E.coli has highest susceptibility for Nitrofurantoin

Resistance

• Infecting organisms are not susceptible to antimicrobial agent selected

• Invariably patient has received recent antimicrobial therapy which produces resistance

Incidence of recurrenceIncidence of recurrence

• One in four women will develop recurrence

• 27% of women will experience a recurrence within 6-12 months

Best Pract Res Clin Obstet Gynaecol 2005;19:861-873

Resistance rates in E coli: International data

Ampicillin TMP-SMX Cipro Nitro

Urol Clin Am;2008:35:69-79

Nitrofurantoin has least resistance compared to other commonly used antibiotics

Resistance to TMP-SMX is more than 75%

Resistance rates in E coli: Indian data

More than 80% of the fluoroquinolone resistant strains were found to be

sensitive to Nitrofurantoin

Indian J Med Sci 2006;60:53-58

Resistance to Fluoroquinolones is as high as 69%

Follow-up

Urine Analysis- Bacteriuria

Urine culture- If symptoms do not resolve or recur within 2 weeks

EAU Guidelines 2006

Recurrence

Recurrent UTI is defined as 3 episodes of UTI in the last 12 months or 2 episodes in the

last 6 months

Recurrent UTI occur in 20-25% of women

Risk Factors History of UTI in mother Behavioural factors - Frequency of sexual intercourse - Spermicide cream - Diaphragm EAU Guidelines 2006

Medicine.2007;35:423-427

Prophylaxis for Recurrent UTI

Pharmacological- Antibiotic prophylaxis

Non Pharmacological- Voiding after intercourse- Cranberry juice- Alkalizer (Potassium citrate)

EAU Guidelines 2006

Antibiotic prophylaxis

Long term prophylactic antimicrobials - Taken regularly at bedtime

Post coital prophylaxis- When related to sexual intercourse

95% decrease in UTI episodes/pt year

EAU Guidelines 2006

EAU Guidelines 2010

Long term prophylactic antimicrobials

Taken at bedtime

Drug Dose

NitrofurantoinNitrofurantoin 50/100mg/day50/100mg/day

TMP-SMXTMP-SMX 40/200mg/day or three times weekly40/200mg/day or three times weekly

CefaclorCefaclor 250mg/day250mg/day

CephalexinCephalexin 125/250mg/day125/250mg/day

NorfloxacinNorfloxacin 200mg/day200mg/day

CiprofloxacinCiprofloxacin 125mg/day125mg/day

Fosfomycin 3 g every 10 days

Post coital prophylaxis

EAU Guidelines 2010

Drug Dose

TMP-SMXTMP-SMX 40/200mg40/200mg

NitrofurantoinNitrofurantoin 50/100mg50/100mg

CephalexinCephalexin 250mg250mg

CinoxacinCinoxacin 250mg250mg

CiprofloxacinCiprofloxacin 125mg125mg

NorfloxacinNorfloxacin 200mg200mg

OfloxacinOfloxacin 100mg100mg

No of symptomatic episodes

Long term prophylaxis with nitrofurantoin for 1year (18 years of experience)

Significantly higher no of patients had no symptomatic episodes of UTI

J Antimicrob Chemother.1998;42: 363-371

0 1 2 3 4 5 6 7 8

Nitrofurantoin has maintained its place in the treatment of UTI due to least

resistance

Different forms of Nitrofurantoin

• Nitrofurantoin Microcrystalline - Introduced in 1953

• Nitrofurantoin Macrocrystals - Introduced in 1968

• Nitrofurantoin Monohydrate/Macrocrystals - Novel formulation

Nitrofurantoin Microcrystalline form hadLimitations like

Nitrofurantoin Macrocrystalline form superior to Nitrofurantoin Microcrystal form

- Severe GI side effects like nausea and vomiting- Four times daily dosing

- Better GI tolerability

Nitrofurantoin Monohydrate/Macrocrystal superior to both

- Better GI tolerability- BID dosing

BID QID

)BID dosing associated with significantly

better compliance than QID dosing

Nitrofurantoin monohydrate/macrocrystals

Nitrofurantoin microcrystalline

Nitrofurantoin Monohydrate/Macrocrystals provides BID dosing and

retains the efficacy and safety profiles of Nitrofurantoin macrocrystals

Complicated UTI

• Pregnancy

• Diabetes

• Paediatric UTI

• Catheter associated urinary tract infection (CAUTI)

• Prostatitis

UTI in PregnancyUTI in Pregnancy

Pregnancy

UTIs are detected in 2 to 8% of pregnant women

Clinical presentation

• Asymptomatic• Symptomatic

- Cystitis - Pyelonephritis

- Low birth weight baby- Low gestational age (<37 weeks) and Prematurity - Neonatal mortality

EAU Guidelines 2006

Recommended treatment regimens for asymptomatic

bacteriuria and cystitis in pregnancy Antibiotic Comments

Nitrofurantoin monohydrate / macrocrystals Avoid in G6PD deficiency 100 mg q12 h, 3–5 days

Amoxicillin Increasing resistance 500 mg q8 h, 3–5 days

Co-amoxicillin/clavulanate 500 mg q12 h, 3–5 days

Cephalexin 500 mg q8 h, 3–5 days Increasing resistance

Fosfomycin 3 g Single dose

Trimethoprim–sulfamethoxazole Avoid trimethoprim in q12 h, 3–5 days first trimester/term and sulfamethoxazole in third trimester/term

EAU Guidelines 2010

Recommended treatment regimens for pyelonephitis in pregnancy

Ceftriaxone 1–2 g IV or IM q24 h Aztreonam 1 g IV q8–12 h Piperacillin–tazobactam 3.375–4.5 g IV q6 h Cefepime 1 g IV q12 h Imipenem–cilastatin 500 mg IV q6 h Ampicillin 2 g IV q6 h + gentamicin 3–5 mg/kg/day IV in 3

divided doses

Outpatient management with appropriate antibiotics should be considered provided symptoms are mild and close follow-up is feasible

UTI in DiabetesUTI in Diabetes

Diabetes

Prevalence of UTI is 26% in women with diabetescompared with 6% in those without diabetes

• Asymptomatic• Symptomatic

- Cystitis - Pyelonephritis

Upper tract involvement in diabetes (pyelonephritis) is 5-fold more frequent than in non diabetics and can lead to serious complications like:

• Renal and perinephric abscess• Papillary necrosis

Int J Anti Agents 2000;15: 247-256

Diabetes

Causative organisms

E.Coli - 75%KlebsiellaEnterobacterS.faecalisFungi

Int J Anti Agents 2008;31S:S54-S57

Asymptomatic: Screening and treatment not warranted

Treatment for UTI in diabetic patients

Symptomatic:

• Long term antibiotics (7-14 days)

- Amoxicillin- Nitrofurantoin-TMP/SMX- Ciprofloxacin

• Choice of antimicrobials is similar in diabetic and non diabetics

• Commonly prescribed antibiotics

• TMP/SMX is not a good first choice as in addition to high resistance it can lead to hypoglycemia

Int J Anti Agents 2008;31S:S54-S57

Paediatric UTIPaediatric UTI

UTI in Children

Incidence of pediatric UTI

Pediatr Clin N Am 2006;53:379-400

Age (Y)Age (Y) Female (%)Female (%) Male (%)Male (%)

< 1< 1 0.70.7 2.72.7

1- 51- 5 0.9-1.40.9-1.4 0.1- 0.20.1- 0.2

6-166-16 0.7- 2.30.7- 2.3 0.04- 0.20.04- 0.2

Risk factors for pediatric UTI

• Neonate /Infant

• Urinary tract anomalies (Vesicoureteral reflux)

• Functional abnormalities (Neurogenic bladder) • Immunocompromised states

Pediatric UTI

• Asymptomatic

• Symptomatic- Cystitis - Pyelonephritis

• Poor renal growth

• Recurrent pyelonephritis• Hypertension• End Stage Renal Disease (ESRD)

Classification of pediatric UTI

Urinary Tract Infection

First Infection Recurrent Infection

Unresolved Bacteriuria

BacterialPersistance

Reinfection

Classification of pediatric UTI

Severe UTI Simple UTI

Fever ≥ 39°CFever ≥ 39°C Mild pyrexiaMild pyrexia

Persistent vomitingPersistent vomiting Good fluid intakeGood fluid intake

Serious dehydrationSerious dehydration Slight dehydrationSlight dehydration

EAU Guidelines 2006

Diagnosis of pediatric UTI

Physical Examination +

Urinalysis/Urine culture

> 2 UTI episodes in girls

> 1 UTI episodes in boys

Imaging tests

EAU Guidelines 2006

Treatment of pediatric UTI

Severe UTI Simple UTI

Parental therapy until afebrile• Adequate hydration• Cephalosporins (3rd generation)• Amoxycillin/clavulanate if cocci are present

Oral therapyParental single-dose therapy (only in case of doubtful compliance)• Cephalosporins (3rd generation)• Gentamicin

Oral therapy to complete 10-14 days of treatment

Oral therapy to complete 5-7 days of treatment

EAU Guidelines 2006

Oral antimicrobials for pediatric UTI

Drug Dose (mg/kg/d) Frequency

CephalexinCephalexin 25-5025-50 q 6 hq 6 h

CefaclorCefaclor 2020 q 8 hq 8 h

CefiximeCefixime 88 q 12-24 hq 12-24 h

CefadroxilCefadroxil 3030 q 12-24 hq 12-24 h

NitrofurantoinNitrofurantoin 5-75-7 q 6 hq 6 h

AmpicillinAmpicillin 50-10050-100 q 6 hq 6 h

AmoxicillinAmoxicillin 20-4020-40 q 8 hq 8 h

Drug Dose (mg/kg/d) Frequency

CefazolinCefazolin 25-5025-50 q 6-8 hq 6-8 h

CefotaximeCefotaxime 50-18050-180 q 4-8 hq 4-8 h

CeftriaxoneCeftriaxone 50-7550-75 q 12-24 hq 12-24 h

CeftriazidimeCeftriazidime 90-15090-150 q 8-12 hq 8-12 h

CefepimeCefepime 100100 q 12 hq 12 h

AmpicillinAmpicillin 50-10050-100 q 6 hq 6 h

GentamicinGentamicin 7.57.5 q 8 hq 8 h

Parenteral antimicrobials for pediatric UTI

Antibiotic prophylaxis for Pediatric UTI

If there is an increased risk of UTI due to congenital abnormalities, low dose

prophylaxis is recommended

Drug Daily dosage (mg/kg/d)

Age limitation

CephalexinCephalexin 2-32-3 NoneNone

NitrofurantoinNitrofurantoin 1-21-2 >1 month>1 month

TMP-SMXTMP-SMX 1-21-2 >2 month>2 month

Catheter Associated Urinary Tract Infections (CAUTI)

The most common nosocomial infection ( 40 %) Causes bacteremia in 2-4 % of patients Risk factors Increasing duration of use Female sex Absence of antibiotics Disconnection of catheter-collecting tube junction

American journal of medicine 1991; 16 (Suppl 3 B) : 65 S -70 S

CAUTI – Pathogenesis

Two routes of entry-

• Periurethral

Common in femalesBacteria from rectal flora – Ecoli

• Intraluminal

Common in men Pseudomonas, Proteus etc

Intraluminal Route : Pathogenesis

BACTERIA

Attached to inner surface of catheter

Growing within urine itself

BIOFILM Planktonic growth

Biofilm Formation

Bacteria attached to inner surface of catheter

Sheets of organisms coat cather

Secrete extracellular matrix of bacterial glycocalyces

Tamm-Horsfall protein and urinary salts are incorporated in biofilm growth

Encrustation of catheter & catheter obstruction

Psudomonas are highly associated with propensity to form biofilm.

BIOFILM FORMATION BIOFILM FORMATION

PLANKTONIC BACTERIAPLANKTONIC BACTERIA

ATTACHMENTATTACHMENT

MICROCOLONIESMICROCOLONIES

BIOFILM COMMUNITYBIOFILM COMMUNITY

Arch Intern Med / Vol.164,Apr 26,2004Arch Intern Med / Vol.164,Apr 26,2004

Decreased susceptibility to antibioticsDecreased susceptibility to antibiotics

• Physical impairment of diffusion of antibiotic agentPhysical impairment of diffusion of antibiotic agent• Trapping of antibiotic within matrix Trapping of antibiotic within matrix • Increased resistance rateIncreased resistance rate

Misleading microbiological laboratory resultMisleading microbiological laboratory result

Lacking of intrinsic defense systemLacking of intrinsic defense system

Clinical ImplicationClinical Implication

Arch Intern Med / Vol.164,Apr 26,2004Arch Intern Med / Vol.164,Apr 26,2004

The duration of catheterisation should be minimal

Prophylactic antibiotics and Chronic antibiotic suppressive therapy is generally not recommended

PreventionPrevention

EAU Guidelines 2010

Treatment for CAUTITreatment for CAUTI

• In case of symptomatic CAUTI, replace or remove the catheter before starting antimicrobial therapy if the indwelling catheter has been in place for > 7 days

• For empirical therapy, broad-spectrum antibiotics should be given based on local susceptibility patterns

• After culture results are available, antibiotic therapy has to be adjusted according to sensitivities of the pathogens

EAU Guidelines 2010

ProstatitisProstatitis

Most common urological diagnosis in men < 50 Most common urological diagnosis in men < 50 years and the third most common > 50 yearsyears and the third most common > 50 years

10% of men have prostatitis like symptoms10% of men have prostatitis like symptoms Life time probability > 25%Life time probability > 25% Rates are similar in Asia, USA and EuropeRates are similar in Asia, USA and Europe

Prostatitis : How big is the problem?Prostatitis : How big is the problem?

Diagnosis: Quantitative segmental bacterial Diagnosis: Quantitative segmental bacterial localization culture (Meares and Stamey)localization culture (Meares and Stamey)

NIH Classification of ProstatitisNIH Classification of Prostatitis

CasesCases (%)(%)

Mid stream Mid stream Urine sepcimenUrine sepcimenWBC WBC CultureCulture

Prostatic Prostatic specimen (EPS specimen (EPS or VB3)or VB3)WBC WBC CultureCulture

ABP (I)ABP (I) < 1< 1 ++ +++ + ++ + ++ +

CBP(II)CBP(II) 5-105-10 + ++ + + ++ +

CP/CPPS(III)CP/CPPS(III)Inflammatory (IIIA)Inflammatory (IIIA)Non Non inflammatory(IIIB)inflammatory(IIIB)

80-9080-90- -- -- -- -

+ -+ -- -- -

AIP AIP (asymptomatic (asymptomatic inflammatory inflammatory prostatitis)prostatitis)

1010 + -+ - - -- -

Which antibiotics?Which antibiotics?Prerequisites for use of antibiotics for CBPPrerequisites for use of antibiotics for CBP

• Active against expected pathogens

• Effective penetration into the prostatic tissue

• Well tolerated – prolonged therapy (up to 12 weeks)

• Convenient to take

Pathogens causing CBPPathogens causing CBP

Generally acceptedGenerally accepted

Escherichia coli Escherichia coli (50-80%)(50-80%) Klebsiella pneumoniaeKlebsiella pneumoniae Proteus miribalisProteus miribalis Pseudomonas Pseudomonas

aeruginosaaeruginosa Enterococcus faecalisEnterococcus faecalis

Potential Potential

Staphylococcus Staphylococcus saprophyticussaprophyticus

Staphylococcus aureusStaphylococcus aureus Staphylococcus Staphylococcus

epidermidisepidermidis StreptococcusStreptococcus Mycoplasma genitaliumMycoplasma genitalium Ureaplasma urealyticumUreaplasma urealyticum Chlamydia trachomatisChlamydia trachomatis

Campbells Urology, 9th edition

Treatment Treatment Chronic Bacterial ProstatitisChronic Bacterial Prostatitis

• favourable pharmacokinetic properties • excellent penetration in prostatic tissue• antibacterial activity against gram negative

pathogens, including Pseudomonas aeruginosa as well as gram positive pathogens

• good safety profile

EAU Guidelines 2010

Eur Urol Suppl 2007;6(2):72

Fluoroquinolones such as ciprofloxacin, levofloxacinand prulifloxacin may be considered as drugs of choicebecause of their:

Prulifloxacin 600 mg Vs Prulifloxacin 600 mg Vs Levofloxacin 500 mg in CBPLevofloxacin 500 mg in CBP

At 2 weeks there was a At 2 weeks there was a greater reduction in greater reduction in symptom scoressymptom scores

At 6 months 5 patients on At 6 months 5 patients on Prulifloxacin had a positive Prulifloxacin had a positive Meares-Stamey test Vs 11 Meares-Stamey test Vs 11 in the levofloxacin groupin the levofloxacin group

Well toleratedWell tolerated

N =96, 4 weeks treatment

Prulifloxacin is as effective and safe as levofloxacin In the treatment of CBPWith prulifloxacin there was trend to an earlier resolution of symptoms.

Eur Urol Suppl 2007;6(2):72

Highlights

• UTI is the common infection occurring in young women

• The most common presentation in young non-pregnant women is acute uncomplicated cystitis

• The recommended treatment for acute uncomplicated cystitis Is short course with antimicrobials like:

- Fosfomycin - Nitrofurantoin - TMP/SMX

• The most common pathogen causing UTI is E.coli

Highlights

• Choice of antibiotics should take into account not only the spectrum of activity but also resistance• E.Coli has highest susceptibility and least resistance for nitrofurantoin as compared to other commonly used antimicrobials

• Nitrofurantoin has maintained its place in the management of Uncomplicated cystitis due to highest susceptibility and least resistance

• The newer formulation of nitrofurantoin (Nitrofurantoin monohydrate/macrocrystals) offers the advantage of better GI tolerability and BID dosing, which improves the compliance

Highlights

• One year prophylaxis with nitrofurantoin significantly reduces the no of symptomatic episodes

• The antimicrobials used for prophylaxis are: Fluoroquinolones, nitrofurantoin,TMP/SMX, cephalosporins etc.

• Recurrent UTI can be managed by offerring long term prophylaxis or post coital prophylaxis

• A major concern in the treatment of UTI is recurrence and one in four women will develop recurrence

Highlights

• Fluroquinolones may be considered for empiric therapy of complicated UTI due to their broad spectrum antibacterial activity and good tissue penetration

• The treatment duration for the symptomatic UTI in pregnant women should be 10-14 days

• Asymptomatic bacteriuria in pregnant women should be treated

• The choice of antimicrobials in diabetic patients is similar to non diabetics but the duration should be 10-14 days

THANK YOU

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