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2.7 THERAPEUTIC TRIALS OF UTI IN DIABETIC
PATIENTS

Many therapeutic trials prefer antimicrobial agents that achieve
high levels in the urine and also in the renal tract tissues, such as Fluoroquinolones,
Trimethoprim-Sulphamethoxazoleand Amoxycillin-Clavulanic acid. This may be the
pathogenesis indicating invasion of E.coli
into the bladder cells (Ornaet
al., 2015). Few therapeutic trials have been
performed specifically with diabetic patients. Due to frequent upper urinary tract
involvement and possibilities of serious complications many experts recommend a
7–14-day oral antimicrobial regimen for bacterial cystitis in diabetic patients,
instead of the usually recommended 3-day course. The standard duration of therapy
for uncomplicated pyelonephritis in both diabetic as well as non-diabetic
patients is 14 days. However, studies have shown a 7-day course of oral ciprofloxacin
is effective for uncomplicated pyelonephritis. Vigilance for complications must
occur throughout the care of an acutely ill patient with UTI. As these
complications are common in patients with diabetes, their anticipation may lead
to earlier interventions and fewer serious adverse outcomes (Geerlings, 2008).

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There is no indication to treat asymptomatic bacteriuria (ASB) in
diabetic patients. Though earlier studies indicated that bacteriuria may be
associated with progression to symptomatic UTI and with deteriorating renal function
in diabetic patients,later studies found that diabetic women with ASB do not
have an increased risk for a faster decline in renal function, and that there
are no short- or long-term benefits from the treatment of ASB in diabetic
women. A placebo-controlled, random­ized prospective study of 105 women having
diabetes 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 ASB
by itself is not associated with an increased rate of renal impairment progression
or long term complications during 6 years of follow-up in patients with
diabetes. Another study that involved diabetic women with ASB for up to 3 years
found that bacteriuria persists or recurs in most women, is benign, and seldom
permanently eradicable. All the above studies showed that women with ASB
received multiple courses of antibiotic therapy, which may result in increased
antibiotic resistance. Acute cystitis in women with good glucose control and
without long-term diabetes complications may be managed as uncomplicated lower
UTI, and treated with one of the following: nitrofurantoin
100 mg three times daily for 5 days, fosfomycintrometamol 3 g single dose, or trimethoprim–sulfamethoxazole 960 mg
twice daily for 3 days (can be administered empirically only if resistance
prevalence is known to be less than 20% and medication was not used in previous
3 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 lower
UTI in diabetic patients are mostly considered complicated lower UTI and should
be treated with antibiotics. In patients with a chronic indwelling catheter,
UTI indicates exchange of the urinary catheter. The wide variety of potential
infecting organisms and increased likelihood of resistance make recommendations
for empiri­cal therapy problematic. Whenever possible, antimicrobial therapy
should 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 be
treated with oral antibiotics in patients with mild to moderate symptoms, with
no alterations in gastrointestinal absorp­tion, such as gastric emptying
impairment or chronic diarrhea caused by diabetic neuropathy. Diabetic patients
with severe symptoms, hemodynamic instability, metabolic alterations, or
symptoms that include administration of oral medication (nausea, vomiting)
should be hospitalized for initial intravenous antibiotic therapy. Treatment
with empiric antibiotics, using broad-spectrum cephalosporins,
fluoroquinolones, aminoglycosides, piperacillin–tazobactam, or

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