16 UTIs Bensman Flashcards
What needs to be looked at in order to classify what type of UTI it is?
Anatomical location. Complication. Recurrence. Symptoms
What epidemiology of UTIs has the highest prevalence?
Females > males. Increase in prevalence in females after puberty. 1/3 of females experience a UTI by age 24. Up to 50% of females will have an episode of a UTI within their lifetime
What are the 3 different routes of entry into the urinary tract?
Ascending. Descending. Lymphatic
What are the characteristics of ascending entry into the urinary tract?
Urethra is colonized by fecal flora and this is transferred to bladder. Most common type. Usually lower infection
What are the characteristics of descending entry into the urinary tract?
Infection of kidneys by hematogenous spread from distant primary infection in the body. < 5% of documented UTIs
What are the characteristics of lymphatic entry into the urinary tract?
Communication between bowel and kidney; kidney and bladder. Very little/limited evidence of this occuring
What is the primary result of the 3 different routes of entry into the urinary tract?
Once the bacteria gets to the site of infection, infection is determined by the organism (size of infectious inoculum and virulence) and competence of host defense mechanisms
What are the host defenses like for innate immunity?
Bacteria stimulates an inflammatory response. Limits tissue invasion and spread
What are the host defenses like for humoral immunity?
Increase in antibodies during UTIs. Role is not clearly defined
What are the host defenses with urine?
Osmolarity, pH, urea/organic acids. Inhibits growth and kills bacteria
What are the host defenses like for micturition?
Bacteria stimulate bladder emptying. Limits initiation and maintenance of UTIs
What are some different virulence factors that bacteria can have that cause UTIs?
P Fimbriae (excreted by E. coli, acts as an adhesion). Hemolysin and aerobactin (secreted by almost all UTI bacteria, scavenges for iron; needed for bacteria growth)
What are the special populations that have an increased risk for UTIs?
Infants. Pregnant women. Elderly
What are the health conditions that have an increased risk for UTIs?
Spinal cord injuries. Catheters. Diabetes. Multiple sclerosis. HIV. Urologic abnormalities
What are the risk factors that increase risk of UTIs with intercourse?
Diaphragms. Condoms. Spermicides. Increased frequency
What is required to diagnose UTIs?
Urine laboratory findings (UA, urine culture) + clinical findings
What can be done for Urine Cultures?
Bacterial count (depending on the classification of the bacteriuria, there are different cut-offs). Gram Stain (begins process for identifying organism). Culture + Sensitivity (identifies the causative organism(s), determines antibiotic susceptibilities for directed therapy)
What is a drawback with Urine Cultures?
Takes several days to get all the results
What is the diagnostic bacterial count for Asymptomatic Bacteriuria (ASB)?
> 10^5 of urine. Women: 2 consecutive voided urine specimens w/ isolation of same bacterial species. Men: 1 clean-catch voided urine specimen w/ 1 bacterial species
What is the diagnostic bacterial count for Catheter Associated Asymptomatic Bacteriuria (CA-ASB)?
> 10^5 of urine. 1 catheterized urine specimen w/ 1 bacterial species
What is the diagnostic bacterial count for Symptomatic Bacteriuria (UTI)?
> 10^2 of urine
What is the diagnostic bacterial count for Catheter Associated Symptomatic Bacteriuria (CA-UTI)?
> 10^3 of urine. > 1 bacterial species + s/sx of a UTI with no other source of infection identified
What are the common urine findings that are looked for in a Urine Analysis?
Visual appearance. Leukocyte Esterase (LE). Nitrite (made from bacteria converting nitrate). White Blood Cells (> 5-10 is (+) for UTI). White Cell Casts. Protein. Hematuria
What is some general information of Urinalysis (UA)?
UA helps to identify pyuria and may aid in reducing delay to antibiotic start in UTI (symptomatic). In asymptomatic bacteriuria, pyuria is not diagnostic of infection. Turn around time in minutes
What are the clinical signs and symptoms of Cystitis?
Dysuria. Urinary frequency. Urinary urgency. Suprapubic discomfort. Localized
What are the clinical signs and symptoms of Pyelonephritis?
Fever. Flank pain. Nausea. Vomiting. + Cystitis symptoms. Systemic
What are the clinical signs and symptoms of Acute Prostatitis?
Fever. Chills. Malaise. Myalgia. Prostate tenderness/pain. Urinary retention. + Cystitis symptoms. Systemic
What are the clinical signs and symptoms of Chronic Prostatitis?
Urinating difficulty. Lower back pain. Perineal pressure. “Boggy”. Enlarged prostate. May be asymptomatic
What are the clinical signs and symptoms of CA-UTI (catheter associated)?
New onset or worsening (fever, rigors, altered mental status, malaise or lethargy with no other identified cause). Pelvic discomfort. Flank pain. Costovertebral angle tenderness. Acute hematuria. Urinary symptoms in those whose catheters have been removed (dysuria, urgent or frequent urination, or suprapubic pain/tenderness). Spinal cord injury (increased spasticity, autonomic dysreflexia, or sense of unease)
What is the Bacterial Etiology that cause asymptomatic bacteriuria (ASB) in women?
PEK (E. coli most common). Coag (-) Staph. Enterococcus spp. GBS. Gardnerella vaginalis
What is the Bacterial Etiology that cause asymptomatic bacteriuria (ASB) in men?
PEK (Proteus: males > females). Coag (-) Staph. Enterococcus
What is the Bacterial Etiology that cause asymptomatic bacteriuria (ASB) in patients with Urologic Device (catheter)?
Usually polymicrobial. P. aeruginosa, P. mirabilus, P. stuartii, M. morganii
What is the most common cause of community acquired UTI?
E. coli
What is the most common cause of hospital acquired UTI?
No one bacteria is most common. PEK, Enterobacter, Pseudomonas aeruginoa, Enterococcus, Staphylococcus
What is the most common cause of Prostatitis?
PEK (E. coli 75%). P. aeruginosa, Enterobacter, Serratia, Staphylococcus
What are the different Antibiotic Therapies used in UTIs?
Amoxicillin. Cephalexin. Bactrim. Nitrofurantoin. Fosfomycin. Ciprofloxacin. Levofloxacin
When should Bactrim be avoided?
If resistance in your area > 20%
When should FQs be avoided?
If resistance in your area > 10%
Which antibiotic has had the most resistance developed towards it for UTIs?
Ciprofloxacin
What should be done for patients with asymptomatic UTI who are pregnant or have Transurethral Resection of the Prostate (TURP)?
Treat
What should be done for patients with asymptomatic UTI who are not pregnant or TURP?
Don’t treat
What should be done for patients with symptomatic UTI that is not complicated?
Cystitis. Short course treatment
What should be done for patients with symptomatic UTI that is complicated?
Upper tract, male, urinary abnormality, catheter. Treat, not short course
What is Asymptomatic Bacteriuria (ASB) defined as?
No signs or symptoms of UT. Diagnosed by urine culture (quantitative bacterial count)
Why are Pregnant Asymptomatic patients treated?
20-30 fold risk of developing pyelonephritis during pregnancy. More likely to deliver prematurely, low birth weight infants. Screen at least 1x early on in pregnancy. Antibiotic treatment: 3-7 days
Why are Urologic Intervention (i.e. TURP) patients treated?
Bacteremia occurs in up to 60% of bacteriuric patients who undergo TURP. 6-10% of these patients develop sepsis. Screen obtain culture results prior to procedure. Antibiotic treatment: initiate immediately before procedure and continue until catheter is removed
What is the definition of Uncomplicated UTIs?
Only lower tract infection (bladder). Healthy females (no males). Normal GU organisms, community acquired. No history of recurrence
What is the definition of Acute Uncomplicated Cystitis?
Most common form of UTI. Inflammation/infection of the bladder. Found in women of childbearing age, often related to sexual activity. Usually does not require a urine culture for bacterial species identification. Outpatient treatment with oral antibiotics. Requires adequate concentration of antibiotics in the urine
What is the DOC for Acute Uncomplicated Cystitis?
Nitrofurantoin monohydrate for 5 days
Besides the DOC, what is another drug used to treat Acute Uncomplicated Cystitis?
Bactrim for 3 days. Don’t use if your clinical practice area has resistance rates > 20%
How is Nitrofurantoin Macrocrystals dosed for Cystitis?
1st line treatment. 100mg PO BID. Duration: 5 days (uncomplicated), 7 days (pregnancy)
When should you not use Nitrofurantoin macrocrystals in a patient?
CrCl < 50
What is some general information about Nitrofurantoin?
Does not achieve adequate serum/tissue concentrations (only use in cystitis). Low collateral damage. Safe in pregnancy
Which bacteria are susceptible to Nitrofurantoin?
E. coli, S. saphrophyticus, Citrobacter, E. faecalis
How is Trimethoprim/Sulfamethoxazole (Bactrim) dosed for Cystitis?
1st line treatment. 160/800 PO BID. 3 days (uncomplicated), 7 days (in pregnancy). Dose adjust in renal impairment (< 30)
What is some general information about Bactrim?
Avoid in Sulfa allergy. May use if local resistance is < 20% (use of agent or travel outside the U.S. in past 3-6 months increases risk of resistance). Pregnancy: avoid in 1st/3rd trimester. Inexpensive
What can you do for patients with a Sulfa Allergy who were going to use Trimethoprim/Sulfamethoxazole?
Can use Trimethoprim 100mg PO BID x3 days (uncomplicated)
How is Fosfomycin dosed for Cystitis?
2nd line treatment. 3g PO x1 dose. Mix w/ 3-4 oz of water, duration: 1 dose (uncomplicated)
What is some general information about Fosfomycin?
Slightly less effective than other short courses for cystitis. Susceptibility is not routinely completed
How are B-Lactams dosed for Cystitis?
2nd line treatment. Amoxicillin/Clavulanate (500/125mg) PO BID or Cefpodoxime 100mg PO BID. 3-7 days (uncomplicated)
What is some general information about B-lactams?
Allergy: PCN. Less effective than other short term courses for cystitis. Do not use amoxicillin/ampicillin - high resistance rates. Pregnancy: safe (Category B)
How are Fluoroquinolones (FQ) dosed for Cystitis?
Reserved treatment. Ciprofloxacin 250mg PO BID. 3 days (uncomplicated). Dose adjust in renal impairment (< 30)
What is some general information about FQs?
High collateral damage (promotes resistance in other antibiotic classes). Reserve more severe infections (last line). Avoid use if local resistance rates > 10%. Avoid in pregnancy
What is the definition of Complicated UTIs?
Upper tract infection. Underlying co-morbidities, urogenital structural abnormalities, pregnant, male. Nosocomial organisms. (+) history of recurrence
What is the normal duration of treatment for acute complicated cystitis?
10-14 days
Which medications are used for acute complicated cystitis in Pregnancy?
1st line: Nitrofurantoin monohydrate for 7 days (avoid after 38th week). 2nd line: TMP/SMX for 7 days (avoid in 1st and 3rd trimester)
What is come general information about Acute Complicated Cystitis in Pregnancy?
Screen all pregnant females at first prenatal visit and again at 28 weeks gestation and treat all UTI (symptomatic, asymptomatic). Does not qualify for short course. Bacterial etiology is similar to uncomplicated cystitis. Follow up urine culture 1-2 weeks after completing treatment and monthly until gestation is recommended
What antibiotics should be avoided in Acute Complicated Cystitis in Pregnancy?
Tetracyclines, FQ due to teratogenic effect, and potential to inhibit cartilage/bone development, respectively
What is Acute Pyelonephritis?
Complicated infection that involves upper tract physiology (kidneys). Urine culture (with sensitivities) + UA required. Do this before antibiotics are administered
What are the general treatment approaches for Pyelonephritis?
Mild cases can be managed in an outpatient setting. Moderate-severe cases should be hospitalized (high-grade fever, nausea, vomiting, dehydration). Requires adequate antibiotic concentration in the urine and blood
What antibiotics are used for Acute Pyelonephritis OUTPATIENT?
1st line: TMP/SMX 160/800mg PO BID for 14 days +/- 1 time IV dose of Ceftriaxone (CTX) or Aminoglycoside (AG). 1st line: Fluoroquinolones PO for 5-7 days +/- one time IV dose of FQ, CTX, or AG
What antibiotics are used for Acute Pyelonephritis INPATIENT?
FQ 400mg Q12h. CEPHs (3/4th gen). Aminoglycosides + Ampicillin 2gm IV Q6h. Extended spectrum PCN +/- AMG. Carbapenem. All of these are used for 10-14 days
What is the definition of Catheter Associated Pyelonephritis?
Current or recent (previous 48 hours) catherization with symptoms of a UTI. Urine culture + sensitivities recommended. Obtain specimen from midstream void if catheter removed or from new, replacement catheter. If catheter has been in > 2 weeks, remove or replace
What is the treatment duration for Catheter Associated Pyelonephritis?
Treat 7-14 days. Prompt response: 7 days. Delayed response: 10-14 days. Antibiotics - guided by your institutions susceptibilities
What is the definition of Prostatitis?
50% of all males develop some form of prostatitis during their lifetime. Inflammation/infection of the prostate gland and surrounding tissues. Acute or Chronic (most common cause of recurrent UTIs in males). Diagnosis with: urine samples, prostatic secretion sample, clinical symptoms
What is the treatment for Prostatitis?
1st line: FQs (acute: 4 weeks. chronic: 6-12 weeks). 1st line: TMP/SMX (acute: 4 weeks. Chronic: 6-12 weeks). Extended spectrum CEPHs/PCN + AMG (acute: 4 weeks. Not for chronic. Avoid using AMG if there is an abscess, consider FQ)
What is the DOC for Prostatitis?
FQs
What is some general information about Prostatitis?
Important to use agents that penetrate the prostate to deliver high concentrations. In acute prostatitis, there is an acute inflammatory response that alters the cellular membrane barrier of the bloodstream and prostate and increases prostatic drug concentrations. Chronic prostatitis is more difficult to treat than acute prostatitis and rarely is there a cure. Chronic prostatitis may require suppressive therapy to limit symptoms from inability to eradicate bacterial pathogen
What is considered a relapse?
Recurrence usually w/in 1-2 weeks after end of treatment: repeat C+S usually demonstrates recurrent of bacteria with SAME bacterial etiology
What is considered a reinfection?
Recurrence usually > 1 month after end of treatment. Recurrence of UTI is caused by DIFFERENT bacterial etiology
What are 80% of recurrences from?
Reinfection
What should be done with < 3 UTIs/year?
May treat as separately occurring infection. Short course therapy (if uncomplicated)
What should be done with 3+ UTIs/year OR > 2 UTIs/6 months?
Long-term prophylaxis therapy may be necessary
What should be done with reinfections associated with sexual activity?
Void after sexual intercourse. Single dose ABX after intercourse
When should UTI prophylaxis be considered?
2+ symptomatic infections in 6 months OR 3+ symptomatic infections in 1 year. When sexual intercourse is cause of re-infection
What are the UTI prophylaxis regimens?
TMP/SMX (40/200 - 80/400mg PO QD or 3x weekly). Nitrofurantoin (50-100mg PO QD). Used for at least 6 months. Monitor urine cultures monthly
What are the UTI prophylaxis regimens used Post Coital?
TMP/SMX (40/200 - 80/400mg PO x1 dose. Nitrofurantoin (50-100mg PO QD). Cephalexin 250mg PO x1 dose. Recommend voiding after intercourse (and before taking antibiotic)
When should follow-up cultures be done for pregnant women?
Monthly until gestation
When should follow-up cultures be done for children?
At 6 weeks and 6 months
What is the Urinary Analgesic used?
Phenazopyridine. 200mg PO TID (taken after meals). Limit to 2 days of use
