■ Fluoroquinolones, e.g., ciprofloxacin, can be used instead of cephalosporins. They exhibit good activity against enterobac-
48 H. HASHIM AND J. REYNARD
taria and P. aeruginosa, but less activity against staphylococci and enterococci. Ciprofloxacin can be given both orally and intravenously. It is well absorbed from the gastrointestinal tract.
■ Metronidazole is used if there is suspicion of an anaerobic source of sepsis.
■ Other drugs that can be used if there is no clinical response to the above include a combination of piperacillin and tazo-bactam. This combination is active against enterobacteria, enterococci, and Pseudomonas.
■ Gentamicin is used in conjunction with other antibiotics because it has a relatively narrow therapeutic spectrum (against gram-negative organisms). Close monitoring of therapeutic levels and renal function is important. It has good activity against enterobacteria and Pseudomonas, with poor activity against streptococci and anaerobes and therefore should ideally be combined with b-lactam antibiotics, e.g., co-trimoxazole but can be combined with ciprofloxacin instead.
If there is clinical improvement, intravenous treatment should continue for at least 48 hours with oral medication thereafter. Make appropriate adjustments when the sensitivity results are available from the urine cultures that were sent. It may take about 48 hours for sensitivity results to become available.
PYELONEPHRITIS AND PYONEPHROSIS
See Chapter 3.
PROSTATIC INFECTIONS AND PROSTATIC ABSCESS
Acute Bacterial Prostatitis [National Institute of Health Classification System (Krieger 1999) Category I Prostatitis]
Acute bacterial prostatitis is infection of the prostate associated with lower urinary tract infection and generalised sepsis. E. coli is the commonest cause. Pseudomonas, Serratia, Klebsiella, and enterococci are less common causes.
The presenting symptoms include acute onset of perineal and suprapubic pain with irritative (frequency, urgency, pain on voiding) and obstructive (hesitancy, poor flow, acute retention) lower urinary tract symptoms, combined with fever, chills, and malaise. The infection may be severe enough to cause septicaemia.