Case 4 - UTIs

Question 1

infection of the urethra is called

Answer 1

urethritis

Question 2

infection of the bladder is called

Answer 2

cystitis

Question 3

infection of the kidneys is called

Answer 3

pyelonephritis

Question 4

lower UTI symptoms

Answer 4

– suprapubic pain
– painful urination (dysuria)
– frequency of urination
– urgency of urination
– Sometimes, blood in urine (haematuria)
– May be vague in the
elderly or children

Question 5

upper UTI symptoms

Answer 5

– More systemic
– Fever
– Loin pain
– Sepsis
– Sometimes haematuria

Question 6

common pathogens in UTIs

Answer 6

• E. coli
• Other Enterobacterales, eg Klebsiella, Proteus
• Enterococci
• Staphylococcus saprophyticus – for young women

Question 7

how do UTIs happen?

Answer 7

• Common in women – anatomy
  – Urethra is close to anus
  – Urethra is short (shorter in women than men)
  – Organisms ascend into bladder

Question 8

Defence against UTI

Answer 8

• Regular flow of urine flushing out any bacteria
• Antimicrobial properties of urine:
  – low pH
  – high urea
  – high osmolality
  – secreted IgA antibodies
  – secretory bactericidal peptides
  – secreted blood group antigens
  – urogenital epithelia have surface defences that reduce adherence of microorganisms

Question 9

How does pyelonephritis happen?

Answer 9

Normally, backflow of urine from the bladder into the ureters is prevented by the ureteric valves, which are created where the ureters enter the bladder obliquely
When this fails, Vesicoureteric reflux can happen (Vesicoureteric reflux is more common in children)

Question 10

when is Pyelonephritis more likely

Answer 10

Pyelonephritis is more likely when:
– urinary tract anomalies make the ureteric valve less effective
– Following urinary tract manipulation/procedure
– In pregnancy
* Progesterone relaxes the ureteric smooth muscle
* Pressure of uterus on bladder

Question 11

Common risk factors for UTI

Answer 11

• Sexual intercourse
• Urinary catheter
• Procedures involving the urinary tract
• Diabetes
• Spinal cord injury
• Enlarged prostate
• Post-menopausal

Question 12

‘Complicated’ UTI:

Answer 12

– involving the upper tract
– Poorly controlled diabetes
– Male
– Immunocompromised
– Patients with renal impairment
– abnormal urinary tract

Question 13

‘Uncomplicated’ UTI:

Answer 13

healthy women with cystitis/urethritis

Question 14

what to do with UTI in children

Answer 14

• UTI in children must be properly diagnosed with a laboratory sample
• If confirmed must be treated and followed up carefully, as can result in renal damage
• Refer to paediatrician

Question 15

what to do with UTI in men

Answer 15

• UTI in men is uncommon and must always be investigated for an underlying cause
• Consider prostatitis
• refer to urologist

Question 16

Diagnosing UTI

Answer 16

• Depending on situation diagnosis may be:
  – Clinical
  – Dipstick in clinic/practice/ward
  – Mid-stream urine (MSU) sent to lab

Question 17

how to manage a woman if she presents with all 3 of: dysuria, new nocturia and cloudy urine

Answer 17

consider immediate antibiotic (if pregnant always immediate) OR back-up if mild symptoms and not pregnant

Question 18

how to manage a woman if they present with 2 or more of: dysuria, new nocturia and cloudy urine

Answer 18

consider immediate antibiotic (if pregnant always immediate) OR back-up if mild symptoms and not pregnant

Question 19

how to manage a woman if they present with 1 of: dysuria, new nocturia and cloudy urine

Answer 19

use urine dipstick to increase diagnostic accuracy

Question 20

how to manage a woman if they present with none of: dysuria, new nocturia and cloudy urine

Answer 20

use urine dipstick if there’s other urinary symptoms

Question 21

Dipstick – what does it detect?

Answer 21

• Haematuria (blood)
• Proteinuria
• Nitrites (product of bacterial metabolism)*
• Leucocyte esterase (from white cells)*
• Ketonuria
• Glucose

*indicate possible bacterial infection

Question 22

When to send MSU (Midstream Specimen of Urine) ?

Answer 22

• suspected UTI in men
• Infant under 3 months
• Child over 3 months with positive dipstick
• Pregnancy
• over 65 y.o. if symptomatic
• Suspected pyelonephritis or sepsis
• failed antibiotic treatment or persistent symptoms
• recurrent UTI (2 episodes in 6months or 3 in 12months)
• if prescribing antibiotic in someone with a urinary catheter
• Risk factors for resistance
• as advised by local microbiologist

Question 23

Interpreting urine reports: microscopy

Answer 23

Red blood cells - can be used to look for:
– Urinary tract malignancy– Bladder/kidney stone– Infection– trauma
white blood cells - can be used to look for:
– inflammation/infection
epithelial cells - can be used to look for:
– ?perineal contamination

Question 24

Interpreting urine results - culture

Answer 24

• > 100 000 colony forming units (cfu)/ml of a
  urinary pathogen is considered significant
• 10 000 - 100 000 cfu/ml pure culture is
  probably significant (especially if the patient is
  drinking a lot of fluids as may be advised in
  a suspected UTI)

Question 25

what to do with ‘Asymptomatic bacteriuria’

Answer 25

* Do not treat – does not reduce morbidity or mortality * Common in over-65s Exceptions to the above: Asymptomatic bacteriuria should be treated in pregnant women And some exceptional circumstances eg renal transplant – discuss with specialist

Question 26

catheters and ‘Asymptomatic bacteriuria’

Answer 26

In CSU (catheter specimen of urine), there''ll almost always be growth of ‘Asymptomatic bacteriuria’ only treat if there's systemic evidence of infection, e.g fever

Question 27

pregnant and ‘Asymptomatic bacteriuria’

Answer 27

antibiotic treatment of and asymptomatic bacteriuria in pregnancy reduces risk of upper UTIs and low birth weight babies therefore women are screened antenatally

Question 28

possible causes of Sterile pyuria

Answer 28

– Recent treated UTI – Current antibiotics – even one dose – Chlamydial urethritis/ other infection e.g gonorrhoea – Prostatitis – Renal tract tuberculosis – consider in patients with fever, weight loss, night sweats, anorexia with no other obvious cause – Drugs – e.g. NSAIDS, steroids, cyclophosphamide, indinavir

Question 29

Management of UTI

Answer 29

* Advise to drink plenty of fluids - helps to flush out infection Antibiotics treatments – Age under 65, empirical treatment: * Nitrofurantoin or trimethoprim – Age over 65, empirical treatment * Pivmecillinam or fosfomycin

Question 30

Risk factors for antibiotic resistance

Answer 30

– abnormalities of genitourinary tract – renal impairment – care home resident – hospitalisation for > 7 days in last 6months – recent travel to a country with increased resistance to antibiotics – previous UTI resistant

Question 31

Haematuria - best detected by

Answer 31

Haematuria - best detected by dipstick