Cystitis and Pyelonephritis Flashcards
What is Cystitis
urinary infection involving the bladder
“lower UTI”
Who is at risk for cystitis
Immunocompromised (DM, HIV, CA, steroids, chemo, malntr) Urinary stasis (retention, obstruction, bladder diverticulum) Congenital abn Sexual activity Spermicide use Diaphragm use Incontinence Pelvic prolapse Cystocele
What are the MC Sx of cystitis (aka irritative voiding Sx)
dysuria (burning)
urgency
frequency
Other Sx of cystits include
Suprapubic discomfort cloudy, stinky urine fever mental status changes SCI (ANS dysreflexia, increased muscle spasticity)
What will a UA for cystitis show
Dipstick: Leukocyte esterase, Nitrites (unless strep) MicroscopyL Pyuria (WBC>5), bacteria
What will a urine culture for cystitis show
> 100,000 organisms, monoculture (only 1 type of organism)
What pathogens cause cystitis
**E. Coli!
Klebsiella, enterobacter, proteus, pseudomonas, candida, staph saprophyticus, etc.
Pathogens have pili which allow bacteria to stick to us better (more virulent)
What pathogens are part of the normal flora and not likely the cause of cystitis
Lactobacillus, corynebacterium, strep, staph epidermidis
What are preferred treatments of Cystitis
Bactrim (or septra) BID x 3 days
Macrobid BID x 7 days (dont use long term, risk for pulmonary fibrosis- also NOT for pyelonephritis)
What antibiotic is effective against Enterococcus
Ampicillin
Amoxicillin
Which antibiotics are beta-lactamase inhibitors
Clavulanic acid (+ augmentin makes Augmentin)
Sulbactam (+ ampicillin makes Unasyn)
Tazobactam (+ piperacillin makes Zosyn)
What antibiotics are not preferred for cystits 2/2 ADE
Fluoroquinolones (Cipro, Levo) x 3 days
Can cause tendonitis and tendon rupture (advise NO weight lifting)
must be 16+ y/o!
What lab must you check if you prescribe Macrobid
Creatinine! Macrobid is cleared renally
What other abx can be used for empiric Tx of cystitis
Fosfomycin (powder) PO single dose (not for pyelo) Cefdinir Augmentin Ceclor Vantin
What should you do if cystitis Sx persist s/p tx
ensure compliance
re-culture
check PVR
Pelvic (vaginitis?)
What meds can you give for persistent Sx
Urgency: Antimuscarinic Dysuria: Phenazopyridine Pelvic pain: NSAIDS Can also give Quercetin (decrease inflammation) Treat constipation and stress
How can you prevent reinfection s/p treating cystitis
Avoid spermicides/diaphragm
Topical vaginal estrogen (normalize flora, restore lactobacilli, and decrease vaginal pH
-Use high caution with: antibiotic prophylaxis and self-start abx therapy
What causes complicated cystitis
Immunosuppression pregnancy male peds indwelling catheter anatomic abn (diverticulum, etc) urinary obstruction urolithiasis renal insufficiency
Why can complicated cystitis occur in the presence of a catheter
Bacteria can colonize and form a biofilm on the catheter
biofilm is resistant to abx
What should you do if a patient with an indwelling catheter has UTI Sx
remove catheter (remove biofilm)
replace catheter
give abx
How can you prevent UTI’s in patients with indwelling cath
sterile technique when placing catheter
keep system closed
dont let urine back flow from bag to bladder
keep bag BELOW bladder level
dont kink tubing
remove cath as soon as it is no longer necessary
What is pyelonephritis
Urinary infection involving renal parenchyma
“upper UTI”
What are symptoms of pyelonephritis
Fever, chills, flank pain, abdominal pain, N/V
If ascending from bladder, urinary Sx (dysuria, frequency, urgency)
If hematogenous spread, no urinary Sx
What will you see on PE for pyelonephritis
Fever
CVA ttp
What will labs for pyelonephritis show
UA: WBC, WBC casts
CBC: leukocytosis w/ left shift
Urine culture
Blood culture may be negative
When would you get imaging in a patient suspected of pyelonephritis
If very ill, unstable, septic, or with DM
immunocompromised, unresponsive to abx, etc.
What imaging can be done to evaluate pyelonephritis
CT Urogram (perinephric stranding, large kidneys, dilated collecting system) Renal US (large kidneys, abn echogenicity)
How do you treat pyelonephritis if patient is mildly ill
Outpatient Fluoroquinolone x 7 days (or other abx x 14 days)
Initial long acting IV Ceftriaxone
Admit if still febrile >72 hours
How do you treat pyelonephritis in moderately or severely ill patients
Admit! Urine and blood cultures IV Fluoroquinolone, aminoglycoside, carbapenem, or cephalosporin- switch to PO when afebrile x 24-48 hrs Imaging for renal abscess D/C home w/ 2 weeks po abx
What is the spectrum of pyelonephritis
Pyelonephritis –> acute bacterial nephritis –> renal abscess
Suspect the latter 2 if patient is not improving
What is Acute Bacterial Nephritis
Bacterial interstitial nephritis of the renal cortex–> renal mass (NO liquefaction)
What is a renal abscess
Purulent fluid collecting in the kidney (often DM or immunocompromised)
MCC is gram NEGATIVE bacteria (unless hematogenous route, then gram + like staph aureus)
How do you treat a renal abscess
IV abx
Percutaneous drainage
surgical drainage
What is chronic pyelonephritis
Scarred, atrophic, poor functioning kidney 2/2 prior infections
Low flow and high renin
(renin= high angiotensin= high aldosterone= water/Na retention)
How does chronic pyelonephritis present
HTN Anemia Proteinuria Renal insufficiency Recurrent UTI Claceal blunting on imaging**
How do you treat chronic pyelonephritis
Manage UTI RF
control HTN
Nephrectomy
