1.14.1 UTIs

Question 1

What are the main risk factors for developing a UTI?

Answer 1

• Female
• Diabetes
• Neurogenic bladder
• Pregnancy
• BPH
• Catheterization (indwelling and intermittent)

Question 2

Define the following:

• Sterile Pyuria
• Bacteriuria
• Asx Bacteriruia

Answer 2

• Sterile Pyuria
  
  • WBCs, without bacteria
• Bacteriuria
  
  • Presence of bacteria on UA
• Asx Bacteriruia
  
  • Bacteria in urine, but no symptoms

Question 3

Describe the following for your patient suspicious for UTI:

• Clinical history
• Labs
• Imaging

Answer 3

• Clinical history
  
  • Dysuria, frequency, urgency, suprapubic tenderness, abd/flank pain, fever, chills, rigors, risk factors, pregnancy, sexual history (PID, vaginitis, urethritis), CVA tenderness
• Labs
  
  • Urinalysis
    
    • Clean catch
    • Epithelials may mean contamination / false positive
    • Sterile pyuria in asymptomatic patient - suspect appendicitis vs diverticulitis
  • Urine culture
  • CBC - leukocytosis?
  • BMP - renal function?
  • Blood cultures - if suspected bacteremia
• Imaging
  
  • Evaluate alternative diagnosis
  • Structural complication, abscess?

Question 4

Your patient’s (CC: flank pain) UA comes back with pyuria and bacteriuria. What guides your decision whether or not to culture?

Answer 4

• Urine culture NOT indicated in
  
  • Uncomplicated cystitis in women
• Urine culture IS indicated in
  
  • Any cystitis in men
  • Relapse or treatment failure
  • Unclear diagnosis
  • Concern for resistant organism
  • Comorbid conditions
  • History of instrumentation
• Correlate clinically
  
  • Low colony count AND symptomatic may indicate infection in:
    
    • Uncomplicated cystitis
    • Catheter related
    • Renal txp
  • High colony count AND asymptomatic
    
    • May be ASB, don’t need Abx
  • High colony count of non-pathogens
    
    • May indicate contamination
  • ANY organism can cause complicated UTI

Question 5

What common organisms might you suspect in your community acquired UTI urine culture?

Hospital acquired?

Answer 5

• Community
  
  • E coli
  • Klebsiella
  • Proteus
  • Staph
• CAUTI
  
  • E coli
  • Klebsiella
  • Citrobacter
  • Enterobacter
  • Pseudomonas
  • MRSA
  • Enterococci/VRE
  • Polymicrobial

Question 6

Your patient has bacteriuria, and is asymptomatic. Will you treat?

The patient is now syptomatic. How will you treat for;

Uncomplicated cystitis

Uncomplicated Pyelonephritis

Complicated UTI

Answer 6

• ASB
  
  • Treat if pregnant, renal txp, or prior to urological procedure
• Symptomatic UTI
  
  • Uncomplicated cystitis
    
    • Oral outpt therapy
  • Uncomplicated Pyelonephritis
    
    • Oral outpt therapy
  • Complicated UTI
    
    • IV inpatient therapy

Question 7

What are your treatment considerations when planning to treat UTI?

Answer 7

• Where is it? Kidney, bladder, ureter, urethra, prostate
• Complicated vs uncomplicated
  
  • Comorbidities
  • Instrumentation
  • Foley/self cath
  • Structural abnormality, i.e. reflux
  • Ureteral stone (not kidney stone)
  • Pregnancy
  • Renal txp
• Outpt vs inpt
  
  • Admit for:
    
    • Failed outpt mgmt
    • Inability to tolerate PO / vomiting
    • Uncontrolled pain
    • AMS/decline in functional status
    • Sepsis

Question 8

Your patient’s UTI, if inadequately treated, can lead to the following complications

Answer 8

• Chronic UTI and continuous need for tx
• Resistant infections
• Renal injury/failure
• Renal abscess
• Sepsis

Question 9

Your patient has cystitis. Describe

• Location
• Symptoms
• Empiric tx
• Alternative regimen

Answer 9

• Location: Bladder
• Symptoms: dysuria, frequency, hematuria, suprapubic discomfort
  
  • Typically does NOT cause fever or AMS
• Empiric tx
  
  • Macrobid 100mg BID x5d
  • Bactrim BID x3d
  • Fosfomycin 3g x1 dose
• Alternative regimen
  
  • B-lactam 5-7d
  • FQ x3d (try to avoid d/t SEs)

Question 10

For pyelonephritis

• Location
• Symptoms
• Empiric tx

Answer 10

• Location: Upper urinary tract (ureters, kidneys)
• Symptoms: Dysuria, frequency, hematuria, nausea, vomiting, diarrhea, fever, flank pain, CVA tenderness
• Empiric tx
  
  • Ceftriaxone 1g IV (1 dose prior to dc)
  • FQ
  • Ertapenem for resistant orgs

Question 11

Prostatitis

• Acute symptoms
• Chronic symptoms
• Infectious vs inflammatory
• Physical exam
• Empiric treatment

Answer 11

• Acute symptoms
  
  • Acute frequency, dysuria urgency, nocturia, perineal pain radiating to back/rectum/penis, hematuria, eurethral discharge, retention, fever, chills
• Chronic symptoms
  
  • Recurrent UTIs, perineal/back pain, urgency, frequency, dysuria
• Infectious vs inflammatory
  
  • Need (+) UA and Culture to diagnose Infectious
  • (-) for bacteria? Inflammatory process
• Physical exam
  
  • Boggy, tender prostate
• Empiric treatment
  
  • <35y, suspect STI: ceftriaxone 250mg IM x1 and Doxy 100mg BID x10d
  • FQ, 10-14 d
  • Bactrim, 10-14d
  • Extended length of treatment for penetration
    
    • If under-dosed, can lead to chronic prostatitis