A/15. Cystitis and urethritis Flashcards
classification of cystitis and urethritis
- Anatomic
*lower: urethritis, cystitis (superficial infection of bladder)
*Upper: pyelonephritis, renal or perinephric abscess, prostitis - clinical:
*Non-complicated: non-preg, immunocompetent.. etc
*complicated: Upper tract infection in women, any UTI in men or pregnant women
or UTI with underlying structural disease, immunosup
Non complicated UTI examples
- Cystitis in immunocompetent,
- non-pregnant women,
- without underlying
structural or neurologic disease
complicated UTI examples
- Upper tract infection in women
- any UTI in men
- UTI in pregnant women,
- UTI with underlying structural disease,
- or immunosuppression
Upper UTI
- Pyelonephritis (inflammatory process of renal parenchyma)
- Renal or perinephric abscess
- Prostatitis
lower UTI
- Urethritis
- Cystitis (superficial infection of bladder)
Who to screen for Asymptomatic bacteriuria
screen and treat it positive in
* pregnant women
* any patient prior to urologic surgery
causes of increased urinary WBC (pyuria):
- Vaginal discharge
- Urinary stone
- Urinary tract tumor
- Urethritis
- Interstitial nephritis
- Renal TB
- Foreign body
Risk factors for complicated UTI
- Male sex
- Older age
- Symptoms >7 days
- History of stone disease
- Infection with drug-resistant organism
- Recent hospitalization
- Urinary tract instrumentation
- Pregnancy
- Diabetes
- Functional/structural abnormalities
Pathology of UTI
Ascending infection vs. disseminated hematogenous spread (much less common)
Pathogenesis (ascending infection):
bacterial adhesion to the epithelium, followed by proliferation, invasion, and initiation of the inflammatory process
Prevalence of ascending infection is much more common in —– and why?
in women
because of the short urethra
compared to the male anatomy
Uncomplicated UTI microorganisms
- Proteus,
- E. coli (80%),
- Klebsiella,
- S. saprophyticus
PEKS
Complicated UTI microorganisms
- E. coli,
- Enterococci,
- Pseudomonas,
- S. epidermidis,
- other GNR= Gram-negative rods
Catheter-associated UTI organisms
- yeast (30%) (eg. candida)
- E. coli,
- S. epidermidis,
- other GNR
Urethritis microorganisms
- C. trachomatis,
- N. gonorrhea,
- Ureaplasma urealyticum,
- T. vaginalis,
- Mycoplasma. genitalium
S. aureus is associated with
with bacteremia and hematogenous seeding
uncommon primary instrumentation;
Clinical findings in cystitis
- dysuria,
- urgency,
- frequency,
- hematuria,
- change of urine color,
- cloudy urine,
- foul-smelling urine,
- suprapubic pain,
- fever generally absent
is fever present in cystitis
No , fever generally absence
Clinical findings urethritis
Urethritis: similar to cystitis + urethral discharge
- dysuria, urgency, frequency,
- hematuria
- change of urine color
- cloudy urine
- foul-smelling urine
- suprapubic pain
- fever generally absent
acute prostatitis clinical findings
- perineal pain
- fever
- pain on DRE
CHRONIC prostatitis clinical findings
similar to cystitis (dysuria, urgency, frequency, hematuria, change of urine color, cloudy urine, foul-smelling
urine, suprapubic pain, fever generally absent)
+
symptoms of obstruction (hesitancy, waek stream)
Pyelonephritis clinical findings
- fever, chills
- flank/back pain,
- nausea/vomiting/diarrhea,
- progression to sepsis
Renal abscess clinical findings
- identical to pyelonephritis (fever, skaing chills, flank/back pain, nausea/vomiting/diarrhea, progression to sepsis)
+ - persistent fever despite appropriate AB
persistent fever despite appropriate AB gives suspicion of
renal abscess
classic signs and symptoms of cystitis for clinical diagnosis
- dysuria
- urinary frequency
- urgency
- and/or suprapubic pain).
For women presenting with atypical urinary symptoms, the
diagnosis is supported by
- the presence of pyuria
- and bacteriuria
on urinalysis and/or culture
Diagnostics of UTI
- Urinalysis: pyuria, bacteriuria, hematuria, nitrites
- Urine dipstick:
*WBC (leukocyte esterase activity)
*nitrite (only Gram-),
*urobilinogen
*protein
*pH, Hgb, ketones, glucose, bilirubin - Urine culture:
*significant bacterial counts > 105 CFU/ml im asymptomatic women
*>103 CFU/ml in men
*>102 CFU/ml in catherized patient - Blood culture: if febrile and possibly complicated UTI
- DNA detection (NAAT, PCR): suspected urethritis with C. trachomatous, N. gonorrhea
- Abdominal and pelvic US: assess degree of renal parenchyma involvement in pyelonephritis
- Abdominal CT: rule-out abscess in patients with pyelonephritis who fail to respond after 72 hrs
- Urologic work-up (VUR investigation, urography): if recurrent UTIs
what can be detected on urinalysis
Urinalysis:
1. pyuria,
2. bacteriuria,
3. hematuria,
4. nitrites
what can urine dipstick show
Urine dipstick:
*WBC (leukocyte esterase activity)
*nitrite (only Gram-),
*urobilinogen
*protein
*pH
*Hgb,
*ketones, glucose,
*bilirubin
urine culture significant bacterial counts in asymptomatic women, men, and in catherized pts
- Urine culture:
*significant bacterial counts
> 105 CFU/ml im asymptomatic women
>103 CFU/ml in men
>102 CFU/ml in catherized patient
When to take blood culture in patient with suspected UTI
if febrile and possibly complicated UTI
DNA detection what methods are used and what microorganisms
DNA detection (NAAT, PCR):
* suspected urethritis with C. trachomatous, N. gonorrhea
NAAT = Nucleic acid amplification test
How to assess degree of renal parenchyma involvement in pyelonephritis
- Abdominal and pelvic US
when to do abdominal CT in pts with pyelonephritis
- Abdominal CT: r
*rule-out abscess in patients with pyelonephritis who fail to respond after 72 hrs
If pts suffers from recurrent UTI what diagnostic method is used to assess
- Urologic work-up (VUR investigation, urography): if recurrent UTIs
what is indicated for all symptomatic UTIs
antimicrobial therapy
choice of antimicrobial agent, dose and
duration of therapy depend on
- the site of infection and
- the presence or absence of complicating conditions
Noncomplicated
cystitis treatment and how long for
Monotherapy with one of the following (3-5 days)
- Fosfomycin (3 g PO single dose)
- Nitrofurantoin (PO 3-5 days) Urinary antiseptic rapidly excreted into urine and acts to suppress bacteria, no systemic effect
- TMP-SMX
- Amoxicillin/clavulanate
- Ciprofloxacin/levofloxacin (check local resistance pattern)
Complicated
cystitis treatment
how long is the treatment
Monotherapy with either one of the above agents for 10-14 days
Fosfomycin (3 g PO single dose)
- Nitrofurantoin (PO 3-5 days)
- TMP-SMX
- Amoxicillin/clavulanate
- Ciprofloxacin/levofloxacin (check local resistance pattern
note- same as in catheterized patient
Catheterized
patient treatment and how long for
Monotherapy with either one of the above agents for 10-14 days + remove/change catheter
- Fosfomycin (3 g PO single dose)
- Nitrofurantoin (PO 3-5 days)
- TMP-SMX
- Amoxicillin/clavulanate
- Ciprofloxacin/levofloxacin (check local resistance pattern
Urethritis treatment
- Neisseria coverage:
-ceftriaxone (IM, 250 mg single dose)
-OR spectinomycin (IM, 2 g single dose)
-OR azithromycin (PO, 1 g single dose) - Chlamydia coverage:
-azithromycin (PO, 1 g single dose)
-OR doxycycline (PO, 100 mg, twice daily x 7 days)
what antibiotics cover neisseia
-ceftriaxone (IM, 250 mg single dose)
-OR spectinomycin (IM, 2 g single dose)
-OR azithromycin (PO, 1 g single dose)
what antibiotics cover chlamydia
- Chlamydia coverage:
-azithromycin (PO, 1 g single dose)
-OR doxycycline (PO, 100 mg, twice daily x 7 days)
Prostatitis treatment and for how long (Acute VS chronic)
Monotherapy with either one of the following:
(14-28 days for acute; 6-12 months for chronic)
- TMP-SMX
- Ciprofloxacin/levofloxacin
Treating chronic prostatitis what to take into count
- choose a drug with high prostate penetration ability.
- During the acute phase, local inflammation makes it easier for most agents to penetrate the gland
(thus, it’s not a crucial issue to be addressed acutely
Pyelonephritis outpatient treatment
Outpatient (x14days) :
ciprofloxacin/levofloxacin
OR amoxicillin/clavulanate
OR cefepime
pyelonephritis inpatient treatment
Inpatient :
ceftriaxone
OR piperacillin/tazobactam
OR imipenem (start IV, change to PO when patient improves clinically and is afebrile; then complete 14 days course
Renal abscess treatment
Drainage + AB as for pyelonephritis
(pyelonephritis Outpatient: ciprofloxacin/levofloxacin OR amoxicillin/clavulanate OR cefepime
Inpatient : ceftriaxone OR piperacillin/tazobactam OR imipenem (start IV, change to PO when patient improves clinically and is afebrile; then complete 14 days course))
Obstructive
pyelonephritis treatment
- AB, antipyretics, fluids
- Urine deviation (percutaneous nephrostomy of Double-J stent)
- Relieving obstructive cause (eg. stone removal
Specific forms of pyelonephritis
- Chronic pyelonephritis
- Xanthogranulomatous pyelonephritis
Chronic pyelonephritis develops based on
recurrent
or
inadequately-treated acute episodes
Chronic pyelonephriti associated with
anatomic/functional condition predisposing to recurrent infections (stone disease, VUR).
Chronic pyelonephritis on imaging
Asymmetric atrophic kidney on imaging; ‘kidney thyroidization’ (eosinophilic nodules which
resemble thyroid gland tissue architecture).
Xanthogranulomatous pyelonephritis what is it
is a rare form of kidney infection (usually Proteus
Xanthogranulomatous pyelonephritis causes ?
- extensive kidney damage due to progressive granulomatous inflammation of the parenchyma;
- gross nodules may resemble tumors
