2.7 THERAPEUTIC TRIALS OF UTI IN DIABETICPATIENTSMany therapeutic trials prefer antimicrobial agents that achievehigh levels in the urine and also in the renal tract tissues, such as Fluoroquinolones,Trimethoprim-Sulphamethoxazoleand Amoxycillin-Clavulanic acid. This may be thepathogenesis indicating invasion of E.

coliinto the bladder cells (Ornaetal., 2015). Few therapeutic trials have beenperformed specifically with diabetic patients. Due to frequent upper urinary tractinvolvement and possibilities of serious complications many experts recommend a7–14-day oral antimicrobial regimen for bacterial cystitis in diabetic patients,instead of the usually recommended 3-day course. The standard duration of therapyfor uncomplicated pyelonephritis in both diabetic as well as non-diabeticpatients is 14 days. However, studies have shown a 7-day course of oral ciprofloxacinis effective for uncomplicated pyelonephritis. Vigilance for complications mustoccur throughout the care of an acutely ill patient with UTI. As thesecomplications are common in patients with diabetes, their anticipation may leadto earlier interventions and fewer serious adverse outcomes (Geerlings, 2008).

There is no indication to treat asymptomatic bacteriuria (ASB) indiabetic patients. Though earlier studies indicated that bacteriuria may beassociated with progression to symptomatic UTI and with deteriorating renal functionin diabetic patients,later studies found that diabetic women with ASB do nothave an increased risk for a faster decline in renal function, and that thereare no short- or long-term benefits from the treatment of ASB in diabeticwomen. A placebo-controlled, random­ized prospective study of 105 women havingdiabetes mellitus found that during a mean follow-up period of 27 months,antibiotic treatment did not affect the rate of symptomatic UTI,pyelonephritis, or hospitalizations for UTI. A study from 2006 found that ASBby itself is not associated with an increased rate of renal impairment progressionor long term complications during 6 years of follow-up in patients withdiabetes. Another study that involved diabetic women with ASB for up to 3 yearsfound that bacteriuria persists or recurs in most women, is benign, and seldompermanently eradicable. All the above studies showed that women with ASBreceived multiple courses of antibiotic therapy, which may result in increasedantibiotic resistance.

Acute cystitis in women with good glucose control andwithout long-term diabetes complications may be managed as uncomplicated lowerUTI, and treated with one of the following: nitrofurantoin100 mg three times daily for 5 days, fosfomycintrometamol 3 g single dose, or trimethoprim–sulfamethoxazole 960 mgtwice daily for 3 days (can be administered empirically only if resistanceprevalence is known to be less than 20% and medication was not used in previous3 months). Quinolones and ?-lactams are alternative second-line treatments.Treatment should be made according to culture results, if obtained (Ooiet al., 2004).

Other cases of lowerUTI in diabetic patients are mostly considered complicated lower UTI and shouldbe treated with antibiotics. In patients with a chronic indwelling catheter,UTI indicates exchange of the urinary catheter. The wide variety of potentialinfecting organisms and increased likelihood of resistance make recommendationsfor empiri­cal therapy problematic. Whenever possible, antimicrobial therapyshould be delayed so specific therapy can be directed at the known pathogen.Therapeutic options include fluoroquinolones, trimethoprim-sulfamethoxazole,and ?-lactams (Hoepelmanet al.,2003).

Pyelonephritis in patients with type 2 diabetes may betreated with oral antibiotics in patients with mild to moderate symptoms, withno alterations in gastrointestinal absorp­tion, such as gastric emptyingimpairment or chronic diarrhea caused by diabetic neuropathy. Diabetic patientswith severe symptoms, hemodynamic instability, metabolic alterations, orsymptoms that include administration of oral medication (nausea, vomiting)should be hospitalized for initial intravenous antibiotic therapy. Treatmentwith empiric antibiotics, using broad-spectrum cephalosporins,fluoroquinolones, aminoglycosides, piperacillin–tazobactam, or

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