Infections of the urinary Tract Flashcards
1
Q
Nitrofurantoin is effective against most common uropathogens. It is____excreted from the urine but does ____. Therefore it is not useful for upper tract, complicated infections, or blood-borne infections It has minimal/maximal effects on the resident bowel and vaginal flora
A
Nitrofurantoin is effective against most common uropathogens. It is rapidly excreted from the urine but does not obtain therapeutic levels in most body tissues, including the gastrointestinal (GI) tract. Therefore it is not useful for upper tract, complicated infections, or blood-borne infections. It has minimal effects on the resident bowel and vaginal flora
2
Q
___ the presence of white blood cells (WBCs) in the urine, is generally indicative of infection and/or an inflammatory response of the urothelium to __,__,___, or other conditions that can contribute to pyuria. Bacteriuria without pyuria is generally indicative of bacterial colonization without overt infection of the urinary tract. Pyuria without bacteriuria, or sterile pyuria, warrants further evaluation
A
Pyuria, the presence of white blood cells (WBCs) in the urine, is generally indicative of infection and/or an inflammatory response of the urothelium to bacteria, stones, an indwelling foreign body, or other conditions that can contribute to pyuria. Bacteriuria without pyuria is generally indicative of bacterial colonization without overt infection of the urinary tract. Pyuria without bacteriuria, or sterile pyuria, warrants further evaluation
3
Q
Acute pyelonephritis is a clinical syndrome of __,__ and ___ that is accompanied by__ and __, a combination that is reasonably specific for an acute bacterial infection of the kidney.
A
Acute pyelonephritis is a clinical syndrome of chills, fever, and flank pain that is accompanied by bacteriuria and pyuria, a combination that is reasonably specific for an acute bacterial infection of the kidney.
4
Q
Xanthogranulomatous pyelonephritis (XGP) is a rare form of ____ often associated with _____ and characterized by destructive replacement of normal renal parenchyma with ___; it is associated with____of renal function
A
Xanthogranulomatous pyelonephritis (XGP) is a rare form of chronic pyelonephritis often associated with stone disease and characterized by destructive replacement of normal renal parenchyma with granulomatous inflammation; it is associated with ipsilateral loss of renal function
5
Q
factors of complicated UTI
A
6
Q
UTIs may also be defined by their relationship to other UTIs:
- A first or isolated infection is one that occurs in an individual who has___ or has one ___ from a
previous UTI. - An unresolved infection is one that __ and is documented to be the __ with a similar ___.
- A recurrent infection is one that occurs after documented, successful resolution of an antecedent infection. Consider these two different types of recurrent infection:
a. Reinfection describes a ___ associated with ___ of bacteria into the urinary tract.
b. Bacterial persistence refers to a recurrent UTI caused by the same bacteria ___ within the urinary tract, such as an __ or the ___.
A
• A first or isolated infection is one that occurs in an individual who has never had a UTI or has one remote infection from a
previous UTI.
• An unresolved infection is one that has not responded to antimicrobial therapy and is documented to be the same organism with a similar resistance profile.
• A recurrent infection is one that occurs after documented, successful resolution of an antecedent infection. Consider these two different types of recurrent infection:
- Reinfection describes a new event associated with reintroduction of bacteria into the urinary tract.
- Bacterial persistence refers to a recurrent UTI caused by the same bacteria reemerging from a focus within the urinary tract, such as an infectious stone or the prostate.
7
Q
The long-term effects of uncomplicated recurrent UTIs are not completely known, but, so far, there is no/there is association between recurrent infections and renal scarring, hypertension, or progressive renal azotemia has been established
A
The long-term effects of uncomplicated recurrent UTIs are not completely known, but, so far, no association between recurrent infections and renal scarring, hypertension, or progressive renal azotemia has been established
8
Q
UTIs occur as a result of interactions between the uropathogen and the host. Successful infection of the urinary tract is determined in part by the virulence factors of the__, __ and___
A
UTIs occur as a result of interactions between the uropathogen and the host. Successful infection of the urinary tract is determined in part by the virulence factors of the bacteria, the inoculum size, and the inadequacy of host defense mechanisms
9
Q
Gram-negative bacteria and their endotoxins, pregnancy, ureteral obstruction, and high lower tract pressures have a significant ____
A
Gram-negative bacteria and their endotoxins, as well as pregnancy, ureteral obstruction, and high lower tract pressures have a significant antiperistaltic effect
10
Q
hematogenous spread: kidney is occasionally secondarily infected in patients with___ originating from oral sites or with ___
A
kidney is occasionally secondarily infected in patients with Staphylococcus aureus bacteremia originating from oral sites or with Candida fungemia
11
Q
Direct extension of bacteria from the adjacent organs via lymphatics may occur in unusual circumstances, such as a __ or ___
A
Direct extension of bacteria from the adjacent organs via lymphatics may occur in unusual circumstances, such as a severe bowel infection or retroperitoneal abscesses.
12
Q
___ is by far the most common cause of UTIs, accounting for 85% of community-acquired and 50% of hospital-acquired infections. Other gram-negative Enterobacteriaceae, including ___ and ____, and gram-positive ___ and __ are responsible for the remainder of most community-acquired infections.
A
E. coli is by far the most common cause of UTIs, accounting for 85% of community-acquired and 50% of hospital-acquired infections. Other gram-negative Enterobacteriaceae, including Proteus and Klebsiella, and gram-positive Enterococcus faecalis and Staphylococcus saprophyticus are responsible for the remainder of most community-acquired infections.
13
Q
___ is a rare pathogen that causes UTIs in older adults with significant comorbidities, including some urologic malignancies
A
Aerococcus urinae is a rare pathogen that causes UTIs in older adults with significant comorbidities, including some urologic malignancies
14
Q
_____, is a gram-negative rod that has been associated with UTIs in immunocompromised patients
____ a gram-negative rod commonly found in environmental sources such as soil, has been identified as the causative agent in UTIs in immunocompromised patients and is particularly dangerous because of its extensive drug resistance
A
Raoultella planticola, is a gram-negative rod that has been associated with UTIs in immunocompromised patients (Skelton et al., 2017).
Myroides odoratimimus, a gram-negative rod commonly found in environmental sources such as soil, has been identified as the causative agent in UTIs in immunocompromised patients and is particularly dangerous because of its extensive drug resistance
15
Q
____ merits special attention as a rapidly emerging cause of multidrug-resistant infections, including UTI
A
E. coli sequence type ST131 (serotype O25b:H4) merits special attention as a rapidly emerging cause of multidrug-resistant infections, including UTI
16
Q
Urinary tuberculosis (UTB) most commonly occurs with __,, __, ___ and ___ with or without systemic symptoms such as __ and ___. Diagnosis and subsequent treatment are often delayed because of nonspecific symptoms, potentially contributing to impaired renal function and eventual renal failure. _____for M. tuberculosis has replaced acid-fast staining as the ideal method of diagnos
A
Urinary tuberculosis (UTB) most commonly occurs with hematuria (either gross hematuria, microhematuria, and/or sterile pyuria), storage symptoms, and/or dysuria, with or without systemic symptoms such as fever and weakness. Diagnosis and subsequent treatment are often delayed because of nonspecific symptoms, potentially contributing to impaired renal function and eventual renal failure. Polymerase chain reaction for M. tuberculosis has replaced acid-fast staining as the ideal method of diagnos
17
Q
The steps of UPEC pathogenesis include (6)
A
The steps of UPEC pathogenesis include (1) UPEC colonization of the periurethral and vaginal tissue as well as the urethra; (2) ascending infection into the bladder lumen and within the urine; (3) adherence to the surface urothelium and interaction with the bladder epithelial cell defense mechanism; (4) biofilm elaboration; (5) invasion and replication by forming bladder Intracellular Bacterial Communities (IBCs), in which quiescent intracellular reservoirs (QIRs) can form and stay dormant in the underlying urothelium; (6) and, in some cases, renal colonization and host tissue damage with high risk for sepsis
18
Q
___ are commonly expressed on nonpathogenic and pathogenic E. coli
A
Type 1 pili are commonly expressed on nonpathogenic and pathogenic E. coli
19
Q
some bacteria grown in a broth medium express pili, whereas the same strain grown on the same medium in a solid state will cease production of pili. This is called
A
phase variation
20
Q
Natural Defenses of the Urinary Tract (3)
A
Periurethral and Urethral Region
Urine
Bladder
21
Q
Uromodulin (Tamm-Horsfall protein), a kidney-derived mannosylated protein that is present in an extraordinarily high concentration in the urine (>100 mg/mL), may play a defensive role by saturating all the mannose-binding sites of the type 1 pili, thus potentially blocking bacterial binding to the uroplakin receptors of the urothelium
A
___, a kidney-derived mannosylated protein that is present in an extraordinarily high concentration in the urine (>100 mg/mL), may play a defensive role by saturating all the mannose-binding sites of the type 1 pili, thus potentially blocking bacterial binding to the uroplakin receptors of the urothelium
22
Q
The early diagnosis of RPN is important to improve prognosis and reduce morbidity. In addition to chronic infection, patients with ___ may have an increased incidence of urothelial tumors; routine urinary cytologic examinations may be helpful to diagnose these tumors early
A
The early diagnosis of RPN is important to improve prognosis and reduce morbidity. In addition to chronic infection, patients with analgesic abuse–associated papillary necrosis may have an increased incidence of urothelial tumors; routine urinary cytologic examinations may be helpful to diagnose these tumors early
23
Q
Renal PAPILLARY NECROSIS: __ and ___ can minimize a decline in renal function. A patient who suffers from an acute ureteral obstruction caused by a sloughed papilla and who has a concomitant UTI has a urologic emergency. In this case, immediate removal of the obstructing papilla by ___ or____ of the kidney by ureteral catheter or percutaneous nephrostomy is necessary
A
adequate antimicrobial therapy to control infection and early recognition and treatment of ureteral obstruction caused by sloughed necrotic tissue can minimize a decline in renal function. A patient who suffers from an acute ureteral obstruction caused by a sloughed papilla and who has a concomitant UTI has a urologic emergency. In this case, immediate removal of the obstructing papilla by stone basket or acute drainage of the kidney by ureteral catheter or percutaneous nephrostomy is necessary
24
Q
UTIs are fivefold more prevalent in ___than in control subjects The pathologic bacteria include higher rates of ___ and ___ in HIV positive patients.
A
UTIs are fivefold more prevalent in HIV-positive individuals than in control subjects (Schonwald et al., 1999). The pathologic bacteria include higher rates of Acinetobacter and Salmonella species in HIVpositive patients.
25
Of all patients with bacteriuria, no group compares in severity and morbidity with those who have \_\_\_
Of all patients with bacteriuria, no group compares in severity and morbidity with those who have SCI.
26
painless gross hematuria, or microhematuria
in the absence of a positive culture, should always raise the suspicion for\_\_\_ , and a ___ must be initiated.
painless gross hematuria, or microhematuria
in the absence of a positive culture, should always raise the suspicion for urologic malignancy, and a hematuria evaluation must be initiated.
27
Before sample collection in circumcised men, the glans should
be cleansed with a \_\_\_. For those uncircumcised, the foreskin should be ___ and the glans cleansed with the ___ before specimen collection. A \_\_\_specimen should be obtained by collecting it in a sterile cup.
Before sample collection in circumcised men, the glans should
be cleansed with a 2% castile soap towelette. For those uncircumcised, the foreskin should be retracted and the glans cleansed with the towelette before specimen collection. A midstream specimen should be obtained by collecting it in a sterile cup.
28
Situations in which a catheterized sample should be considered include when the voided sample shows clear evidence of ___ (i.e., many \_\_\_), a patient has a\_\_\_, the patient is unable to provide an adequate clean-catch sample, or the patient cannot provide any sample at all.
Situations in which a catheterized sample should be considered include when the voided sample shows clear evidence of contamination (i.e., many squamous epithelial cells), a patient has a pessary, the patient is unable to provide an adequate clean-catch sample, or the patient cannot provide any sample at all. Although
29
Leukocyte esterase is produced by the \_\_\_\_. Its presence is an indication of \_\_\_, but not \_\_\_specifically. the presence of WBCs and therefore leukocyte esterase is **uncommon/not uncommon** in women with vaginal contamination. Nitrites are present when bacteria reduce \_\_\_, via ___ activity. **ALL /NOT ALL** bacteria produce nitrites.
Leukocyte esterase is produced by the **breakdown of WBCs in the urine**. Its presence is an indication of **pyuria,** but not **bacteria** specifically. As mentioned previously, the presence of WBCs and therefore leukocyte esterase **is not uncommon** in women with vaginal contamination. Nitrites are present when bacteria reduce **dietary nitrates, via bacterial nitrate reductase activity**. **Not all** bacteria produce nitrites, though, so the absence of nitrites does not mean bacteria are not present
30
Other conditions known to cause pyuria include aside from UTI: (4)
GU tuberculosis, urolithiasis, injury to the urothelium (including chlamydial urethritis), and interstitial nephriti
31
a standard urine culture may be negative. In this scenario a culture should be sent specifically looking for ___ organisms such as\_\_ or \_\_
a standard urine culture may be negative. In this scenario a culture should be sent specifically looking for **atypical** organisms such as **Ureaplasma urealyticum or Mycoplasma hominis.**
32
The term asymptomatic bacteriuria is appropriately used when
a person has no signs or symptoms of a UTI, yet bacteria are identified in a noncontaminated urine sample. In women, the term asymptomatic bacteriuria is used when the ___ is identified in quantitative counts of greater than or equal to ____ in ___ voided samples that are obtained in a fashion that \_\_\_.
In men, ___ voided sample that identifies one bacterial species in quantitative counts greater than or equal to\_\_\_ CFUs is necessary to use the term asymptomatic bacteriuria appropriately
The term asymptomatic bacteriuria is appropriately used when
a person has no signs or symptoms of a UTI, yet bacteria are identified in a noncontaminated urine sample. In women, the term asymptomatic bacteriuria is used when the same bacteria is identified in quantitative counts of greater than or equal to 100,000 CFUs in two consecutive voided samples that are obtained in a fashion that minimizes contamination. In men, only one cleancatch voided sample that identifies one bacterial species in quantitative counts greater than or equal to 100,000 CFUs is necessary to use the term asymptomatic bacteriuria appropriately
33
guidelines clearly stipulate that, in the majority of patients, asymptomatic bacteriuria **SHOULD/ should not be** treated. it should always be treated in __ and in patients who are undergoing procedures in which ___ is anticipated
Should not, pregnant, transmucosal bleeding
34
Nitrofurantoin can cause\_\_\_and \_\_\_, such as pulmonary fibrosis, when used chronically. Nitrofurantoin should also be avoided in patients with suspicion of or known ___ deficiency because it can lead to hemolytic anemia. It had always been recommended that nitrofurantoin be avoided in patients with chronic renal insufficiency, defined as a CrCl less than 30 mL/min, because of lack of efficacy from poor renal concentrating ability
Nitrofurantoin can cause **GI upset and rare pulmonary issues,** such as pulmonary fibrosis, when used chronically. Nitrofurantoin should also be avoided in patients with suspicion of or known **glucose6-phosphate dehydrogenase (G6PD) deficienc**y because it can lead to hemolytic anemia. It had always been recommended that nitrofurantoin be avoided in patients with chronic renal insufficiency, defined as a CrCl less than 30 mL/min, because of lack of efficacy from poor renal concentrating ability
35
Fosfomycin, an oral bactericidal antimicrobial agent similar to phosphonic acid in chemical structure, is active against most uropathogens. Its major benefit is \_\_\_, as well as its efficacy against the majority of __ and \_\_\_. Further, it has been shown to be effective as a single-dose agent when used as an empirical treatment for \_\_-. It is an excellent oral option for MDR bacteria that would otherwise necessitate treatment with intravenous antibiotics
Fosfomycin, an oral bactericidal antimicrobial agent similar to phosphonic acid in chemical structure, is active against most uropathogens. Its major **benefit is its limited cross-resistance between most other common antibacterial agents**, as well as its efficacy against the majority of **gram-negative organisms and vancomycin-resistant Enterococcus (VRE).** Further, it has been shown to be effective as a single-dose agent when used as an empirical treatment for **uncomplicated cystitis.** It is an excellent oral option for MDR bacteria that would otherwise necessitate treatment with intravenous antibiotics
36
Woman with acute uncomplicated cystitis • Absence of fever, flank pain, or other suspicion for pyelonephritis • Able to take oral medication, next step in management
37
Approximately 90% of women are asymptomatic ___ after initiating antimicrobial therapy A follow-up visit or culture is **required/not required** in women who are asymptomatic after therapy. Further urologic evaluation is unnecessary in women who respond to therapy . However, UTIs in most men should be considered complicated until proven otherwise
Approximately 90% of women are asymptomatic within 72 hours after initiating antimicrobial therapy (Fihn et al., 1985). A follow-up visit or culture is not required in women who are asymptomatic after therapy. Further urologic evaluation is unnecessary in women who respond to therapy (Abarbanel et al., 2003; Lipsky, 1989). However, UTIs in most men should be considered complicated until proven otherwise
38
unresolved urinary tract infection causes: (4)
SUMMARIZED ANSWER: **ANTIMICROBIALS ARE NOT EFFECTIVE TO BEGIN WITH**
**DEVELOPMENT OF RESISTANCE IN PREVIOUSLY SUSCEPTIBLE SPECIES**
**PRESENCE OF UNSUSPECTED PATHOGEN**
**REINTRODUCTION OF NEW SPECIES WHILE UNDERGOING THERAPY for the 1st speceis being treated**
Most commonly, the bacteria are resistant to the antimicrobial agent selected to treat the infection. Typically, the patient has received the antimicrobial therapy in the recent past and developed bowel colonization with resistant bacteria.
The second most common cause is development of resistance in a previously susceptible population of bacteria during the course of treatment of UTIs. This problem occurs in approximately 5% of the patients receiving antimicrobial therapy. It is easy to recognize clinically because the culture on therapy shows that the previous susceptible population has been replaced by resistant bacteria of the same species. It can be shown that resistant organisms were actually present before contact with the initial antimicrobial agent, but they were present in such low numbers that it was impossible to detect by in vitro susceptibility studies before therapy. When the antimicrobial concentration in the urine is insufficient to kill all the bacteria present, the more resistant forms will emerge. This characteristically is seen in patients who are underdosed or who are poorly compliant and hence have inadequate dose regimens. The third cause is the presence of an unsuspected, second pathogen that was present initially and is resistant to the antimicrobial therapy chosen. Treatment of the dominant organism unmasks the presence of the second strain.
The fourth cause is rapid reintroduction of a new resistant species while the patient is undergoing initial therapy. Rapid reinfection that mimics unresolved bacteriuria should alert the clinician to the possibility of an enterovesical fistula.
39
A recurrent UTI is defined as \_\_\_or
\_\_\_
A recurrent UTI is defined as two UTIs in a 6-month period or
three or more UTIs in a 12-month period
40
risk factors for recurrent UTI
41
Significant risk factors for recurrence in women (6)
Significant risk factors for recurrence in women include s**exual activity, a new sexual partner within the past year, menopause, spermicidal use, family history of UTI in a first-degree female relative, and recent antimicrobial use**
42
In patients with emptying symptoms or a distended bladder on physical examination, documentation of a \_\_\_
In patients with emptying symptoms or a distended bladder on physical examination, documentation of a **postvoid residual is critical**
43
Cranberry products for UTI prophylaxis have been investigated for years in the scientific and lay press. One of the active ingredients in cranberry is the \_\_\_, which prevents the ___ from adhering to uroepithelial cells
Cranberry products for UTI prophylaxis have been investigated for years in the scientific and lay press. One of the active ingredients in cranberry is the **polyphenol type A proanthocyanidin (PAC**), which prevents the **P fimbriae of E. coli** from adhering to uroepithelial cells
44
decreased estrogen levels contribute to the transformation to __ and \_\_, which creates a more hospitable environment for bacteria to thrive.
decreased estrogen levels contribute to the transformation to **atrophic vaginal epithelium and increased vaginal pH,** which creates a more hospitable environment for bacteria to thrive. Indeed, the lack of estrogen causes marked changes in the vaginal microflora, **including a loss of lactobacilli and increased colonization by E. coli**
45
vaginal estrogen is effective in preventing recurrent UTIs in postmenopausal women. The beneficial effect from vaginal estrogen use can take at ___ weeks to manifest
vaginal estrogen is effective in preventing recurrent UTIs in postmenopausal women. The beneficial effect from vaginal estrogen use can take a**t least 12 weeks to manifest**
46
the relationship between laboratory findings
and the presence of ___ often is poor. Bacteriuria and pyuria, the hallmarks of UTI, **are/are not** predictive of renal infection.
patients with significant renal infection may have sterile urine if the _ or \_\_.
the relationship between laboratory findings
and the presence of **renal infection** often is poor. Bacteriuria and pyuria, the hallmarks of UTI, **are not predictive of renal infection**. Conversely, patients with significant renal infection may have sterile urine if the **ureter draining the kidney is obstructed or the infection is outside of the collecting system**
47
UA of acute pyelenophritis.
the relationship between laboratory findings
and the presence of renal infection is \_\_. Bacteriuria and pyuria, the hallmarks of UTI, **are not/are** predictive of renal infection. Conversely, patients with significant renal infection may have sterile urine if the ureter draining the kidney is __ or \_\_
the relationship between laboratory findings
and the presence of renal infection often is poor. Bacteriuria and pyuria, the hallmarks of UTI, are not predictive of renal infection. Conversely, patients with significant renal infection may have sterile urine if the ureter draining the kidney is obstructed or the infection is outside of the collecting system
48
opd pyeloneph tx: __ is an appropriate first-line therapy in patients not requiring hospitalization where the prevalence of uropathogen resistance to quinolones in the community does not exceed \_\_
Oral ciprofloxacin (500 mg twice daily) for 7 days is an appropriate first-line therapy in patients not requiring hospitalization where the prevalence of uropathogen resistance to quinolones in the community does not exceed 10%
49
pyelonephritis: solitary obstructed kidney causes acute renal failure; antimicrobial agents are dosed based on the GFR. Any substantial obstruction must be relieved expediently by the safest and simplest means, such as __ or \_\_
solitary obstructed kidney causes acute renal failure; antimicrobial agents are dosed based on the GFR. Any substantial obstruction must be relieved expediently by the safest and simplest means, such as ureteral stent or percutaneous nephrostomy tube placement
50
Emphysematous pyelonephritis is a urologic emergency characterized by an \_\_\_l and __ infection caused by ___ uropathogens.
usually occurs in patients with \_\_,
Emphysematous pyelonephritis is a urologic emergency characterized by an **acute necrotizing parenchymal** and **perirenal infection** caused by **gas-forming** uropathogens. The pathogenesis is poorly understood. Because the condition usually occurs in patients with **diabetes**, it has been postulated that the high tissue glucose levels provide the substrate for microorganisms such as E. coli, which are able to produce carbon dioxide by the fermentation of sugar
51
diagnosis of emphysematous pyelonephritis is established radiographically. ____ that is distributed in the parenchyma may appear on ___ as __ over the involved kidney
he diagnosis is established radiographically. Tissue gas that is distributed in the parenchyma may appear on abdominal radiographs as mottled gas shadows over the involved kidney
52
Empmysetous pyelonephritis: Obstruction is demonstrated in approximately \_\_\_. A ___ should be performed to assess the degree of renal function impairment in the involved kidney and the status of the contralateral kidney.
Obstruction is demonstrated in approximately 25% of the cases. A nuclear renal scan should be performed to assess the degree of renal function impairment in the involved kidney and the status of the contralateral kidney.
53
renal abscess: A thorough history may reveal a ___ before the onset of urinary tract symptoms or symptoms consistent with UTI or pyelonephritis in the weeks prior The infection may have occurred \_\_\_
A thorough history may reveal a **gram-positive source of infection 1 to 8 weeks** before the onset of urinary tract symptoms or symptoms consistent with UTI or pyelonephritis in the weeks prior (Hung et al., 2007). The infection may have occurred in **any area of the body. Multiple skin carbuncles and IV drug abuse introduce grampositive organisms into the bloodstream. Other common sites are the mouth, lungs, and bladder**
54
although the classic treatment for an abscess has been \_\_\_, there is good evidence that use of IV antimicrobial agents and careful observation of a small abscess less than ___ in a clinically stable patient is appropriate.
Antibiotics, if begun early enough in the course of the process, may obviate surgical procedures
lthough the classic treatment for an abscess has been percutaneous or open incision and drainage, there is good evidence that use of IV antimicrobial agents and careful observation of a small abscess less than 3 cm or even 5 cm in a clinically stable patient is appropriate. Antibiotics, if begun early enough in the course of the process, may obviate surgical procedures
55
\_\_\_\_\_ is bacterial infection in a hydronephrotic kidney. The term ___ refers to infected hydronephrosis associated with ___ of the parenchyma of the kidney, in which there is \_\_\_
Tx:
Once the diagnosis of pyonephrosis is made, the treatment is initiated with appropriate\_\_ and \_\_
Infected hydronephrosis is bacterial infection in a hydronephrotic kidney. The term pyonephrosis refers to infected hydronephrosis associated with suppurative destruction of the parenchyma of the kidney, in which there is total or nearly total loss of renal function
Once the diagnosis of pyonephrosis is made, the treatment is initiated with appropriate antimicrobial drugs and drainage of the infected pelvis
56
\_\_ extends beyond the renal capsule but is contained by Gerota fascia and usually results from rupture of an acute cortical abscess into the perinephric space, extravasated infected urine from obstruction, or from hematogenous seeding from sites of infection
A perinephric abscess extends beyond the renal capsule but is contained by Gerota fascia and usually results from rupture of an acute cortical abscess into the perinephric space, extravasated infected urine from obstruction, or from hematogenous seeding from sites of infection
57
```
Xanthogranulomatous pyelonephritis (XGP) is a rare, severe, chronic renal infection typically resulting in diffuse renal destruction. Most cases are ___ and result in a \_\_
associated with ____ secondary to \_\_\_. XGP is characterized by accumulation of ____ . It begins within the pelvis and calyces and subsequently extends into and destroys renal parenchymal and adjacent tissues. It has been known to imitate almost every other inflammatory disease of the kidney, as well as renal cell carcinoma, on radiographic examination
```
```
Xanthogranulomatous pyelonephritis (XGP) is a rare, severe, chronic renal infection typically resulting in diffuse renal destruction. Most cases are **unilateral** and result in a **nonfunctioning,
enlarged kidney**associated with**obstructive uropathy secondary to nephrolithiasis**. XGP is characterized by**=---** It begins within the pelvis and calyces and subsequently extends into and destroys renal parenchymal and adjacent tissues. It has been known to imitate almost every other inflammatory disease of the kidney, as well as renal cell carcinoma, on radiographic examination
```
58
The primary factors involved in the pathogenesis of XGP are:
he primary factors involved in the pathogenesis of XGP are **nephrolithiasis, obstruction, and infection**
59
\_ to be the most common organism involved with XGP
Proteus to be the most common organism involved with XGP (
60
XGP has been associated with:
XGP has been associated with r**enal cell carcinoma, papillary transitional cell carcinoma of the pelvis or bladder, and infiltrating squamous cell carcinoma of the pelvis**
61
Malacoplakia, from the Greek word meaning “soft plaque,” is an unusual inflammatory disease originally described to affect the bladder but has been found to affect the GU and GI tracts, skin, lungs, bones, and mesenteric lymph nodes
It is hypothesized that bacteria or bacterial fragments form
the nidus for the calcium phosphate crystals that laminate the \_\_\_. Most investigations into the pathogenesis of this disease support theories that a defect in intraphagosomal bacterial digestion accounts for the unusual immunologic response that causes malacoplakia.
\_\_\_ from the Greek word meaning “soft plaque,” is an unusual inflammatory disease originally described to affect the bladder but has been found to affect the GU and GI tracts, skin, lungs, bones, and mesenteric lymph nodes
It is hypothesized that bacteria or bacterial fragments form
the nidus for the calcium phosphate crystals that laminate the Michaelis-Gutmann bodies. Most investigations into the pathogenesis of this disease support theories that a defect in intraphagosomal bacterial digestion accounts for the unusual immunologic response that causes malacoplakia.
62
identift A, B, C
(A) Cut surface demonstrates extensive cortical and upper medullary replacement by multifocal, confluent, tumorlike masses.
(B) Cortical surface exhibits multiple, firm, plaquelike lesions.
(C) Hallmark of malacoplakia is demonstration of the Michaelis-Gutmann body (arrows), which represents incompletely destroyed bacteria surrounded by lipoprotein membrane (hematoxylin)
63
Multifocal malacoplakia on excretory urography typically is seen as \_\_\_
Multifocal malacoplakia on excretory urography typically is seen as **enlarged kidneys with multiple filling defects**
64
fournier's gangrene: Predisposing factors include diabetes mellitus, local trauma, paraphimosis, periurethral extravasation of urine, perirectal or perianal infections, and surgery such as circumcision or herniorrhaphy. In cases originating in the genitalia, specifically as a result of urethral obstruction, the infecting bacteria probably pass through\_\_\_ and spread along the ____ of the scrotum and penis, \_\_\_\_of the perineum, and ___ of the anterior abdominal wall
Predisposing factors include diabetes mellitus, local trauma, paraphimosis, periurethral extravasation of urine, perirectal or perianal infections, and surgery such as circumcision or herniorrhaphy. In cases originating in the genitalia, specifically as a result of urethral obstruction, the infecting bacteria probably pass through Buck fascia of the penis and spread along the Dartos fascia of the scrotum and penis, Colles fascia of the perineum, and Scarpa fascia of the anterior abdominal wall
65
fournier's gangrene: Because __ is often an early finding, a plain film of the abdomen may be helpful in identifying air. Scrotal ultrasonography is also useful in this regard
Because crepitus (subcutaneous gas) is often an early finding, a plain film of the abdomen may be helpful in identifying air. Scrotal ultrasonography is also useful in this regard
66
Periurethral abscess is frequently a sequela of \_\_, __ and ___ \_\_\_ is also associated with periurethral abscess formation
Periurethral abscess is frequently a sequela of gonorrhea, urethral stricture disease, or urethral catheterization. Frequent instrumentation is also associated with periurethral abscess formation
67
characteristics of sepsis spectrum
68
It is not surprising that untreated bacteriuria in the \_\_- is accompanied by a substantial increase in the incidence of acute pyelonephritis because half of these women have upper tract bacteriuria
It is not surprising that untreated bacteriuria in the first trimester is accompanied by a substantial increase in the incidence of acute pyelonephritis because half of these women have upper tract bacteriuria
69
pregnancy:
This hydroureter has been attributed to the muscle-relaxing effects of ___ during pregnancy and to ___ by the enlarging uterus at the pelvic brim
This hydroureter has been attributed to the muscle-relaxing effects of increased progesterone during pregnancy and to mechanical obstruction of the ureters by the enlarging uterus at the pelvic brim
70
Cunnington’s review suggests that ascending GU tract infections may contribute to up to 50% of premature deliveries, especially when they occur before \_\_\_
Cunnington’s review suggests that ascending GU tract infections may contribute to up to 50% of premature deliveries, especially when they occur before 30 weeks’ gestation
71
oral antibiotic for pregnant women, what to avoid
72
CDC define a CAUTI as a \_\_\_\_To be diagnosed with a CAUTI, patients must have one symptom of a UTI (5) and a \_\_\_.
CDC define a CAUTI as a **UTI after placement of an indwelling urinary catheter for more than 2 days** (Centers for Disease Control and Prevention: Urinary Tract Infection, 2015). To be diagnosed with a CAUTI, patients must have one symptom of a UTI (s**uprapubic tenderness, CVA tenderness, urinary frequency/ urgency/dysuria, or fever \>100.4°F**) and a urine culture with a single organism more than 100,000 CFU/mL.
73
The development of bacteriuria in the presence of an indwelling catheter is inevitable and occurs at an incidence of approximately ___ per day of catheterization. Sterile and clean intermittent catheterization has been associated with rates of bacteriuria ranging from ___ per catheterization
The development of bacteriuria in the presence of an indwelling catheter is inevitable and occurs at an incidence of approximately 10% per day of catheterization. Sterile and clean intermittent catheterization has been associated with rates of bacteriuria ranging from 1% to 3% per catheterization
74
CAUTI: The catheter-meatal junction should be cleaned daily with \_\_\_, but antimicrobial agents should be avoided because they lead to colonization with resistant pathogens, such as\_\_\_
The catheter-meatal junction should be cleaned daily with water, but antimicrobial agents should be avoided because they lead to colonization with resistant pathogens, such as Pseudomonas.
75
UTI and SCI: Although never rigorously compared with indwelling urethral catheterization, CIC has been shown to decrease lower urinary tract complications by maintaining __ and by reducing the ___ (Stover et al., 1989). CIC also appears to reduce complications associated with an indwelling catheter, such as (5)
Although never rigorously compared with indwelling urethral catheterization, CIC has been shown to decrease lower urinary tract complications by maintaining **low intravesical pressure** and by reducing the i**ncidence of stones** (Stover et al., 1989). CIC also appears to reduce complications associated with an **indwelling catheter, such as UTI, fever, bacteremia, and local infections such as epididymitis and prostatitis**
76
cauti: Urinalysis will show bacteriuria and pyuria. Pyuria is not diagnostic of infections because it may occur from the \_\_
Urinalysis will show bacteriuria and pyuria. Pyuria is not diagnostic of infections because it may occur from the i**rritative effects of the catheter.**
77
SCI px on catheters: Chronic infection and inflammation of the bladder mucosa could be the __ in these patient, __ produced in infected urine have also been implicated
Chronic infection and inflammation of the bladder mucosa could be the **carcinogenic stimulus** in these patients (Pyrah et al., 1955). **Nitrosamines** produced in infected urine have also been implicated
78
When used as Antimicrobial Prophylaxis, vancomycin and fluoroquinolones should be initiated within ___ the procedure. Single-dose AP is most appropriate in the majority of uncomplicated urologic surgery.
When used as AP, vancomycin and fluoroquinolones should be initiated within **120 minutes** of the procedure. Single-dose AP is most appropriate in the majority of uncomplicated urologic surgery.
79
The most common cause for infection after transrectal prostate biopsy is \_\_
The most common cause for infection after transrectal prostate biopsy is **fluoroquinolone-resistant E. coli**
80
screening before TRUS-Bx and targeted prophylaxis should be considered as a thoughtful, predictable\_\_\_ to empirical prophylaxis. That being said, there are a number of issues related to the actual process of targeted prophylaxis including: (5)
Thus screening before TRUS-Bx and targeted prophylaxis should be considered as a thoughtful, predictable **alternative** to empirical prophylaxis. That being said, there are a number of issues related to the actual process of targeted prophylaxis including **costs, time of extra visits, special culture media, and lab requirements**
81
The EAU guideline recommends the use of AP in men before transrectal prostate biopsy as well as ___ with ___ in men before transrectal prostate biopsy.
The EAU guideline recommends the use of AP in men before transrectal prostate biopsy as well as **rectal cleansing with povidone-iodine** in men before transrectal prostate biopsy.
82
wound classfication of 1. Opening into urinary tract, as in nephrectomy, cystectomy, prostatectomy, endoscopic procedures.
2. PCNL
1. Clean-contaminated ( class 2)
2. contaminated (class 3)
83
Patients With Indwelling Orthopedic Hardware
when to give AP?
The commission did not advise AP for urologic patients with joint replacements, pins, plates, or screws that were at least 2 years old. However, if the prosthetic joint or implant was inserted within 2 years, prophylaxis was recommended with either an oral quinolone or 2 g of ampicillin intravenously and 1.5 mg/ kg of gentamicin (vancomycin if ampicillin allergy) intravenously 30 to 60 minutes before the procedure.
84
4. Most recurrent infections in female patients are: a. complicated. b. reinfections. c. due to bacterial resistance. d. due to hereditary susceptibility factors. e. composed of multiple organisms.
Reinfections. Recurrent infections are hypothesized to be secondary to either bacterial persistence within the urinary tract or, more commonly, novel reinfection. Persistence, caused by the same bacterial strain, usually leads to recurrent infections in a short time frame, whereas reinfections generally occur over a more remote period. Reinfection is likely secondary to ascent of uropathogens from fecal flora into the urinary tract or from reemergence of bacteria from uroepithelial intracellular colonies.
85
Rates of reinfection (i.e., time to recurrence) are influenced by: a. bladder dysfunction. b. renal scarring. c. vesicoureteral reflux. d. antimicrobial treatment. e. age.
d. Antimicrobial treatment. Whether a patient receives no treatment or short-term, long-term, or prophylactic antimicrobial treatment, the risk of recurrent bacteriuria remains the same; antimicrobial treatment appears to alter only the time until recurrence.
86
The long-term effect of uncomplicated recurrent UTIs is: a. renal scarring. b. hypertension. c. azotemia. d. ureteral vesical reflux. e. minimal.
e. Minimal. The long-term effects of uncomplicated recurrent UTIs are not completely known, but so far, no association between recurrent infections and renal scarring, hypertension, or progressive renal azotemia has been established.
87
The ascending route of infection is least enhanced by: a. catheterization. b. spermicidal agents. c. indwelling catheter. d. fecal soilage of perineum. e. frequent voiding.
e. Frequent voiding. This route is further enhanced in individuals with significant soilage of the perineum with feces, women using spermicidal agents, and patients with intermittent or indwelling catheters.
88
Approximately 10% of symptomatic lower UTIs in young, sexually active female patients are caused by: a. Escherichia coli (E. coli). b. Staphylococcus saprophyticus. c. Pseudomonas. d. Proteus mirabilis. e. Staphylococcus epidermidis.
b. Staphylococcus saprophyticus. S. saprophyticus is recognized as causing frequent symptomatic UTIs in young, sexually active females, whereas it rarely causes infection in males and elderly individuals.
89
The virulence factor that is most important for adherence is: a. hemolysin. b. K antigen. c. pili. d. colicin production. e. O serogroup
c. Pili. Studies have demonstrated that interactions between FimH and receptors expressed on the luminal surface of the bladder epithelium are critical to the ability of many uropathogenic E. coli strains to colonize the bladder and cause disease.
90
Phase variation of bacterial pili: a. occurs only in vitro. b. affects bacterial virulence. c. is characteristic of pyelonephritic E. coli. d. is irreversible. e. refers to change in pilus length.
Affects bacterial virulence. This process is called phase variation and has obvious biologic and clinical implications. For example, the presence of type 1 pili may be advantageous to the bacteria for adhering to and colonizing the bladder mucosa but disadvantageous because the pili enhance phagocytosis and killing by neutrophils.
91
The finding that first suggested a biologic difference in women susceptible to UTIs is: a. increased adherence of bacteria to vaginal cells. b. decreased estrogen concentration in vaginal cells. c. elevated vaginal pH. d. nonsecretor status. e. postmenopausal status.
a. Increased adherence of bacteria to vaginal cells. These studies established increased adherence of pathogenic bacteria to vaginal epithelial cells as the first demonstrable biologic difference that could be shown in women susceptible to UTI
92
The primary bladder defense is: a. low urine pH. b. low urine osmolarity. c. voiding. d. Tamm-Horsfall protein (uromucoid). e. vaginal mucus
c. Voiding. Bacteria presumably make their way into the bladder fairly often. Whether small inocula of bacteria persist, multiply, and infect the host depends in part on the ability of the bladder to empty.
93
The validity of a midstream urine specimen should be questioned if microscopy reveals: a. squamous epithelial cells. b. red blood cells. c. bacteria. d. white blood cells. e. casts
Squamous epithelial cells. The validation of the midstream urine specimen can be questioned if numerous squamous epithelial cells (indicative of preputial, vaginal, or urethral contaminants) are present.
94
Urinary tract imaging is NOT usually indicated for recurrent UTIs in:
a. women. b. girls. c. men. d. boys. e. spinal cord–injured patients
a. Women. Imaging and cystoscopic evaluation are not warranted in all women with recurrent UTIs. Indeed, the yield of imaging in women without suspected complicated UTI is low and is not recommended by the American College of Radiology, the Canadian Urological Association Guidelines, or the European Association of Urology Guidelines. However, in women with risk factors for a complicated UTI the evaluation should include imaging and cystoscopy
95
The most sensitive imaging modality for diagnosing renal abscess is: a. ultrasonography. b. indium scanning. c. gallium scanning. d. excretory urography. e. CT.
e. CT. CT and magnetic resonance imaging are more sensitive than excretory urography or ultrasonography in the diagnosis of acute focal bacterial nephritis, renal and perirenal abscesses, and radiolucent calculi
96
Treatment of UTIs depends most on an antimicrobial agent’s: a. serum half-life. b. serum level. c. urine level. d. duration of therapy. e. frequency of therapy.
c. Urine level. Efficacy of the antimicrobial therapy is critically dependent on the antimicrobial levels in the urine and the length of time that this level remains above the minimum inhibitory concentration of the infecting organism. Thus resolution of infection is closely associated with the susceptibility of the bacteria to the concentration of the antimicrobial agent achieved in the urine.
97
An ideal class of drugs for the treatment of uncomplicated symptomatic UTIs in women is: a. aminopenicillins. b. aminoglycosides. c. fluoroquinolones. d. cephalosporins. e. nitrofurantoin.
e. Nitrofurantoin. According to the Infectious Diseases Society of America 2010 update, nitrofurantoin 100 mg twice daily for 5 days or Bactrim DS twice daily for 3 days should be preferential regimens for the treatment of uncomplicated UTIs in women. Sensitivity to these agents should be confirmed on urine culture, especially if the patient does not report a resolution of symptoms at the end of their course.
98
The host factor least likely to be associated with an increased risk of infection is: a. advanced age. b. a history of previous infection in the site/organ of interest. c. residence in a chronic care facility. d. indwelling orthopedic pins. e. coexistent infection.
d
99
Treatment of asymptomatic bacteriuria is most indicated in patients who are: a. elderly. b. catheterized. c. pregnant. d. confused. e. incontinent.
a. Pregnant women. In populations other than those for whom treatment has been documented to be beneficial (e.g., pregnant women and patients undergoing urologic interventions), screening for or treatment of asymptomatic bacteriuria is not appropriate and should be discouraged.
100
Screening for bacteriuria is beneficial in: a. pregnant women. b. elderly patients. c. men. d. children. e. spinal cord–injured patients
Screening for bacteriuria is beneficial in: a. pregnant women. b. elderly patients. c. men. d. children. e. spinal cord–injured patients
101
The most common cause of unresolved bacteriuria during antimicrobial therapy is: a. development of bacterial resistance. b. rapid reinfections. c. azotemia. d. staghorn calculi. e. initial bacterial resistance.
. e. Initial bacterial resistance. Most commonly, the bacteria are resistant to the antimicrobial agent selected to treat the infection.
102
Nitrofurantoin is effective because of the concentration of the drug in the: a. urine. b. vaginal mucus. c. bowel. d. serum
a. Urine. Nitrofurantoin, which does not alter the bowel flora, is present for brief periods at high concentrations in the urine and leads to repeated elimination of bacteria from the urine, presumably by interfering with bacterial initiation of infection
103
The most common cause of acute pyelonephritis in young women is: a. vesicoureteral reflux. b. P-piliated bacteria. c. type 1 piliated bacteria. d. recurrent UTIs. e. bacterial endotoxin.
b. P-piliated bacteria. If vesicourethral reflux is absent, a patient bearing the P blood group phenotype may have special susceptibility to recurrent pyelonephritis caused by E. coli that have P pili and bind to the P blood group antigen receptors.
104
An optimal oral antibiotic agent for the treatment of acute uncomplicated pyelonephritis in a pregnant women is: a. TMP-SMX b. Cephalexin c. Amoxicillin d. Levofloxacin e. Macrobid
b. Cephalexin. Macrobid is concentrated in the urine and cannot treat blood-borne infections. Amoxicillin has been used to treat cystitis in pregnancy but does not have broad enough gramnegative coverage for the treatment of pyelonephritis. Levofloxacin is contraindicated in pregnancy due to possible damage to fetal cartilage, and trimethoprim should be avoided in pregnancy because it may cause fetal megaloblastic anemia, and, in the first trimester, neural tube and cardiovascular defects by inhibiting folic acid metabolism.
105
A patient with acute pyelonephritis, persistent fever, and flank pain for 24 hours warrants: a. observation. b. CT. c. change in antimicrobial therapy. d. ultrasonography. e. blood cultures
a. Observation. Even though the urine usually becomes sterile within a few hours of starting antimicrobial therapy, patients with acute uncomplicated pyelonephritis may continue to have fever, chills, and flank pain for several more days after initiation of successful antimicrobial therapy. They should be observed.
106
Emphysematous pyelonephritis usually occurs in: a. children b. adults with a history of renal transplant c. women with a history of recurrent uncomplicated UTIs d. diabetic adults e. adults on clean intermittent catheterization
d. Diabetic adults. Emphysematous pyelonephritis predominantly affects female diabetics and can occur in insulin-dependent and non-insulin-dependent patients in the absence of ureteral obstruction. Nondiabetic patients can also develop this form of pyelonephritis but often have ureteric obstruction and do not seem to develop extensive disease
107
0. The primary treatment for a small perirenal abscess in a functioning kidney is: a. nephrectomy. b. partial nephrectomy. c. open surgical drainage. d. percutaneous drainage. e. retrograde ureteral drainage.
d. Percutaneous drainage. Although surgical drainage, or nephrectomy if the kidney is nonfunctioning or severely infected, is the classic treatment for perinephric abscesses, renal ultrasonography and CT make percutaneous aspiration and drainage of small perirenal collections possible.
108
Most patients with chronic pyelonephritis present with: a. hypertension. b. renal failure. c. chronic infection. d. flank pain. e. no symptoms.
e. No symptoms. There are no symptoms of chronic pyelonephritis until it produces renal insufficiency, and then the symptoms are similar to those of any other form of chronic renal failure
109
The most common bacterial cause of xanthogranulomatous pyelonephritis is: a. E. coli. b. Pseudomonas. c. Klebsiella. d. Proteus mirabilis. e. Staphylococcus
d. Proteus mirabilis. Although review of the literature shows Proteus to be the most common organism involved with xanthogranulomatous pyelonephritis, E. coli is also common.
110
Michaelis-Gutmann bodies are associated with the following disease process: a. Xanthogranulomatous pyelonephritis b. Malacoplakia c. Renal echinococcosis d. Chronic pyelonephritis e. Acute focal bacterial nephritis
b. Malacoplakia. Malacoplakia, from the Greek word meaning “soft plaque,” is an unusual inflammatory disease that was originally described to affect the bladder. It is an inflammatory lesion described originally by Michaelis and Gutmann 1902. It was characterized by von Hansemann 1903 as soft, yellow-brown plaques with granulomatous lesions in which the histiocytes contain distinct basophilic lysosomal inclusion bodies or Michaelis-Gutmann bodies. Although its exact pathogenesis is unknown, malacoplakia probably results from abnormal macrophage function in response to a bacterial infection, which is most often E. coli.
111
Treatment of renal echinococcosis involves which of the following: a. treatment with antibiotics and follow-up imaging to confirm regression of the hydatid cyst b. observation c. aspiration of cyst contents d. surgical removal of the hydatid cyst e. injection of the hydatid cyst with targeted antibiotics
d. Surgical removal of the hydatid cyst. Surgery remains the mainstay of treatment of renal echinococcosis. The cyst should be removed without rupture to reduce the chance of seeding, antigen reaction, and recurrence. If the cyst ruptures or cannot be removed and marsupialization is required, the contents of the cyst initially should be aspirated and filled with a scolicidal agent.
112
The most reliable early clinical indicator of septicemia is: a. chills. b. fever. c. hyperventilation. d. lethargy. e. change in mental status.
c. Hyperventilation. Even before temperature extremes and the onset of chills, bacteremic patients often begin to hyperventilate. Thus the earliest metabolic change in septicemia is a resultant respiratory alkalosis.
113
Compared with non-pregnant women, pregnant women have a higher prevalence of: a. asymptomatic bacteriuria. b. acute cystitis. c. acute pyelonephritis. d. recurrent cystitis. e. bacterial persistence
c
114
Clinical pyelonephritis during pregnancy is most commonly linked to: a. maternal sepsis. b. maternal anemia. c. maternal hypertension. d. eclampsia. e. congenital malformations.
a. Maternal sepsis. Pregnant women with asymptomatic bacteriuria are at higher risk for developing a symptomatic UTI that results in adverse fetal sequelae, complications associated with bacteriuria during pregnancy, and pyelonephritis and its possible sequelae, such as sepsis in the mother. Therefore all women with asymptomatic bacteriuria should be treated
115
The drug thought to be safe in any phase of pregnancy is: a. a fluoroquinolone. b. nitrofurantoin. c. a sulfonamide. d. penicillin. e. tetracycline.
d. Penicillin. The aminopenicillins and cephalosporins are considered safe and generally effective throughout pregnancy. In patients with penicillin allergy, nitrofurantoin is a reasonable alternative.
116
The majority of elderly patients with bacteriuria are: a. asymptomatic. b. febrile. c. incontinent. d. confused. e. dysuric
a
117
The most effective measure for reducing catheter-associated UTI is: a. closed drainage. b. antimicrobial prophylaxis. c. catheter irrigation. d. intermittent catheterization. e. daily meatal care.
a. Closed drainage. Careful aseptic insertion of the catheter and maintenance of a closed dependent drainage system are essential to minimize development of bacteriuria
118
All of the following conditions are predisposing factors to the development of Fournier gangrene EXCEPT: a. obesity b. paraphimosis c. diabetes mellitus d. perirectal infections e. urethral strictures
a. Obesity. An association between Fournier gangrene and urethral obstruction associated with strictures and extravasation and instrumentation has been well documented. Predisposing factors include diabetes mellitus, local trauma, paraphimosis, periurethral extravasation of urine, perirectal or perianal infections, and surgery such as circumcision or herniorrhaphy.
119
Which of the following is not a risk factor for UTI in a renal transplant recipient? a. Cadaveric graft b. Diabetes c. Prolonged hemodialysis prior to transplant d. Female gender e. Polycystic native kidneys
e. Polycystic native kidneys. Transplant recipients are at higher risk for vesicoureteral reflux. Risk factors for infection include cadaveric graft, diabetes, prolonged hemodialysis prior to transplantation, two episodes of asymptomatic bacteriuria, and female gender.
120
Administration of an antimicrobial agent within\_\_\_ of the initiation of a procedure and for a period of time that \_\_\_\_. Surgical antimicrobial prophylaxis entails treatment with an antimicrobial agent before and for a limited time after a procedure to prevent local or systemic postprocedural infections.
Administration of an antimicrobial agent within **60 to 120 minutes** of the initiation of a procedure and for a period of time that covers the **duration of the procedure**. Surgical antimicrobial prophylaxis entails treatment with an antimicrobial agent before and for a limited time after a procedure to prevent local or systemic postprocedural infections.
121
Which of the following organisms is NOT associated with positive nitrites on urine analysis? a. Enterococcus b. E. coli c. Proteus mirabilis d. Klebsiella pneumoniae
a. Enterococcus. Most gram-negative bacteria are capable of producing positive results on a nitrite test. Pseudomonas aeruginosa and most gram-positive organisms do not produce nitrites. 51. c. History of human papilloma virus (HPV). HPV history
122
A 45-year-old woman is found to have a raised bladder lesion on cystoscopy. The biopsy shown in Fig. 55.3 reveals malakoplakia. The next step in management is: a. intravesical bacille Calmette-Guérin. b. fulguration of the lesions. c. intravesical mitomycin C. d. treat with a sulfonamide for several months. e. a 3-day course of ciprofloxacin.
d. Treat with a sulfonamide for several months. Fig. 55.3A shows von Hansemann histiocytes, and Fig. 55.3B demonstrates the Michaelis-Gutmann bodies, both of which are characteristic of malakoplakia. It is thought to be infectious in origin, and therefore the treatment is an extended course of an antibiotic that achieves a high intracellular concentration.
123
A 68-year-old diabetic woman presents to the emergency room with the chief complaint of abdominal pain. CT scan findings of her pelvis are shown in Fig. 55.7. The next step in her management is:
a. inpatient antibiotics, Foley catheter placement, and glucose management b. collection of a urine sample and discharge home with empiric antibiotic coverage c. emergent exploration and surgical debridement with placement of a suprapubic tube d. obtain an ultrasound to assess the upper urinary tract e. reassurance
a. Inpatient antibiotics, Foley catheter placement, and glucose management. The figure is an example of emphysematous pyelonephritis. The majority (90%) of these patients are treated with medical therapy alone, which consists of antibiotics (often parenteral), bladder drainage, and treatment of comorbid conditions such as poorly controlled diabetes. The need for surgical intervention is rare and is reserved for those cases that respond poorly to initial medical management or severe necrotizing infections.
124
Empiric UTI treatment
3 days of TMP/SMX
5 days of Nitrofurantoin 100 mg po bid
1 time dose of 3 grams Fosfomycin
125
Recurrent UTI definition
___ in 6 months
___ in 12 months
2 in 6
3 in 12
126
Multiple infections caused by the same bacteria (bacterial persistence) is often due to ____
GU tract issue - BPH, stones, UI
127
Cystoscopy and upper tract imaging should not be routinely obtained in the ___ patient with r UTI
index pt = young healthy female
128
Imaging for rUTI - ____
U/S or CT for stones
129
Surgery to reduce rUTI - ____
stone surgery (50-80% effective)
130
Screening for asymptomatic bacteriuria in 2 patients only - ___ & ____
pregnant
| pre-op endoscopic procedure
131
Prophylactic antibiotics to reduce rUTI are effective during the course of antibiotics; ____ than placebo once stopped
no different
132
Proanthocyanins in ____ prevent adhesion of bacteria to urothelium
cranberry
133
Estrogen for rUTI
Clinicians should recommend vaginal estrogen to peri-and post- menopausal women with rUTI
Patients on systemic estrogen should still be placed on vaginal estrogen
134
Repeat urine culture if UTI symptoms persist on treatment beyond ____ days
7
135
Treatment of nephrogenic adenoma
complete surgical resection
136
Pyelonephritis workup
Urine & blood cultures
CBC, BUN, Creatinine
Imaging: CT scan
137
Empiric pyelonephritis treatment
Ciprofloxacin 500 bid or 1000 mg ER for 7 days
| TMP/SMX DS bid for 14 days
138
Treatment for renal abscess <5 cm
IV antibiotics
139
Treatment for renal abscess >5 cm
Percutaneous IR drainage
140
Treatment for perinephric abscess <3 cm
IV antibiotics
141
Treatment for perinephric abscess >3 cm
IR drainage
142
Dx of air in collecting system
emphysematous pyelitis
143
Treatment of emphysematous pyelitis
PCN or stent
144
Dx of air in renal parenchyma
emphysematous pyelonephritis
145
Treatment of emphysematous pyelonephritis
IR drainage or emergent nephrectomy
146
Dx with infected, unilateral enlarged kidney, poor function and stone
xanthogranulomatous pyelonephritis (XGP)
147
XGP treatment
IV antibiotics --> nephrectomy
148
In 20-40% of pregnant women, bacteruria can progress to _____
pyelonephritis
149
Antibiotics safe for UTI in pregnancy
Amoxicillin, Keflex, Ceftriaxone
150
#1 antibiotic to avoid during pregnancy
Bactrim
151
Treatment of febrile UTI after transrectal procedure
Carbapenem, Amikacin
152
Treatment of febrile UTI after transrectal procedure
Carbapenem, Amikacin
153
Next step in men with prostatitis not responsive to antibiotic therapy
CT/MRI looking for abscess
154
Wait ____ after febrile UTI in men to collect screening PSA
6 months
155
Suspect ____ in men with recurrent UTI
chronic bacterial prostatis
156
Treatment for chronic bacterial prostatis
1. Ciprofloxacin x4 weeks
| 2. Bactrim x6-12 weeks
157
Treatment for Asymptomatic candiduria
None, change catheter
158
Candida glabarata is commonly resistant to ___
Fluconazole
159
Indications for treating asymptomatic funguria
Neutropenic patients
Infants with low birth weight
Patients with renal allografts
Patients who are to undergo GU tract procedure
160
Peri-op treatment for Asymptomatic candiduria
Fluconazole 400mg daily
161
Treatment for symptomatic fungal UTI
Fluconazole 200mg x2 weeks
162
____ antimicrobial prophylaxis is appropriate in the majority of uncomplicated urologic cases.

Single dose
163
Parenteral antimicrobial prophylaxis agents should be administered within ___ of an incision
1 hour
164
____ prophylaxis is not recommended for routine cystoscopy or for urodynamic studies in healthy adults
Antibiotic
165
Antimicrobial prophylaxis solely for the prevention of infectious endocarditis is ___ for genitourinary procedures
NOT required
166
Antimicrobial prophylaxis for the prevention of prosthetic hip or knee prostheses is recommended within ___ years of prosthetic joint placement
2
167
Single-dose antifungal prophylaxis is recommended for patients with _____ undergoing endoscopic, robotic, or open surgery on the urinary tract.
asymptomatic funguria
168
New Sepsis Definitions quick SOFA criteria:
Respiratory rate ≥ 22/min
Altered mentation
Systolic blood pressure ≤ 100 mmHg
169
What is SIRS and what are the criteria?
Systemic Inflammatory Response Syndrome
Hypo- (<36) or hyperthermia (>38,3)
Tachycardia (>90/min)
Tachypnoea (>20/min) and/or pCO2 <33mmHg
Leucocytosis (>12/nl) or leukopenia (<4/nl)
170
What is a Urosepsis?
SIRS + UTI
171
How many women will have a UTI in their lifetime?
50%
172
What is the risk for another UTI after a woman has had one?
~20%
173
What is the risk for another UTI after a woman has had two?
30%
174
How many women who have had 3 UTI:s will have very frequent UTI:s?
80%
175
When should you treat asymptomatic bacteriuria?
Pregnant women
| Before urological procedures
176
When can you use ciprofloxacin when treating a complicated UTI?
Local rexsistance <10% and
The entire treatment is given orally
Patients do not require hospitalization
Patient has an anyphylaxis for beta-lactam antimicrobials
177
How should an uncomplicated UTI be treated:
Use a combination of:
amoxicillin + aminoglycoside or
second generation cephalosporin + aminoglycoside or
third generationcephalosporin iv as empirical treatment of complicatied UTI with systmeic symptoms
178
What is the definition of antibiotic prophylaxis
Short, usually, single dose, administration of an antibiotik substance in normal dosage prior to start of operation
179
In what urological procedure should antibiotic profylaxis be given regardless the culture?
```
Ureteroscopy
PNL
Tur P
Tur B (high risk patients)
Prostate biopsy (also use rectal cleansing)
```
180
Imaging findings in pyelo
Enlarged kidney
Delayed nephrogram
Wedge-shaped non-enhancing region
181
Specific finding on UA in pyelonephritis
white blood cell casts
182
Outpatient antibiotic tx for pyelo
Levofloxacin
Ciprofloxacin
Bactrim
10-14 days
183
Antibiotics for pregnant pt with pyelo
IV Ceftriaxone
IV Amp + Gent
Transition to oral Keflex
184
If persistent fevers 3-5 days after appropriate abx for pyelo, ____ to rule out____
CT A/P with IV contrast
Renal abscess
185
E Coli is pathogenic due to ____ that bind to P group
Fimbriae
186
Treatment of <3cm renal abscess
IV antibiotics
187
Treatment of 3-5cm renal abscess
PCN drain + IV abx
188
Treatment of >5cm renal abscess
PCN or open drainage or nephrectomy
189
Chronically inflamed kidney with loss of parenchyma & renal function
Xanthogranulomatous Pyelonephritis (XGP)
190
XGP is associated with ___ and ___ co-morbidity
infections
DM
191
Gas-producing infection of renal parenchyma
Emphysematous Pyelonephritis
192
Treatment of Emphysematous Pyelonephritis
Broad spectrum abx + PCN drainage
193
Antibiotics for infected renal cyst
Ciprofloxacin
Bactrim
Clindamycin
Chloramphenicol
194
Gas producing bacterial infection in collecting system
Emphysematous Pyelitis
195
Most common organisms in Emphysematous Pyelitis
E Coli
| Klebsiella
196
Infected hydronephrosis with parenchyma destruction
Pyonephrosis
197
Tx of pyonephrosis
Abx + PCN drainage
198
Recurrent UTIs
>___ in 6 months
>___ in 1 year
>2 in 6 months
>3 in 1 year
199
1st line antibiotic therapies for cystitis
____ x1 day
____ x3 days
____ x5 days
Fosfomycin x1 day
Bactrim x 3 days
Macrobid (Nitrofurantoin) x5 days
200
Tx for rUTIs with vaginal atrophy
intravaginal estrogen
201
In complicated or recurrent UTIs, next work-up is ____ & ____
cystoscopy & upper tract imaging
