Infections of the urinary Tract

Question 1

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

Answer 1

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

Question 2

___ 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

Answer 2

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

Question 3

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.

Answer 3

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.

Question 4

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

Answer 4

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

Question 5

factors of complicated UTI

Answer 5

Question 6

UTIs may also be defined by their relationship to other UTIs:

1. A first or isolated infection is one that occurs in an individual who has___ or has one ___ from a
   previous UTI.
2. An unresolved infection is one that __ and is documented to be the __ with a similar ___.
3. 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 ___.

Answer 6

• 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:

1. Reinfection describes a new event associated with reintroduction of bacteria into the urinary tract.
2. 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.

Question 7

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

Answer 7

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

Question 8

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___

Answer 8

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

Question 9

Gram-negative bacteria and their endotoxins, pregnancy, ureteral obstruction, and high lower tract pressures have a significant ____

Answer 9

Gram-negative bacteria and their endotoxins, as well as pregnancy, ureteral obstruction, and high lower tract pressures have a significant antiperistaltic effect

Question 10

hematogenous spread: kidney is occasionally secondarily infected in patients with___ originating from oral sites or with ___

Answer 10

kidney is occasionally secondarily infected in patients with Staphylococcus aureus bacteremia originating from oral sites or with Candida fungemia

Question 11

Direct extension of bacteria from the adjacent organs via lymphatics may occur in unusual circumstances, such as a __ or ___

Answer 11

Direct extension of bacteria from the adjacent organs via lymphatics may occur in unusual circumstances, such as a severe bowel infection or retroperitoneal abscesses.

Question 12

___ 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.

Answer 12

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.

Question 13

___ is a rare pathogen that causes UTIs in older adults with significant comorbidities, including some urologic malignancies

Answer 13

Aerococcus urinae is a rare pathogen that causes UTIs in older adults with significant comorbidities, including some urologic malignancies

Question 14

_____, 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

Answer 14

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

Question 15

____ merits special attention as a rapidly emerging cause of multidrug-resistant infections, including UTI

Answer 15

E. coli sequence type ST131 (serotype O25b:H4) merits special attention as a rapidly emerging cause of multidrug-resistant infections, including UTI

Question 16

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

Answer 16

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

Question 17

The steps of UPEC pathogenesis include (6)

Answer 17

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

Question 18

___ are commonly expressed on nonpathogenic and pathogenic E. coli

Answer 18

Type 1 pili are commonly expressed on nonpathogenic and pathogenic E. coli

Question 19

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

Answer 19

phase variation

Question 20

Natural Defenses of the Urinary Tract (3)

Answer 20

Periurethral and Urethral Region

Urine

Bladder

Question 21

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

Answer 21

___, 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

Question 22

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

Answer 22

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

Question 23

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

Answer 23

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

Question 24

UTIs are fivefold more prevalent in ___than in control subjects The pathologic bacteria include higher rates of ___ and ___ in HIV positive patients.

Answer 24

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.

Question 25

Of all patients with bacteriuria, no group compares in severity and morbidity with those who have ___

Answer 25

Of all patients with bacteriuria, no group compares in severity and morbidity with those who have SCI.

Question 26

painless gross hematuria, or microhematuria
in the absence of a positive culture, should always raise the suspicion for___ , and a ___ must be initiated.

Answer 26

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.

Question 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.

Answer 27

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.

Question 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.

Answer 28

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

Question 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.

Answer 29

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

Question 30

Other conditions known to cause pyuria include aside from UTI: (4)

Answer 30

GU tuberculosis, urolithiasis, injury to the urothelium (including chlamydial urethritis), and interstitial nephriti

Question 31

a standard urine culture may be negative. In this scenario a culture should be sent specifically looking for ___ organisms such as__ or __

Answer 31

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.

Question 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

Answer 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 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

Question 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

Answer 33

Should not, pregnant, transmucosal bleeding

Question 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

Answer 34

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) 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

Question 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

Answer 35

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

Question 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

Answer 36

Question 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

Answer 37

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

Question 38

unresolved urinary tract infection causes: (4)

Answer 38

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.

Question 39

A recurrent UTI is defined as ___or
___

Answer 39

A recurrent UTI is defined as two UTIs in a 6-month period or
three or more UTIs in a 12-month period

Question 40

risk factors for recurrent UTI

Answer 40

Question 41

Significant risk factors for recurrence in women (6)

Answer 41

Significant risk factors for recurrence in women include sexual 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

Question 42

In patients with emptying symptoms or a distended bladder on physical examination, documentation of a ___

Answer 42

In patients with emptying symptoms or a distended bladder on physical examination, documentation of a postvoid residual is critical

Question 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

Answer 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 polyphenol type A proanthocyanidin (PAC), which prevents the P fimbriae of E. coli from adhering to uroepithelial cells

Question 44

decreased estrogen levels contribute to the transformation to __ and __, which creates a more hospitable environment for bacteria to thrive.

Answer 44

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

Question 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

Answer 45

vaginal estrogen is effective in preventing recurrent UTIs in postmenopausal women. The beneficial effect from vaginal estrogen use can take at least 12 weeks to manifest

Question 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 __.

Answer 46

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

Question 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 __

Answer 47

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

Question 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 __

Answer 48

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%

Question 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 __

Answer 49

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

Question 50

Emphysematous pyelonephritis is a urologic emergency characterized by an ___l and __ infection caused by ___ uropathogens.

usually occurs in patients with __,

Answer 50

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

Question 51

diagnosis of emphysematous pyelonephritis is established radiographically. ____ that is distributed in the parenchyma may appear on ___ as __ over the involved kidney

Answer 51

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

Question 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.

Answer 52

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.

Question 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 ___

Answer 53

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

Question 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

Answer 54

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

Question 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 __

Answer 55

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

Question 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

Answer 56

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

Question 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

Answer 57

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

Question 58

The primary factors involved in the pathogenesis of XGP are:

Answer 58

he primary factors involved in the pathogenesis of XGP are nephrolithiasis, obstruction, and infection

Question 59

_ to be the most common organism involved with XGP

Answer 59

Proteus to be the most common organism involved with XGP (

Question 60

XGP has been associated with:

Answer 60

XGP has been associated with renal cell carcinoma, papillary transitional cell carcinoma of the pelvis or bladder, and infiltrating squamous cell carcinoma of the pelvis

Question 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.

Answer 61

___ 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.

Question 62

identift A, B, C

Answer 62

(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)

Question 63

Multifocal malacoplakia on excretory urography typically is seen as ___

Answer 63

Multifocal malacoplakia on excretory urography typically is seen as enlarged kidneys with multiple filling defects

Question 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

Answer 64

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

Question 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

Answer 65

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

Question 66

Periurethral abscess is frequently a sequela of __, __ and ___ ___ is also associated with periurethral abscess formation

Answer 66

Periurethral abscess is frequently a sequela of gonorrhea, urethral stricture disease, or urethral catheterization. Frequent instrumentation is also associated with periurethral abscess formation

Question 67

characteristics of sepsis spectrum

Answer 67

Question 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

Answer 68

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

Question 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

Answer 69

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

Question 70

Cunnington’s review suggests that ascending GU tract infections may contribute to up to 50% of premature deliveries, especially when they occur before ___

Answer 70

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

Question 71

oral antibiotic for pregnant women, what to avoid

Answer 71

Question 72

CDC define a CAUTI as a ____To be diagnosed with a CAUTI, patients must have one symptom of a UTI (5) and a ___.

Answer 72

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 (suprapubic 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.

Question 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

Answer 73

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

Question 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___

Answer 74

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.

Question 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)

Answer 75

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 incidence 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

Question 76

cauti: Urinalysis will show bacteriuria and pyuria. Pyuria is not diagnostic of infections because it may occur from the __

Answer 76

Urinalysis will show bacteriuria and pyuria. Pyuria is not diagnostic of infections because it may occur from the irritative effects of the catheter.

Question 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

Answer 77

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

Question 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.

Answer 78

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.

Question 79

The most common cause for infection after transrectal prostate biopsy is __

Answer 79

The most common cause for infection after transrectal prostate biopsy is fluoroquinolone-resistant E. coli

Question 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)

Answer 80

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

Question 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.

Answer 81

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.

Question 82

wound classfication of 1. Opening into urinary tract, as in nephrectomy, cystectomy, prostatectomy, endoscopic procedures.

2. PCNL

Answer 82

1. Clean-contaminated ( class 2)
2. contaminated (class 3)

Question 83

Patients With Indwelling Orthopedic Hardware

when to give AP?

Answer 83

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.

Question 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.

Answer 84

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.

Question 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.

Answer 85

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.

Question 86

The long-term effect of uncomplicated recurrent UTIs is: a. renal scarring. b. hypertension. c. azotemia. d. ureteral vesical reflux. e. minimal.

Answer 86

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.

Question 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.

Answer 87

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.

Question 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.

Answer 88

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.

Question 89

The virulence factor that is most important for adherence is: a. hemolysin. b. K antigen. c. pili. d. colicin production. e. O serogroup

Answer 89

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.

Question 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.

Answer 90

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.

Question 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.

Answer 91

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

Question 92

The primary bladder defense is: a. low urine pH. b. low urine osmolarity. c. voiding. d. Tamm-Horsfall protein (uromucoid). e. vaginal mucus

Answer 92

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.

Question 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

Answer 93

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.

Question 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

Answer 94

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

Question 95

The most sensitive imaging modality for diagnosing renal abscess is: a. ultrasonography. b. indium scanning. c. gallium scanning. d. excretory urography. e. CT.

Answer 95

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

Question 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.

Answer 96

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.

Question 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.

Answer 97

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.

Question 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.

Answer 98

d

Question 99

Treatment of asymptomatic bacteriuria is most indicated in patients who are: a. elderly. b. catheterized. c. pregnant. d. confused. e. incontinent.

Answer 99

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.

Question 100

Screening for bacteriuria is beneficial in: a. pregnant women. b. elderly patients. c. men. d. children. e. spinal cord–injured patients

Answer 100

Screening for bacteriuria is beneficial in: a. pregnant women. b. elderly patients. c. men. d. children. e. spinal cord–injured patients

Question 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.

Answer 101

. e. Initial bacterial resistance. Most commonly, the bacteria are resistant to the antimicrobial agent selected to treat the infection.

Question 102

Nitrofurantoin is effective because of the concentration of the drug in the: a. urine. b. vaginal mucus. c. bowel. d. serum

Answer 102

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

Question 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.

Answer 103

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.

Question 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

Answer 104

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.

Question 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

Answer 105

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.

Question 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

Answer 106

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

Question 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.

Answer 107

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.

Question 108

Most patients with chronic pyelonephritis present with: a. hypertension. b. renal failure. c. chronic infection. d. flank pain. e. no symptoms.

Answer 108

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

Question 109

The most common bacterial cause of xanthogranulomatous pyelonephritis is: a. E. coli. b. Pseudomonas. c. Klebsiella. d. Proteus mirabilis. e. Staphylococcus

Answer 109

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.

Question 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

Answer 110

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.

Question 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

Answer 111

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.

Question 112

The most reliable early clinical indicator of septicemia is: a. chills. b. fever. c. hyperventilation. d. lethargy. e. change in mental status.

Answer 112

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.

Question 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

Answer 113

c

Question 114

Clinical pyelonephritis during pregnancy is most commonly linked to: a. maternal sepsis. b. maternal anemia. c. maternal hypertension. d. eclampsia. e. congenital malformations.

Answer 114

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

Question 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.

Answer 115

d. Penicillin. The aminopenicillins and cephalosporins are considered safe and generally effective throughout pregnancy. In patients with penicillin allergy, nitrofurantoin is a reasonable alternative.

Question 116

The majority of elderly patients with bacteriuria are: a. asymptomatic. b. febrile. c. incontinent. d. confused. e. dysuric

Answer 116

a

Question 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.

Answer 117

a. Closed drainage. Careful aseptic insertion of the catheter and maintenance of a closed dependent drainage system are essential to minimize development of bacteriuria

Question 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

Answer 118

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.

Question 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

Answer 119

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.

Question 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.

Answer 120

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.

Question 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

Answer 121

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

Question 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.

Answer 122

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.

Question 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

Answer 123

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.