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infec y3s1 > IC13 UTI > Flashcards

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
Q

Collection method of urinalysis

A

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

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26
Q

Components of Microscopic urinalysis

A

WBC, RBC, microorganisms, WBC casts, Squamous epithelial cells

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27
Q

Requirments for UTI diagnosis
WBC

A

> 10 WBCs/mm3 = pyuria
Signifies presence of inflammation, may or may not be due to infection

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28
Q

Requirments for UTI diagnosis
RBC

A

> 5/ HPF or gross = hematuria
Frequent in UTI but non-specific

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29
Q

Requirments for UTI diagnosis
microorganisms

A

Identify bacteria/ yeast using gram-stain

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30
Q

Requirments for UTI diagnosis
WBC casts

A

Masses of cells & proteins forming in renal tubules
Indication of UTI/ disease

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31
Q

Requirments for UTI diagnosis
squamous epithelial cells

A

Presence = indicates contamination
(Urine not well collected)
Less likely UTI

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32
Q

Components of Chemical urinalysis

A

Nitrite, Leukocyte esterase (LE)

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33
Q

Requirments of UTI diagnosis
Nitrite

A

Positive test ⇒ G- bacteria (reduces nitrate to nitrite)
Requires >10^5 bacteria/ mL

34
Q

Chemical urinalysis: Nitrite
Causes of false positives

A

Presence of G+ organism & P.aeruginosa
Low urinary pH, frequent voiding & dilute urine

35
Q

Requirments of UTI diagnosis
Leukocyte esterase (LE)

A

Positive test ⇒ detection of esterase activity of leukocytes in urine
Correlates with significant pyuria (> 10 WBCs/mm3)

36
Q

Likely pathogens in Uncomplicated/ community acquired UTI

A

Escherichia coli (>85%) ⇒ from ascending route
Staphylococcus saprophyticus (5-15%) ⇒ common coloniser

Others (gut bacteria):
Enterococcus faecalis, Klebsiella pneumoniae, Proteus spp

37
Q

Likely pathogens in Complicated/ healthcare-associated UTI

A

E. coli (50%)
Enterococci ⇒ G+
Proteus spp, Klebsiella spp, Enterobacter spp, P. aeruginosa

38
Q

Considerations for Healthcare-associated UTI

A

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
Q

Other possible microbes of UTI

A

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
Q

Individuals requiring treatment

A

Symptomatic patients
Pregnant women
Patients undergoing urologic procedures

41
Q

Purpose of treating pregnant women

A

reduce risk of developing pyelonephritis, pre-term labour & low birth rate infant

42
Q

Purpose of treating Patients undergoing urologic procedures

A

Reduction of bacteria load to prevent infection
Prevent postoperative bacteremia & sepsis

43
Q

empiric treatment of:
Cystitis in women AND Community-acquired UTI in men
(Cystitis & no concern for prostatitis)

A

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
Q

treatment of Cystitis in women AND Community-acquired UTI in men (Cystitis & no concern for prostatitis)
nitrofurantoin requirements

A

eGFR >30 mL/ min
Accumulation of drug ⇒ neuropathy, numbness, lung fibrosis

45
Q

treatment of Cystitis in women AND Community-acquired UTI in men (Cystitis & no concern for prostatitis)
fosfomycin indication

A

ESBL-producing E.coli → higher risk of developing resistance

46
Q

treatment of cystitis in women AND Community-acquired UTI in men (Cystitis & no concern for prostatitis)
Caution for fluoroquinolones

A

risks: neurotoxicity in elderly + resistance to other AB

47
Q

empiric treatment of Community-acquired pyelonephritis in women
ORAL

A

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
Q

empiric treatment of Community-acquired pyelonephritis in women
IV

A

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
Q

empiric treatment for Community-acquired UTI in men
Cystitis & have concern for prostatitis

A

Treat for 10-14 days; 6 weeks if prostatitis confirmed
PO ciprofloxacin 500 mg BD or
PO co-trimoxazole 160/800 mg BD

50
Q

empiric treatment of Nosocomial/ healthcare-associated UTI
days of treatment

A

7-14 days

51
Q

empiric treatment of Nosocomial/ healthcare-associated UTI
pathogen considerations

A

P.aeruginosa
ESBL-producing E.coli & Klebsiella

52
Q

empiric treatment of Nosocomial/ healthcare-associated UTI
ORAL (less sick patients)

A

PO levofloxacin 750 mg
PO ciprofloxacin 500 mg BD

53
Q

empiric treatment of Nosocomial/ healthcare-associated UTI
IV

A

IV cefepime 2g q12h +/- IV amikacin 15mg/kg/d
IV imipenem 500 mg q6h –> avoid in elderly
IV meropenem 1g q8h

54
Q

empiric treatment of Catheter-associated UTI
Duration of treatment

A

7 days → prompt resolution of symptoms (ie: no fever in 72 hours)
10-14 days → if have delayed response (important to identify reasons)

55
Q

empiric treatment of Catheter-associated UTI
pathogen considerations

A

Pseudomonas

56
Q

empiric treatment of Catheter-associated UTI
IV

A

IV imipenem 500 mg q6h or
IV meropenem 1g q8h
IV cefepime 2g q12H +/- IV amikacin 15mg/kg (1 dose or OD)

57
Q

empiric treatment of Catheter-associated UTI
ORAL

A

PO/ IV levofloxacin 750 mg x 5 days (for mild CA-UTI)
PO Co-trimoxazole 960mg bid x 3 days

58
Q

empiric treatment of Catheter-associated UTI
indications for PO co-trimoxazole

A

women ≤65 years with CA-UTI & without upper urinary tract symptoms after an indwelling catheter has been removed

59
Q

Culture-directed treatment of pregnant women
ideal therapy

A

Beta-lactams ⇒ safe; first-line treatment of UTI

60
Q

Culture-directed treatment of pregnant women
Duration of treatment

A

4-7 days for ASB/ cystitis
14 days for pyelonephritis

61
Q

Culture-directed treatment of pregnant women
drugs to avoid

A

Ciprofloxacin
Co-trimoxazole (1st & 3rd trimester)
Nitrofurantoin at term (38-42 weeks)

62
Q

Culture-directed treatment of pregnant women
ciprofloxacin avoid

A

Possible fetal cartilage damage & arthropathies

63
Q

Culture-directed treatment of pregnant women
cotrimoxazole avoid

A

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
Q

Culture-directed treatment of pregnant women
nitrofurantoin avoid

A

Concerns of G6PD-deficient foetus

65
Q

Culture-directed treatment of pregnant women
use with caution

A

Aminoglycosides

66
Q

organism factors in treatment

A

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
Q

host factors in treatment

A

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
Q

drug factors in treatment

A

Active against suspected organism
Ability to reach site of infection
PK-PD characteristics
Route of administration
SE profiles
DDI
Cost

69
Q

Adjunctive therapy for UTI
fever & pain

A

NSAIDs. paracetamol

70
Q

Adjunctive therapy for UTI
Urinary symptoms

A

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
Q

Adjunctive therapy for UTI
Vomiting

A

rehydration

72
Q

Non-pharmacological preventions of UTIs
general

F, U, S, U

A

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
Q

Non-pharmacological preventions of UTIs
women-specific

W, BC

A

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
Q

Non-pharmacological preventions of UTIs
Catheter-associated UTI

C, LT, CS, A

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
Q

Resolution of signs & symptoms after treatment

A

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
Q

Bacteriological clearance after treatment

A

Repeat culture not required for patients who responded
Culture to document clearance of infection for pregnant women

77
Q

Reasons for unsatisfactory response after treatment

D, COA, C, NC, RF, DDI, C/A, HD, SI, T

A

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
Q

Catheter associated UTI
definition

A

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
Q

Catheter associated UTI
Causative organisms

A

Short term (<7 days): 85% single organisms
Reflects what is present in environment

Long term (>28 days): 95% polymicrobial, 2-3 organisms

80
Q

Catheter associated UTI
Drawing culture from catheter

A

Remove old catheter → insert new catheter → draw culture

81
Q

Catheter associated UTI
Treatment process

A

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

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