Dysuria: urinary tract infection

Question 1

Dysuria presentation, what further questions must it revolve around?

Answer 1

Bladder dysfunction
Is there frequency, urgency and cramping pain (strangury)
If so, cystitis
If not, urethritis

Question 2

How will you diagnose cystitis

Answer 2

Urine dipstick: WBC/leuckocyte esterase

Midstream urine: $35. Microscopy, culture/susceptibility

Question 3

Common sense cost saving versus midstream urine (more expenny)
Dipstick: Pyuria in the absence of ___ DOES NOT indicate _____
If further problems ____ and send for ____

Answer 3

symptoms
cystitis
reassess
culture

Question 4

Cystitis treatment

Answer 4

Following pyuria and symptoms
Antibiotics e.g trimethoprim or sulphamethoxazole

can resolve on own

Question 5

How common is cystitis

Answer 5

Women more: sexually active and post menopausal (low estrogen) and institutionalised

Question 6

Risk factors for cystitis

Answer 6

past UTI, sex, diaphragm use, etc

Question 7

Older people with cystitis features

Answer 7

Women: post menopause; urinary tract abnormalities; neurological disease
Male: strictures, stones, prostatic disease, neurological disease

Question 8

Bacteria that cause cystitis

Answer 8

E coli >80% * (causes most pyelonephritis)
Staphyococcus saprophyticus younger women*
Some enterobacteriae, strep agalactiae, enterococcus, pseudomonas aeruginosa; candida albicans (catheters)

Question 9

How does E coli cause cysitits

• Sequesters ___
• _____ for _____ attachment (type _ bladder to _ kidney)
• polysaccharide ____ only in uropathogenic. Resists phagocytes, protects with __ swings
• alpha _____ damages ____ cells, causing cytokine release, fever, malaise neutrophil recruitment

Answer 9

• Sequesters iron
• Fimbriae for urothelial attachment (type 3 bladder to 1 kidney)
• polysaccharide capsule only in uropathogenic. Resists phagocytes, protects with pH swings
• alpha haemolysin damages transitional cells, causing cytokine release, fever, malaise neutrophil recruitment

Question 10

Defence against UTI’s/ uropathogenic E coli

____ ____: lactobacilli produce H2O2, kills competing flora (staph sapro. detoxifies H2O2). Flora chnages in PM women
____: low pH, and osmolality changes
_____: bacteria with type 1/3 fimbriae adhere
_______ protein: made in ____ to bind type 1 _____ bacteria. Swithcing bacteria avoid
____ ____: inhibits bacterial growth
innate+ adaptive immunnity

Answer 10

Microbial flora: lactobacilli produce H2O2, kills competing flora (staph sapro. detoxifies H2O2). Flora chnages in PM women
Urine: low pH, and osmolality changes
Urination: bacteria with type 1/3 fimbriae adhere
Tamm-Horsfall protein: made in LoH to bind type 1 fimbriae bacteria. Swithcing bacteria avoid
Prostatic fluid: inhibits bacterial growth
innate+ adaptive immunnity

Question 11

How does trimethoprim work?
_______ antibiotic
____ synthesis important in bacteria for ___ synthesis.
trimethoprim inhibits enzyme ___ ____ in step dihydropteroic acid to ____ acid
Also early antibiotics _____ and dapsomes that inhibit dihydropteroate synthetase

Answer 11

Bacteriostatic antibiotic
Folate synthesis important in bacteria for DNA synthesis.
trimethoprim inhibits enzyme dihydrofolate synthetase in step dihydropteroic acid to dihydrofolic acid
Also early antibiotics sulphonamides and dapsomes that inhibit dihydropteroate synthetase

Question 12

How is antibiotic resistance to trimethoprim occurring

Answer 12

1) alter enzyme target
2) make more enzyme
3) scavenge thymidines/surrounding folate

Question 13

Two NZ folate antagonists

Answer 13

co-trimoxazole: sulphamethoxazole+ trimethoprim

Trimethoprim

Question 14

Bad uses of trimethoprim
Avoid in ____
Long periods= suppression on __ ___ function
Allergy: typically rash, can be severe in ________syndrome

Answer 14

Avoid in pregnancy
Long periods= suppression on bone marrow function
Allergy: typically rash, can be severe in Stevens-Johnson syndrome

Question 15

Good options to treat cystitis says Steve Ritchie

Answer 15

Trimethoprim 300mg nocte 3 days

Nitrofuratoin 50mg QID 3 days (hardbecause 4 times a day, harder for non hospitalised)

Question 16

causes of Recurrent cystitis

Answer 16

intercourse
form of contraception
abnormal urinary tracts or urodynamics

Question 17

Pyelonephritis signs and symptoms + management

Answer 17

Flank pain, loin to groin, haematuria, fever malaise, nausea, bactaremia. 10% mortality
Stone differential?
Management: investigate blood cultures, urine cultures blood tests for renal function.
US not required for diagnosis unless stones suspected

Question 18

pyelonephritis treatment

Answer 18

Often IV then oral
gentamicin (due to enteric gram -ve bacteria for the most part)
cefuroxime/amoxy-clav as alternatives
historically 14 days
be watchful for septic shock symptoms