Urinary Tract Infections Unraveled Materials

URINARY TRACT INFECTIONS UNRAVELED: COMPREHENSIVE APPROACHES TO DIAGNOSIS AND MANAGEMENT FOR HEALTHCARE PROVIDERS

L. Austin Fredrickson, MD, FACP

Dr. Fredrickson is an Assistant Professor of Internal Medicine at the Northeast Ohio Medical University College of Medicine, where he serves as a course director and core teaching faculty. He is board-certified in Internal Medicine and is a practicing general internist.

Topic Overview

Urinary Tract Infections (UTIs) are among the most prevalent bacterial infections encountered in clinical practice, affecting individuals across all age groups, and presenting unique challenges in diagnosis, treatment, and prevention. As the landscape of antibiotic resistance grows and patient demographics shift, it becomes increasingly critical for healthcare professionals to stay abreast of the latest insights and strategies related to UTIs.

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RxCe.com LLC is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education.

Universal Activity Number (UAN): The ACPE Universal Activity Number assigned to this activity is 

Pharmacist  0669-0000-23-207-H01-P

Pharmacy Technician  0669-0000-23-208-H01-T

Credits: 1 contact hour of continuing education credit

Type of Activity: Knowledge

Media: Internet/Home study Fee Information: $4.99

Estimated time to complete activity: 1 contact hour, including Course Test and course evaluation

Release Date: December 4, 2023 Expiration Date: December 4, 2026

Target Audience: This educational activity is for pharmacists.

How to Earn Credit: From December 4, 2023, through December 4, 2026, participants must:

Read the “learning objectives” and “author and planning team disclosures;”

Study the section entitled “educational activity;” and

Complete the Course Test and Evaluation form. The Course Test will be graded automatically. Following successful completion of the Course Test with a score of 70% or higher, a statement of participation will be made available immediately. (No partial credit will be given.)

Credit for this course will be uploaded to CPE Monitor®.

Learning Objectives: Upon completion of this educational activity, participants should be able to:

Describe the anatomy and pathophysiology of urinary tract infections (UTIs), including common microorganism causes

Recall the clinical presentation of UTI, including signs and symptoms

Compare and contrast approaches to diagnosing UTIs

Describe the pharmacologic management of UTIs, including mechanisms of action and side effects of commonly utilized antibiotic agents

Disclosures

The following individuals were involved in developing this activity: Austin Fredrickson, MD, FACP, Liz Fredrickson, PharmD, BCPS, and Pamela M. Sardo, PharmD, BS. Pamela M. Sardo was an employee of Rhythm Pharmaceuticals until March 2022 and has no conflicts of interest or relationships regarding the subject matter discussed. There are no financial relationships relevant to this activity to report or disclose by any of the individuals involved in the development of this activity.

© RxCe.com LLC 2023: All rights reserved. No reproduction of all or part of any content herein is allowed without the prior, written permission of RxCe.com LLC.

Introduction

Urinary tract infections represent one of the most prevalent bacterial infections encountered in clinical practice, affecting individuals across all age groups and presenting distinct challenges in terms of diagnosis, treatment, and prevention. The treatment of urinary tract infections involves eradicating the causative organism and averting recurrent infections. Complications associated with this condition may also arise. Antibiotics are used in treatment, but causative organisms can become resistant to these drugs. As the landscape of antibiotic resistance continues to evolve, alongside shifts in patient demographics, it becomes increasingly imperative for healthcare professionals to remain well-informed about the latest insights and treatment strategies pertaining to urinary tract infections.

Definitions and Classification

Urinary tract infections (UTIs) are characterized by the presence of microorganisms in the urinary tract that cannot be attributed to contamination or normal urogenital flora.1 These infections manifest as either cystitis, affecting the bladder or lower urinary tract, or pyelonephritis, involving the upper urinary tract or kidney.1 Broadly, UTIs are categorized into two types: upper UTIs and lower UTIs.1 Lower UTIs manifest as cystitis within the bladder, or urethritis within the urethra, whereas upper UTIs include pyelonephritis, an infection of the kidney(s).1 Additionally, UTIs can be further delineated as either complicated or uncomplicated.1 Uncomplicated UTIs typically affect normally healthy individuals, predominantly women between the ages of 15 and 45.1 On the other hand, complicated UTIs arise in all other situations that do not meet simple UTI criteria, often they arise due to some lesion or abnormality in the urinary tract, such as the presence of a stone or an indwelling catheter.1 Similarly, UTIs are complicated in all immunocompromised patients, male patients, and those with fever, calculi, sepsis, and obstruction.1 The presence of complicated UTIs is often signaled by specific symptoms in conjunction with pyuria or bacteriuria, including:

Fever of >99.92

Flank pain2

Costovertebral angle tenderness2

Other signs and symptoms of systemic illness, such as chills or significant malaise2

Finally, UTIs can be categorized as recurrent when two or more UTIs occur within a span of six months or three or more UTIs occur within the span of a year.1 If a different organism causes the second or third UTI, this is referred to as a reinfection.1 A relapse is a repeat infection with the initial organism, suggesting a persistent infectious source may be present.1

Asymptomatic bacteriuria (ASB) occurs when significant bacteriuria (meaning more than 105 bacteria/mL) is present despite no UTI signs and symptoms.1 This is more common among patients 65 years of age and older. Significant bacteriuria is the presence of microorganisms that are causing a true infection rather than contamination of the urine.1 The diagnostic criteria for significant bacteriuria are detailed in Table 1.1

Table 1

Diagnostic Criteria for Significant Bacteriuria1,2

Terminology pertaining to urinary tract infections is defined and summarized in Table 2.

Table 2

Terminology Pertaining to Urinary Tract Infections1,3,4

Epidemiology and Etiology

Clinicians may encounter UTIs in various clinical settings, including primary care offices and emergency departments, and an estimated 150 million new cases are present each year in the United States.3 UTIs are most prevalent among female patients, given the anatomical length of the urethra is much shorter than males.2 In fact, approximately half of women will develop a UTI before the age of 35, while almost 70% will experience at least one UTI during their lifetime.2

The initiating event of a UTI is inoculation.3 Normally, the urinary tract is resistant to invading microorganisms.1 Important factors contributing to the infection are host factors, inoculum size, and the virulence of the microorganism.1,3 There are several risk factors associated with UTIs, which vary depending on the patient's age.1,3 Common risk factors include sexual intercourse, a prior history of UTIs, use of spermicide-coated condoms, and comorbidities such as diabetes mellitus or other causes of glucosuria.2 Predisposing factors are summarized in Table 3.

Table 3

Predisposing Factors to Infection2,3

Microbial Spectrum Causing UTIs

The most prevalent causative microorganisms of UTIs often originate from the gastrointestinal tract.1 In uncomplicated UTIs, the primary culprits include Escherichia coli (E. coli), accounting for a substantial 75-90% of community-acquired infections, along with Staphylococcus saprophyticus, Klebsiella pneumoniae, Proteus, Pseudomonas aeruginosa, and Enterococcus spp.1 Notably, microorganisms such as lactobacilli, enterococci, Group B streptococci, and coagulase-negative staphylococci (excluding S. saprophyticus) are more likely to signify specimen contamination.2

In the case of complicated UTIs, E. coli remains a common culprit, although it is responsible for only about half of the infections.1 Other frequently encountered microorganisms in complicated UTIs encompass Proteus spp., K. pneumoniae, Enterobacter spp., P. aeruginosa, staphylococci, and enterococci.1 In the context of hospitalized patients, Enterococci species have emerged as a prevalent cause, with vancomycin-resistant strains such as E. faecalis and E. faecium being more common among patients with prolonged hospital stays or residing in institutional healthcare settings.1 Typically, UTIs are attributed to a single microorganism; however, certain patients, including those with indwelling catheters or kidney stones, may exhibit multiple culprits as they can ‘seed’ easier.1 In such instances, it is advised for clinicians to verify the causative bacteria through a repeat evaluation, as the presence of multiple microorganisms could possibly also be indicative of contamination.1,2

It is also essential to acknowledge that pregnancy can also be a significant predisposing factor for UTIs, with an estimated 5-10% of women experiencing a UTI during their pregnancy.1,2 Within the spectrum of pregnancy-associated UTIs, bacteriuria can manifest as asymptomatic bacteriuria (ASB), cystitis, or pyelonephritis.1,2

Pathophysiology

There are three routes by which bacteria can gain access to the urinary tract. These include the ascending, descending, and lymphatic pathways.1,3 As stated above, UTIs are more likely in female patients, given their anatomic location and length of the urethra, and ascending UTIs are the most common.1 The female urethra can become colonized by bacteria that originate from fecal or vaginal flora due to proximity and activity.1 Descending pathways, including infection from an adjacent intraabdominal organ or fistula, are less common. Lymphatics can also serve as a pathway, typically from infected nearby tissues.1

Diagnosis of UTI

The classic signs and symptoms of UTIs are detailed in Table 4. Classic symptoms of cystitis include dysuria, urinary frequency, urinary urgency, and suprapubic pain.2 Dysuria is a key symptom; in fact, acute-onset dysuria is associated with 90% accuracy in UTI diagnosis when women do not have symptoms of vaginal irritation or discharge.4 Hematuria (microscopic or macroscopic) is common, but generally, patients do not present with signs of fever.1 Additionally, patients with significant bacteriuria may not have any signs or symptoms of UTIs.1 Older adult patients can sometimes present with altered mental status, a change in eating habits, or gastrointestinal symptoms when a UTI is present, making a diagnosis in this population difficult.1 Acute- onset dysuria is a notable diagnostic indicator in older women, especially when

the patient is also experiencing either new or worsening symptoms.4 Non- specific symptoms in this patient population, such as cloudy urine, vaginal dryness or burning, pelvic discomfort, and urinary incontinence, are common but also tend to occur more chronically. In particular, chronic nocturia and incontinence were not found to be specific for UTI.5

Table 4

Signs and Symptoms of UTIs in Adult Patients1

In the diagnostic process of bacterial UTIs, it is crucial to emphasize that symptoms alone should not serve as the sole basis for diagnosis.1 Instead, a comprehensive approach involving physical examination and laboratory testing should be employed to differentiate between contamination and infection.1 Central to this diagnostic evaluation is the collection and examination of urine samples.1 The preferred method for this purpose is the midstream clean-catch technique, which involves voiding the first 20mL of urine and then collecting the subsequent portion of the urinary flow.1

Diagnosis of a UTI hinges on the isolation of a substantial bacterial quantity from the urine specimen.1,2 Specifically, when 105 colony-forming units per milliliter (CFU/mL) or more bacteria are detected, it indicates the presence of a UTI.1,2 However, it is important to note that approximately 50% of women presenting with UTI symptoms may exhibit lower bacterial counts.1 In several studies, a threshold of 102 CFU/mL or greater has demonstrated an 88-93% positive predictive value for bladder bacteriuria in patients with a strong suspicion of UTI.6,7

The confirmation of pyuria, signifying the presence of leukocytes, further supports the diagnosis of significant bacteriuria when observed in symptomatic patients.1 Pyuria is defined as a white blood cell (WBC) count

exceeding 10 x 106/L.1 It is imperative to recognize that pyuria is indicative of inflammation but not necessarily indicative of infection.1 To detect pyuria, a leukocyte esterase dipstick test can be effectively employed. Furthermore, it is essential to underscore that hematuria, the presence of blood in the urine, is nonspecific to UTIs.1 Dipstick tests can also be utilized to determine the presence of nitrite in urine, which is produced by bacteria as they reduce nitrate to nitrite, serving as an additional diagnostic indicator.1

Management of UTIs

The treatment of UTIs revolves around four primary objectives:

1) eradicating the causative organism, 2) preventing or addressing any associated complications, 3) averting recurrent infections, and 4) mitigating the risk of antimicrobial resistance.1 The comprehensive management plan for a UTI patient entails a systematic evaluation, careful antibiotic selection, determination of therapy duration, and diligent follow-up.1

In the process of selecting appropriate antimicrobial agents, clinicians must consider several critical factors, including the severity of the patient's clinical presentation, the precise site of infection, the distinction between complicated and uncomplicated cases, antibiotic susceptibility patterns, potential side effects, and any recent history of antibiotic exposure.1 The chosen antibiotics should be able to attain therapeutic concentrations within the urinary tract, enabling the effective eradication of the offending bacteria.1

Beyond pharmacological interventions, nonpharmacologic options can also play a role in managing UTIs.1 One such strategy involves increasing fluid intake, which serves to dilute bacteria and facilitate the expulsion of infected urine through voiding.1 Additionally, the consumption of cranberry juice has been long advised as a means to augment the activity of antibiotics in the urine while also serving as a prophylactic measure against UTIs.1 This effect is attributed to the presence of fructose and proanthocyanins in cranberry juice, which disrupt bacterial adherence mechanisms.1 While studies have not consistently demonstrated significant benefits, individuals experiencing

recurrent UTIs may derive some advantage from a daily intake of 36 mg of proanthocyanins.1

On the other hand, the use of ascorbic acid to acidify urine is not a recommended approach, as it lacks the capacity to substantially alter urine acidity.1 For symptomatic relief of UTIs, over-the-counter phenazopyridine is available and can effectively alleviate dysuria, predominately by diminishing bladder spasms. However, it is important to note potential side effects, which encompass the discoloration of bodily fluids to a red-orange hue, rare instances of anaphylaxis, and, infrequently, acute renal failure.1 The recommended dosage is a maximum of 200 mg three times a day, with a duration of use limited to 1-2 days.1

Pharmacologic Management

Antibiotics are the cornerstone of the treatment of UTIs. Practitioners must employ good antimicrobial stewardship practices when prescribing antibiotic therapy. The antibiotic therapy chosen depends on several factors, including the site of the infection, host factors, and bacterial factors.1 Whichever antibiotic is selected, it should be well-tolerated by the patient, absorbed well, achieve high urinary concentration, and have a spectrum of activity that targets suspected or confirmed pathogens.1 Commonly utilized antibiotics are detailed in Tables 5 and 6.

Table 5

Common Oral Antimicrobial Therapies for UTIs1

Table 6

Common Parenteral Antibiotics Utilized for UTIs1

It is vital that clinicians approach the treatment of UTIs from an antimicrobial stewardship perspective. This considers not only a patient’s antibiotic use history but also geographic resistance patterns.1 For example, the resistance of E. coli to amoxicillin is nearly 40%.1 Resistance of E. coli to TMP-SMX continues to grow and is around 27%.1 Patients with current or recent exposure to antibiotics are most likely to develop E. coli resistance with TMP-SMX.1 Due to increased resistance, first-line agents for the treatment of acute, uncomplicated UTIs include nitrofurantoin, Fosfomycin, and TMP-SMX, with nitrofurantoin and Fosfomycin having the highest E. coli susceptibility with little effect on a patient’s gut flora.1

Acute, Uncomplicated Urinary Tract Infections

Acute, uncomplicated UTIs are the most common form and most likely to occur in females of childbearing age.1 Therapy should target E. coli, given this is the most common microorganism.1 If patients present with lower tract symptoms and significant bacteriuria is present, a short-course therapy of antibiotics can be initiated.1 This includes a three-day course of TMP-SMX, a 5-days course of nitrofurantoin, or a one-time dose of Fosfomycin. Dosing is detailed in Table 7.8,10,19 If clinical failure occurs, a urine culture can be

performed to determine the presence of microbes.1 If this is positive, the patient can be retreated for two weeks with a follow-up urine culture.1 If the culture remains positive after two weeks, whether a relapse or reinfection is present should be determined.1 Relapses should prompt a urologic work-up, while reinfection, if frequent, should prompt a discussion about urologic hygiene, risk factors, and possibly suppressive postcoital therapy.1 Fluoroquinolones are not recommended for initial therapy and should be saved for patients with pyelonephritis.1

Table 7

Antibiotic Dosing for Acute, Uncomplicated Urinary Tract Infections8,10,19

Symptomatic Bacteriuria

Symptomatic bacteriuria is present when patients present with dysuria and pyuria but less than 105 bacteria/mL.1 Patients may have some other infection present (such as Chlamydia), which requires treatment.1

Asymptomatic Bacteriuria

Relapse and reinfection are common with ASB, making it challenging to treat and eradicate.1 If patients are not pregnant, treatment is controversial.1 Patients with neurocognitive baseline deficits may be more difficult to ascertain if symptom changes are due to UTI or another source.

Complicated UTIs

Patients who present with high-grade fevers and severe flank pain necessitate immediate attention for the management of acute pyelonephritis.1 While milder cases may be effectively treated with oral antibiotics, severely ill patients will invariably require intravenous antibiotics and hospital admission.1 The duration of oral antibiotic therapy typically spans 7 to 14 days, with the specific choice of agent influencing the duration.1

In cases of mild to moderate pyelonephritis, fluoroquinolones stand as the first-line treatment option.1 Alternatively, TMP-SMX represents a viable second-line choice.1 For instances of severe pyelonephritis, a regimen with broad-spectrum coverage becomes imperative.1 Here, therapeutic options encompass fluoroquinolones, aminoglycosides in conjunction with or without ampicillin, as well as extended-spectrum cephalosporins either with or without aminoglycosides and carbapenems.1

Furthermore, it is essential to consider the potential involvement of Pseudomonas and enterococci in patients who have been hospitalized within the past six months, those with urinary catheters, or individuals residing in nursing homes.1 These factors warrant a heightened clinical suspicion and appropriate consideration in the selection of antibiotics.1

Recurrent Infections

It is estimated that 80% of recurrent infections are reinfections, or an infection by a different microorganism than the initial infection.1 Management is patient-specific and depends on predisposing factors, the number of

episodes per year, and the patient’s preference.1,4 It is recommended that clinicians obtain a thorough and complete patient history and perform a pelvic examination in women with recurrent UTIS.4 To diagnose a recurrent infection, clinicians must document positive urine cultures associated with prior symptomatic episodes.4 Further, guidelines recommend clinicians obtain a urinalysis, urine culture, and sensitivity with each symptomatic acute cystitis episode before initiating treatment in patients with recurrent UTIs.4

Asymptomatic bacteriuria should not be treated.4 Management options include self-administered antibiotic therapy, postcoital therapy, and continuous, low-dose prophylaxis.1 First-line therapies include nitrofurantoin, TMP-SMX, and Fosfomycin. The choice depends on the local antibiogram for the treatment of symptomatic UTIs in women.1 Guidelines suggest clinicians offer patient-initiated treatment (self-start treatment) to select patients with acute episodes while awaiting urine cultures.4 Short-course therapies are preferred in these settings.4 Prophylactic therapy options include TMP-SMX (1/2 single strength tablet), trimethoprim 100 mg daily, levofloxacin 500 mg daily, and nitrofurantoin 50 or 100 mg daily.1 Therapy duration is commonly 6 months.1

Antimicrobial Stewardship

Resistance among various urologic pathogens has significantly increased in the past two decades.4 This includes an increase in extended-spectrum B- lactamase (ESBL) producing bacteria.4 Because an uncomplicated UTI is among the most common reasons for women to be exposed to antibiotics, it is critical that clinicians practice antimicrobial stewardship to avoid contributing to resistance levels and having their patients experience untoward outcomes.4 Antimicrobial stewardship programs are multifactorial and involve reducing the use of inappropriate treatments, decreasing the use of broad-spectrum antibiotics, utilizing antimicrobial therapy for the shortest, most effective duration, and adhering to current guideline recommendations.4

Summary

Most urinary tract infections are caused by E. coli, and complicated infections can be associated with Enterococcus faecalis and other gram- negative bacteria.1

Lower urinary tract infection symptoms include dysuria, frequency, and nocturia. Fever, nausea, and vomiting are symptoms associated with upper urinary tract infections.1

There are multiple antimicrobial treatments for UTIs, as well as OTC options.

The goals of UTI treatment include eradicating the invading organism, preventing and treating sequelae, preventing re-infections, and avoiding antimicrobial resistance through the use of good antimicrobial stewardship practices.1

Clostridium difficile-associated diarrhea (CDAD) has been reported with the use of nearly all antibacterial agents. If the pharmacy technician notices a patient purchasing an anti-diarrheal with an antibiotic, the pharmacist should be notified.20

In a private counseling area, patients can be counseled to keep the genital area clean and dry and to avoid potentially irritating products in the genital area, such as scented soaps, deodorants, powders, or douches23

Patients may be counseled to use a spermicide alternative contraception

Patients may be counseled to keep well hydrated because beverages such as coffee, tea, alcohol, and high-sugar drinks can contribute to UTIs

Pharmacy technicians can add auxiliary labels regarding drinking with plenty of water, completing the full course of therapy as directed by the prescriber, and product-specific auxiliary labels warning of prolonged exposure to sunlight

Course Test

What defines a lower urinary tract infection (UTI)?

Infection of the bladder and kidneys

Infection of the bladder or urethra

Infection of the kidneys only

Infection of the ureter only

Which of the following is a characteristic of complicated UTIs?

Affects only healthy individuals

Occurs due to simple UTI criteria

Arises due to lesions or abnormalities in the urinary tract

Occurs exclusively in women aged 15 to 45

What is the definition of recurrent UTIs?

Two or more UTIs within six months or three or more within a year

UTIs that occur only in women

A single UTI that recurs after treatment

UTIs that occur only in immunocompromised patients

Which of the following correctly ties the definition of asymptomatic bacteriuria (ASB) to its treatment for most healthy, uncomplicated patients?

Presence of bacteria in the urine causing illness: antibiotics

Infection of the urinary tract with symptoms: monitoring alone

Significant bacteriuria without UTI signs and symptoms: no treatment

Presence of bacteria in urine only in symptomatic males: no treatment

Which microorganism accounts for a substantial percentage of community-acquired uncomplicated UTIs?

Escherichia coli (E. coli)

Staphylococcus saprophyticus

Klebsiella pneumoniae

Proteus

What symptom is associated with 90% accuracy in UTI diagnosis in women without vaginal irritation or discharge?

Hematuria

Suprapubic pain

Urinary frequency

Acute-onset dysuria

Which of the following is the best recommended initial therapy for acute, uncomplicated UTIs?

Amoxicillin

Ciprofloxacin

Trimethoprim-sulfamethoxazole (TMP-SMX)

Levofloxacin

What should be done if clinical failure occurs after the initial treatment of a UTI?

Perform a urine culture to determine the presence and identity of microbes

Immediately switch to a broader antibiotic

Increase the dosage of the current antibiotic

Stop antibiotic therapy altogether

A sexually active but nonpregnant 38-year-old woman presents for a life insurance examination. She is found to have 105 bacterial/mL present in her urine upon routine testing. She denies any urinary symptoms, immunocompromised state, or urogenital abnormality. Her condition can best be diagnosed as

complicated UTI.

uncomplicated UTI.

asymptomatic bacteria.

a sexually transmitted infection.

Which diagnostic method provides information about the specific bacteria causing the infection and their susceptibility to antibiotics when evaluating a patient with a UTI?

Urinalysis, microscopic

Urine culture

Renal ultrasonography

Urine dipstick test

References

Fernandez JM, Coyle EA. Urinary Tract Infections. In: DiPiro JT, Yee GC, Haines ST, Nolin TD, Ellingrod VL, Posey L. eds. DiPiro’s Pharmacotherapy: A Pathophysiologic Approach, 12th Edition. McGraw Hill; 2023.

Gupta K. Acute simple cystitis in females. Uptodate. June 12, 2023. Accessed October 2023.

Abou Heidar NF, Degheili JA, Yacoubian AA, Khauli RB. Management of urinary tract infection in women: A practical approach for everyday practice. Urol Ann. 2019;11(4):339-346. doi:10.4103/UA.UA_104_19

Anger JT, Bixler BR, Holmes RS, Lee UJ, Santiago-Lastra Y, Selph SS. Updates to Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline. J Urol. 2022;208(3):536-541. doi:10.1097/JU.0000000000002860

Boscia JA, Kobasa WD, Abrutyn E, Levison ME, Kaplan AM, Kaye D. Lack of association between bacteriuria and symptoms in the elderly. Am J Med. 1986;81(6):979-982. doi:10.1016/0002-9343(86)90391-8

Stamm WE, Counts GW, Running KR et al: Diagnosis of coliform infection in acutely dysuric women. N Engl J Med. 1982;307:463.

Hooton TM, Roberts PL, Cox ME, Stapleton AE. Voided midstream urine culture and acute cystitis in premenopausal women. N Engl J Med. 2013;369(20):1883-1891. doi:10.1056/NEJMoa1302186

Sulfamethoxazole and Trimethoprim (Double Strength) Tablets, USP. Prescribing information. Fosun Pharma USA Inc. September 2019. https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/018598s0 52lbl.pdf. Accessed November 16, 2023.

Macrodantin. Prescribing information. Almatica Pharma LLC. June 2020. https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/016620Or ig1s076lbl.pdf. Accessed November 16, 2023.

Monurol. Prescribing information. Allergan USA, Inc. May 2018. https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/050717s0 09lbl.pdf. Accessed November 16, 2023.

Cipro. Prescribing information. Bayer HealthCare Pharmaceuticals Inc. November 2011. https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/019537s0 74,020780s032lbl.pdf. Accessed November 16, 2023.

Amoxicillin/Clavulanate Potassium Tablets. Prescribing information. Penn Labs, Inc. December 2006. https://www.accessdata.fda.gov/drugsatfda_docs/label/2008/050564s0 50lbl.pdf. Accessed November 16, 2023.

Cefaclor. Prescribing information. Eli Lilly. March 2003. https://www.accessdata.fda.gov/drugsatfda_docs/label/2004/50521slr0 27,50522slr027_cefaclor_lbl.pdf. Accessed November 16, 2023.

Gentamycin sulfate. Prescribing information. Hospira, Inc. October 2022. https://labeling.pfizer.com/ShowLabeling.aspx?id=4470.

Accessed November 16, 2023.

Unasyn. Prescribing information. Pfizer Inc. April 2018. https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/050608s0 46lbl.pdf. Accessed November 16, 2023.

Rocephin. Prescribing information. Roche Laboratories, Inc. 2009. https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/050585s0 61lbl.pdf. Accessed November 16, 2023.

Primaxin. Prescribing information. Merck & Co., Inc. 2018. https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/050587s0 81lbl.pdf. Accessed November 16, 2023.

Cipro. Prescribing information. Bayer HealthCare Pharmaceuticals Inc. November 2011. https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/019537s0 74,020780s032lbl.pdf. Accessed November 16, 2023.

Macrodantin. Prescribing information. Almatica Pharma LLC. June 2020. https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/016620Or ig1s076lbl.pdf. Accessed November 16, 2023.

Urinary tract infections (UTIs). NHS. March 2022. www.nhs.uk/conditions/urinary-tract-infections-utis. Accessed November 16, 2023.

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The information provided in this course is general in nature, and it is solely designed to provide participants with continuing education credit(s). This course and materials are not meant to substitute for the independent, professional judgment of any participant regarding that participant’s professional practice, including but not limited to patient assessment, diagnosis, treatment, and/or health management. Medical and pharmacy practices, rules, and laws vary from state to state, and this course does not cover the laws of each state; therefore, participants must consult the laws of their state as they relate to their professional practice.

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