Genitourinary Infections Flashcards
Genitourinary infections - what are the types of infections?
pyelonephritis (ascending/upper UTI), cystitis (lower/uncomplicated UTI), urethritis (STIs), prostatitis, epididymitis (STIs)
Genitourinary infections - what are the risk factors for females?
Pregnancy
Sexual intercourse
Diaphragm/spermicide use
Genitourinary infections - what are the risk factors for males?
Lack of circumcision
Prostatic enlargement
Condom catheter drainage
Genitourinary infections - what are the risk factors for both?
Previous UTI
Urologic instrumentation and catheterization!
Urinary tract obstruction!
Neurogenic bladder!
Renal transplantation!
Structural abnormalities
Diabetes mellitus
Frequent sexual intercourse or new sex partner Lack of urination after sexual intercourse
What are the characteristics of complicated UTIs?
anatomical abnormality, recent urologic procedure or instrumentation, immunocompromised patients, recurrent infections despite appropriate treatment, male sex, UTI in pregnancy
What are examples of anatomical abnormality of urinary tract?
Obstruction (commonly due to calculi)
Hydronephrosis (fluid/swelling around kidney)
Renal tract calculi
Colovesical fistula (connect bladder to colon)
What are examples of recent urologic procedure/instrumentation?
Placement of nephrostomy tubes (above obstruction)
Ureteric stenting (if no obstruction)
Suprapubic catheter
Foley catheter
What is an uncomplicated UTI?
▪Patient not meeting criteria for complicated UTI
▪Pre-menopausal women, normal anatomy
What is the most common pathogen for all UTI infections?
escherichia coli
What is the clinical presentation of a UTI?
▪New onset of dysuria, increased urinary urgency, and increased
urinary frequency
▪Suprapubic “heaviness” sensation and/or pain
▪Urine may be foul smelling or turbid – not correlated with infection
▪Hematuria can occur in some cases – alone does not mean complicated infection
What is the clinical presentation of pyelonephritis?
The same as a UTI plus:
▪Systemic signs of infection – fever, chills, rigors, nausea, vomiting, diarrhea
▪Flank pain – costovertebral angle (CVA) tenderness
What is the clinical presentation of a complicated UTI?
Signs and symptoms atypical and non-specific in some cases
▪Classic UTI symptoms commonly present, but not always
▪Fever
▪Malaise
▪Altered mental status (this alone does NOT automatically mean UTI is present!)
▪Urinary incontinence
▪Change in appetite
Catheter-associated UTI
▪Classic UTI symptoms often not present
▪Pain over kidney and bladder
▪Fever
▪Lethargy and malaise
What do you need to have to diagnose a UTI and pyelonephritis?
cystitis symptoms and pyelonephritis symptoms PLUS microbiologic criteria
What are the cystitis symptoms?
Dysuria
Increased urinary frequency
Increased urinary urgency
Suprapubic heaviness/pain
What are the pyelonephritis symptoms?
Fever, chills, rigors
CVA tenderness
Malaise
What is the microbiologic criteria?
≥ 10^5 of ≥ 1 bacterial species from a clean void
≥ 10^3 of ≥ 1 bacterial species from a catheter (placed in last 48-hr)
Diagnosis of UTI and pyelonephritis - urinalysis
4 key components related to UTI
▪Bacteria present (depends on how lab reports it)
▪WBC present (≥ 10 cells/hpf)
▪Leukocyte (WBC) esterase present
▪Nitrite may or may not be present (Enterobacterales convert nitrates to nitrites) ▪Remember – diagnosis relies on correlation with symptoms
▪Turnaround time – Hours
Diagnosis of UTI and pyelonephritis - urine culture
▪Assists with identification of organism and confirm susceptibility to antibiotic selection ▪Repeat urine culture after treatment generally not recommended
▪Many labs institute criteria for urine culture ordering to reduce overtreatment of UTI ▪Turnaround time – 2-3 days
What is asymptomatic bacteriuria?
Asymptomatic bacteriuria (ASB) does not require treatment outside of a few specific cases
▪Most common situation requiring treatment – ASB in pregnancy
leads to overdiagnosing –> overtreating –> antimicrobial resistance
Characteristics of an Ideal Oral Antibiotic for UTI
medium to high bioavailability
medium to high renal excretion
low risk for “collateral damage” and adverse effects
high likelihood of susceptibility
What are the commonly used oral agents for UTI treatment?
▪Nitrofurantoin (uncomplicated only) ▪Sulfamethoxazole/trimethoprim
▪Fluoroquinolones – ciprofloxacin, levofloxacin
▪Fosfomycin (uncomplicated only)
Beta-lactams
▪Cephalexin
▪Cefadroxil
▪Cefpodoxime
▪Amoxicillin/clavulanate
▪Amoxicillin (only after susceptibility is confirmed)
What is the treatment of duration?
uncomplicated: 3-7 days
complicated: 7-14 days
the threshold of 20% is the resistance prevalence at which the agent is no longer recommended for empirical treatment
Which antibiotics have the lowest resistance rate to E. coli?
nitrofurantoin monohydrate/macrocrystals, cephalexin or cefadroxil, cefpodoxime, amoxicillin/clavulanate
SMP/TMX and ciprofloxacin are both over 20% resistance
What is the empiric UTI treatment for hospitalized patients?
▪Important to base empiric treatment selection on local susceptibility rates to common pathogens
▪Examples of commonly used options for empiric therapy
▪Ampicillin + gentamicin (best % likelihood to cover all organisms at IU)
▪Cefazolin +/- gentamicin
▪Ceftriaxone
▪Cefepime
▪Gentamicin
What are the considerations for UTI treatment in hospitalized patients?
Bacteremia can occur in patients with complicated UTI and pyelonephritis
▪Bacteremia ≠ Longer antibiotic duration
⎻ Duration resembles complicated UTI – 7-14 days
De-escalate to narrowest antibiotic option once urine culture with susceptibilities
return
▪It is OK to use a narrow spectrum antibiotic once susceptibilities return even if patient was critically ill upon admission
What is the treatment for prostatitis?
Must consider antibiotic penetration into the prostate
▪No active transport of antibiotics into the prostate tissue
▪Need an option with high level of free drug, low protein binding
Recommended treatment options
▪Fluoroquinolones
▪Sulfamethoxazole/trimethoprim
▪Some beta-lactams (cephalexin, amoxicillin/clavulanate)
Treatment duration – 2-4 weeks
What is a recurrent UTI?
Definition of recurrent UTI
▪3 or more infections in 1 year
▪2 or more infections in 6 months
Important to consider potential causes for recurrent infections
▪Sexual intercourse and diaphragm/spermicide use
▪Postmenopausal women
▪Urologic abnormality
May consider prophylactic antibiotic if no correctable cause identified
▪Select narrowest spectrum option (ex. nitrofurantoin b/c of unique MOA)
