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IC13 UTI Flashcards

1
Q

Define Asymptomatic Bacteriuria

A

Bacteria present in urine but no symptoms of UTI

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2
Q

Define Urinary Tract Infection [UTI]

A

Bacteria present in urine + have urinary symptoms

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3
Q

Classification of UTI: complicated

A

men, children, pregnant women

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4
Q

Classification of UTI: uncomplicated

A

healthy premenopausal, non-pregnant women with no history suggestive of an abnormal urinary tract

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5
Q

Types of UTI

A

Upper UTI: pyelonephritis (kidneys)

Lower UTI: Cystitis (bladder), Urethritis (urethra), Prostatitis (prostate), Epididymitis (epididymis)

Catheter associated UTI

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6
Q

People to be screened for ASB

A

ONLY
1. Pregnant women
2. Patients undergoing urologic treatment with expected mucosal trauma/ bleeding

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7
Q

Reasons for pregnant women to be screened for ASB

A

ASB in early pregnancy → 20-30% increase risk of pyelonephritis
Prevention of: pyelonephritis, preterm labour & infant low birth weight

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8
Q

When to screen pregnant women for ASB

A

one of first visits (12-16 weeks gestation)

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9
Q

Reasons for Patients undergoing urologic treatment with expected mucosal trauma/ bleeding

A

Procedures cause break in urinary tract (except placement of urinary catheter)
Presence of bacteria in urine can enter BS ⇒ bacteremia & sepsis
Prevention of: bacteremia & urosepsis

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10
Q

When to screen patients undergoing urologic treatment with expected mucosal trauma/ bleeding

A

prior to procedure (2-3 days)

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11
Q

Prevalence of UTI
(0-6 months)

A

Males > Females
M: Higher rates of structural & functional abnormalities in urinary tract in boys

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12
Q

Prevalence of UTI
(1 - adult)

A

Females > Males
F: Shorter urethra; have easier access of bacteria to bladder (common: cystitis)
M: Have added protection from anti-bacterial substances secreted by prostate

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13
Q

Prevalence of UTI
(>65 years)

A

Equal
F: Shorter urethra; have easier access of bacteria to bladder (common: cystitis)
M: More comorbidities relating to obstruction/ retention of urine
BPH, urine/ bowel incontinence due to stroke/ muscular dysfunction, urine catheter

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14
Q

Routes of infection

A
  1. Ascending
  2. Hematogenous (descending)
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15
Q

Derivation of ascending infection

A

Colonic/ faecal flora colonise periurethral area/ urethra
ascend to bladder & kidney

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16
Q

Derivation of hematogenous infection

A

Organism at distant primary site → enters BS → urinary tract ⇒ causes UTI
ie: heart valves (endocarditis), bone (osteomyelitis)

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17
Q

Possible organisms in ascending infection

A

E.coli, Klebsiella, Proteus

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18
Q

Possible organisms in hematogenous infection

A

Staphylococcus aureus, Mycobacterium Tuberculosis

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19
Q

Risk factors of ascending infection

A

females (shorter urethra), use of spermicides, diaphragms as contraceptives

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20
Q

Host defence mechanisms against UTI

M, AB, AH, P [MAAP]

A

Bacteria in bladder stimulates micturition with increased diuresis
(emptying of bladder ⇒ removal of bacteria)

Antibacterial properties of urine & prostatic secretion
(Enzymes produced act against bacteria)

Anti-adherence mechanisms in bladder
(Prevents attachment of bacteria to bladder mucosa ⇒ cannot invade urinary tract tissues)

Inflammatory response with polymorphonuclear leukocytes (PMNs)
(Leads to phagocytosis ⇒ prevent/ control spread)

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21
Q

Risk factors of UTI

F, S, UT, ND, D, C, B, DM, P, D/S, G, P

A

Females > males
Sexual intercourse
Abnormalities of the urinary tract
(prostatic hypertrophy, kidney stones, urethral strictures, vesicoureteral reflux)
Neurological dysfunctions: stroke, diabetes, spinal cord injuries
Anti-cholinergic drugs
Catheterization & other mechanical instrumentation
Formation of biofilms
Diabetes (especially uncontrolled)
Pregnancy
Use of diaphragms & spermicides → alters vaginal flora
Genetic association (positive family history)
Previous UTI

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22
Q

Subjective evidence of Cystitis
(urinary symptoms)

A

Dysuria (pain on urination), urgency, frequency, nocturia (increased urination at night), gross hematuria (blood in urine)
Suprapubic heaviness/ pain

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23
Q

Subjective evidence of Pyelonephritis
(urinary symptoms)

A

More serious presentation
fever, rigours, headache, nausea, vomiting, malaise
flank pain, costovertebral tenderness (renal punch), abdominal pain

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24
Q

Individuals to collect objective evidence

A

Pregnant women, recurrent UTI (relapse within 2 weeks/ frequent), pyelonephritis, catheter associated UTI, all men

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25
Collection method of urinalysis
Midstream clean-catch → throw away first 20-30 mLs (due to possibility of contamination), then collect next 30 mL Catheterisation → insertion of tube into urethra Suprapubic bladder aspiration → needle aimed at bladder
26
Components of Microscopic urinalysis
WBC, RBC, microorganisms, WBC casts, Squamous epithelial cells
27
Requirments for UTI diagnosis WBC
> 10 WBCs/mm3 = pyuria Signifies presence of inflammation, may or may not be due to infection
28
Requirments for UTI diagnosis RBC
>5/ HPF or gross = hematuria Frequent in UTI but non-specific
29
Requirments for UTI diagnosis microorganisms
Identify bacteria/ yeast using gram-stain
30
Requirments for UTI diagnosis WBC casts
Masses of cells & proteins forming in renal tubules Indication of UTI/ disease
31
Requirments for UTI diagnosis squamous epithelial cells
Presence = indicates contamination (Urine not well collected) Less likely UTI
32
Components of Chemical urinalysis
Nitrite, Leukocyte esterase (LE)
33
Requirments of UTI diagnosis Nitrite
Positive test ⇒ G- bacteria (reduces nitrate to nitrite) Requires >10^5 bacteria/ mL
34
Chemical urinalysis: Nitrite Causes of false positives
Presence of G+ organism & P.aeruginosa Low urinary pH, frequent voiding & dilute urine
35
Requirments of UTI diagnosis Leukocyte esterase (LE)
Positive test ⇒ detection of esterase activity of leukocytes in urine Correlates with significant pyuria (> 10 WBCs/mm3)
36
Likely pathogens in Uncomplicated/ community acquired UTI
Escherichia coli (>85%) ⇒ from ascending route Staphylococcus saprophyticus (5-15%) ⇒ common coloniser Others (gut bacteria): Enterococcus faecalis, Klebsiella pneumoniae, Proteus spp
37
Likely pathogens in Complicated/ healthcare-associated UTI
E. coli (50%) Enterococci ⇒ G+ Proteus spp, Klebsiella spp, Enterobacter spp, P. aeruginosa
38
Considerations for Healthcare-associated UTI
recent &/ or frequent exposure to healthcare settings: Recent hospitalisation, AM use, invasive urological procedures Long term urinary catheter usage to consider more resistant strains of bacteria
39
Other possible microbes of UTI
S.aureus: due to bacteremia To consider other primary site of infections yeast/ candida: possible contaminant Possibly enter via hematogenous route of infection (descending) Usually do not require treatment
40
Individuals requiring treatment
Symptomatic patients Pregnant women Patients undergoing urologic procedures
41
Purpose of treating pregnant women
reduce risk of developing pyelonephritis, pre-term labour & low birth rate infant
42
Purpose of treating Patients undergoing urologic procedures
Reduction of bacteria load to prevent infection Prevent postoperative bacteremia & sepsis
43
empiric treatment of: Cystitis in women AND Community-acquired UTI in men (Cystitis & no concern for prostatitis)
PO co-trimoxazole 800/160 mg BD x 3 days PO nitrofurantoin 50 mg QID x 5 days PO fosfomycin 3 g single dose Alternatives: *PO beta-lactams x 5-7 days* PO cefuroxime 250 mg BD PO amoxicillin-clavulanate 625 mg BD PO cephalexin 250-500 mg QID *PO fluoroquinolones x 3 days* PO ciprofloxacin 250 mg BD PO levofloxacin 250 mg OD
44
treatment of Cystitis in women AND Community-acquired UTI in men (Cystitis & no concern for prostatitis) nitrofurantoin requirements
eGFR >30 mL/ min Accumulation of drug ⇒ neuropathy, numbness, lung fibrosis
45
treatment of Cystitis in women AND Community-acquired UTI in men (Cystitis & no concern for prostatitis) fosfomycin indication
ESBL-producing E.coli → higher risk of developing resistance
46
treatment of cystitis in women AND Community-acquired UTI in men (Cystitis & no concern for prostatitis) Caution for fluoroquinolones
risks: neurotoxicity in elderly + resistance to other AB
47
empiric treatment of Community-acquired pyelonephritis in women ORAL
*PO fluoroquinolones ⇒ first line (short duration + effective)* Generally give higher dose than cystitis PO ciprofloxacin 500 mg BD x 7 days (F = 80%; hence to give 500 mg to get required dose of 400 mg) (Not for ESBL-producing bacteria) PO levofloxacin 750 mg OD x 5 days PO co-trimoxazole 160/800 mg BD x 10-14 days *PO Beta-lactam x 10-14 days* PO cefuroxime 250-500 mg BD PO amoxicillin-clavulanate 625 mg TDS PO cephalexin 500 mg QID
48
empiric treatment of Community-acquired pyelonephritis in women IV
*First agent* IV ciprofloxacin 400 mg BD or IV cefazolin 1g q8h or IV amoxi-clav 1.2g q8h *Second agent* (And/ or): IV/IM gentamicin 5mg/kg To cover G- Good action against ESBLs Good concentration in urinary tract Switch to oral when patient improved or able to take orally
49
empiric treatment for Community-acquired UTI in men Cystitis & have concern for prostatitis
Treat for 10-14 days; 6 weeks if prostatitis confirmed PO ciprofloxacin 500 mg BD or PO co-trimoxazole 160/800 mg BD
50
empiric treatment of Nosocomial/ healthcare-associated UTI days of treatment
7-14 days
51
empiric treatment of Nosocomial/ healthcare-associated UTI pathogen considerations
P.aeruginosa ESBL-producing E.coli & Klebsiella
52
empiric treatment of Nosocomial/ healthcare-associated UTI ORAL (less sick patients)
PO levofloxacin 750 mg PO ciprofloxacin 500 mg BD
53
empiric treatment of Nosocomial/ healthcare-associated UTI IV
IV cefepime 2g q12h +/- IV amikacin 15mg/kg/d IV imipenem 500 mg q6h --> avoid in elderly IV meropenem 1g q8h
54
empiric treatment of Catheter-associated UTI Duration of treatment
7 days → prompt resolution of symptoms (ie: no fever in 72 hours) 10-14 days → if have delayed response (important to identify reasons)
55
empiric treatment of Catheter-associated UTI pathogen considerations
Pseudomonas
56
empiric treatment of Catheter-associated UTI IV
IV imipenem 500 mg q6h or IV meropenem 1g q8h IV cefepime 2g q12H +/- IV amikacin 15mg/kg (1 dose or OD)
57
empiric treatment of Catheter-associated UTI ORAL
PO/ IV levofloxacin 750 mg x 5 days (for mild CA-UTI) PO Co-trimoxazole 960mg bid x 3 days
58
empiric treatment of Catheter-associated UTI indications for PO co-trimoxazole
women ≤65 years with CA-UTI & without upper urinary tract symptoms after an indwelling catheter has been removed
59
Culture-directed treatment of pregnant women ideal therapy
Beta-lactams ⇒ safe; first-line treatment of UTI
60
Culture-directed treatment of pregnant women Duration of treatment
4-7 days for ASB/ cystitis 14 days for pyelonephritis
61
Culture-directed treatment of pregnant women drugs to avoid
Ciprofloxacin Co-trimoxazole (1st & 3rd trimester) Nitrofurantoin at term (38-42 weeks)
62
Culture-directed treatment of pregnant women ciprofloxacin avoid
Possible fetal cartilage damage & arthropathies
63
Culture-directed treatment of pregnant women cotrimoxazole avoid
1st trimester Folate antagonism of TMP → cause neural tube defects 3rd trimester Risk of kernicterus (hyperbilirubinemia) in newborns Due to competitive binding between bilirubin & sulfonamides to plasma albumin Concerns of G6PD-deficient foetus
64
Culture-directed treatment of pregnant women nitrofurantoin avoid
Concerns of G6PD-deficient foetus
65
Culture-directed treatment of pregnant women use with caution
Aminoglycosides
66
organism factors in treatment
Identity of infecting organism Susceptibility of infecting organism If empiric → consider local resistance patterns (antibiogram) If culture-directed → select active AB according to AST Combination therapy may be required
67
host factors in treatment
Age History of allergy & ADR G6PD deficiency Pregnancy or lactation Renal or hepatic impairment Status of host immune function Severity of illness Recent antimicrobial use Healthcare-associated risk factors
68
drug factors in treatment
Active against suspected organism Ability to reach site of infection PK-PD characteristics Route of administration SE profiles DDI Cost
69
Adjunctive therapy for UTI fever & pain
NSAIDs. paracetamol
70
Adjunctive therapy for UTI Urinary symptoms
Phenazopyridine Dose: 100-200 mg TDS Azo dye; exerts topical analgesic effect on urinary tract mucosa ⇒ symptomatic relief Avoid in G6PD deficient patients ADR: N/V, orange-red discolouration of urine & stool Urine alkalinisation Relief discomfort in mild UTI Unproven benefit
71
Adjunctive therapy for UTI Vomiting
rehydration
72
Non-pharmacological preventions of UTIs general F, U, S, U
Drink lots of fluid to flush the bacteria ⇒ 6-8 glasses a day Take note of other health problems that might restrict fluid intake (ie HF) Urinate frequently & go when you first feel the urge. Bacteria can grow when urine stays in the bladder too long. Urinate shortly after sex → flushes away bacteria that might have entered urethra during sex Wear cotton underwear & loose-fitting clothes so that air can keep the area dry. Avoid tight-fitting jeans & nylon underwear → traps moisture & can help bacteria grow
73
Non-pharmacological preventions of UTIs women-specific W, BC
Always wipe from front to back, especially after a bowel movement Alter birth control methods Diaphragm/ spermicide ⇒ increases bacteria growth Unlubricated condoms/ spermicidal condoms → increases irritation ⇒ helps bacteria grow
74
Non-pharmacological preventions of UTIs Catheter-associated UTI C, LT, CS, A
Avoid unnecessary catheter use Use for minimal duration Long-term indwelling catheters changed before blockage is likely to occur Use of closed system Ensure aseptic insertion technique Avoid: Topical antiseptic or antibiotics Prophylactic antibiotics and antiseptic Chronic suppressive antibiotics
75
Resolution of signs & symptoms after treatment
By 24 to 72 hrs after initiation of effective antibiotics Failure to respond clinically within 2 to 3 days OR have persistently positive blood/ urine cultures → further investigation required
76
Bacteriological clearance after treatment
Repeat culture not required for patients who responded Culture to document clearance of infection for pregnant women
77
Reasons for unsatisfactory response after treatment D, COA, C, NC, RF, DDI, C/A, HD, SI, T
Inappropriate diagnosis: Non-infectious causes, Non-bacterial infections Inappropriate choice of agent: Resistance/ development of resistance Subtherapeutic concentration Non-compliance from patient Improving renal function → better clearance of drug (less retained in body) DDI collections/ abscess → needs surgery/ drainage Impaired host defence Superinfection Toxicity of drug
78
Catheter associated UTI definition
Presence of signs/ symptoms compatible with UTI; no identified source of infection 10^3 cfu/mL of ≥1 bacterial species in a single catheter urine specimen in patients with indwelling urethral, indwelling suprapubic OR intermittent catheterization OR in a midstream voided urine specimen from a patient whose catheter has been removed within the previous 48 h
79
Catheter associated UTI Causative organisms
Short term (<7 days): 85% single organisms Reflects what is present in environment Long term (>28 days): 95% polymicrobial, 2-3 organisms
80
Catheter associated UTI Drawing culture from catheter
Remove old catheter → insert new catheter → draw culture
81
Catheter associated UTI Treatment process
Not required if asymptomatic; insertion of catheter is NOT traumatic procedure Ideally to remove catheter - If catheter in place for >2 weeks at onset of CA-UTI & is still indicated → important to replace catheter - Helps to hasten resolution of symptoms & reduce risk of subsequent CA-bacteriuria & CA-UTI

infec y3s1 (7 decks)

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