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MBBS IV - Junior Clerkship WCS > JC73 (Surgery) - UTI > Flashcards

JC73 (Surgery) - UTI Flashcards

1
Q

Define upper and lower UTI by anatomical structures

A

o Upper UTI: Kidney to ureter at vesicoureteric junction

o Lower UTI: Urinary bladder/ Prostate/ Urethra

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2
Q

Define complicated vs uncomplicated UTI

A

Uncomplicated:
Patient without structural and functional abnormality or underlying condition
No risk of failing standard therapy

Complicated:
Patient with structural and functional abnormality or an underlying condition that increases the risk of infection or failing therapy

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3
Q

Pathogens that typically cause community-acquired UTI

A

Facultative aerobes from intestinal tract
85% E.coli

Others:

  • Proteus
  • Klebsiella spp
  • Entercoccus
  • Staphylococcus saprophyticus
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4
Q

Pathogens that cause nosocomial UTI

A

50% by E.coli

Others:

  • Pseudomonas
  • Providencia
  • Citrobacter
  • Coagulase-negative staphylococcus
  • Serratia
  • Enterobacter spp.

(in the hospital, a CCP PEES and gets infected)

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5
Q

Risk factors for complicated UTI

A

 All causes of neurogenic bladder, mechanical bladder outlet obstruction (e.g. strictures, stones, clots…etc), vesicoureteral reflux

 Altered immunity: DM, immunocompromised or pregnancy, sepsis…etc

 Recent hospitalization (nosocomial infections) or presence of indwelling catheter/ iatrogenic damage to urinary tract

(Males are less prone to UTI and thus it is usually considered complicated when present)

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6
Q

Define recurrent UTI

A

≥ 2 infections in 6 months or ≥ 3 infections in 12 months due to reinfection or relapse from a persistent focus

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7
Q

Difference between reinfection and relapse in recurrent UTI

A

Reinfection: infecting strain is different from original and the recurrence occurs > 2 weeks of the completion of treatment for original infection

Relapse: infecting strain is the same from original and the recurrence occurs ≤ 2 weeks of the completion of treatment for original infection

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8
Q

Sources of bacterial persistence in recurrent UTI/ correctable bacterial persistence causing UTI

A

Infections:
- Struvite stones/ mixed kidney stones,
- infected atrophic kidneys/ renal abscesses

Anatomical/ developmental defects:
- ureteral stump after nephrectomy,
- medullary sponge kidney/ Cacchi-Ricci disease (birth defect in renal tubules)
- papillary necrosis (uncontrolled DM, Analgesics abuse)
- Urachus adnormalities (duct between bladder and umblilcus): urachal cyst, urachal diverticulum
- Urinary fistulas e.g. vesicovaginal/ vesicocolic fistulas from Bladder CA

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9
Q

Presence of bacteria and WBC in urine must equate to UTI. True or False. Why

A

False

Bacteriuria and pyuria does not mean UTI

Bacteriuria: UTI or colonization or contamination of sample
Pyuria: inflammatory process in urinary tract

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10
Q

DDx of pyuria

A

Inflammatory condition in urothelium:

UTI, Urolithiasis, Malignancy, Tuberculous infection

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11
Q

Classical triad of symptoms in acute pyelonephritis

A

(i) Fever ≥ 38.0oC
(ii) Chills
(ii) Loin pain or tenderness

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12
Q

Risk factors of UTI

A

 Female sex - Shorter urethral length

 Lack of circumcision - foreskin bind to uropathogens, partial obstruction

 Vesicoureteral reflux (VUR) (most common in children UTI due to incompetence of UV Valve)

 Urinary obstruction - urine stasis

 Bladder and bowel dysfunction - incontinence, abnormal voiding

 Urinary instrumentation - Bladder catheterization

 Sexual activity

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13
Q

Causes of urinary obstruction

A
  • Anatomical: Posterior urethral valves/ Ureteropelvic junction obstruction
  • Neurological: Myelomeningocele, neurogenic bladder
  • Functional: Bladder and bowel dysfunction

read full flashcards at urinary obstruction WCS

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14
Q

Risk factors for recurrent UTI in pre-menopausal women

A
  1. Genetics - Increased susceptibility to vaginal colonization with uropathogens and bacterial adherence
  2. Pelvic anatomy - Urethra-to-anus distance
  3. Sexual activity - Frequent sexual intercourse, New sexual partners, Diaphragm or spermicide use
  4. Drug - Recurrent antimicrobial use (alteration of vaginal flora)
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15
Q

Risk factors for recurrent UTI in post-menopausal women

A
  1. Estrogen deficiency - atrophic vaginitis
  2. Pelvic organ prolapse/ cystocele - Urinary incontinence
  3. Indiscriminant use of antimicrobials
  4. Large residual volume post-void (decreased sensitivity to bladder volume due to aging)
  5. History of recurrent UTI
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16
Q

Viruses that cause UTI

A
  • Adenovirus
  • Enterovirus
  • Echovirus
  • Coxsackievirus
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17
Q

Fungi and parasites that cause UTI

A

Fungi:
* Candida
* Aspergillus
* Cryptococcus neoformans

Parasites:
- filariasis,
- trichomoniasis,
- leishmaniasis,
- malaria
- schistosomiasis

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18
Q

Normal defense mechanisms against UTI

A
  1. Normal flora: lactobacilli in introitus, vagina and periurethral area produces low pH
  2. Host immunity: cervical secretory IgA
  3. Urine: anterograde flow, pH and Tamm-Horsfall protein to prevent bacteria adherence
  4. Bladder: normal emptying, exfoliation of urothelial cells, immune receptors on superficial urothelial cells to recognize LPS and activate local inflammation
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19
Q

Factors that can alter normal defense mechanisms against UTI

A

Normal flora: Altered by antimicrobial

Urine: Altered by urinary tract obstruction

Bladder: Altered by urinary tract obstruction, neurogenic bladder, indwelling catheter, vesicoureteral reflux and bladder diverticulum

20
Q

Genetic factors that increase risk of UTI

A
  1. Genetically determined vaginal cell susceptibility to bacterial adherence
  2. Lewis blood group: affects cellular fucosylation and bacterial adherence
21
Q

Lewis blood groups asso. with increase risk of UTI (not important)

A

Le a-b- and Le a+b- = recurrent UTI

Le b- = premenopausal acute pyelonephritis

22
Q

4 virulence factors in uropathogens

A
  1. Bacterial adhesins (fimbrial not afimbrial)
    a) Fimbrial adhesins (pili)
    - Type 1 (mannose-sensitive) pili for E. coli, acute cystits
    - Type P (mannose-resistant) pili, acute pyelonephritis
    - Type S pili, cystitis and nephritis
    b) Afimbiral adhesins
  2. Toxins: hemolysin HlyA
  3. Urease: urea to ammonia increase pH
  4. IgA inactivating protein
23
Q

Routes of UTI spread (3)

A
  1. Ascending spread (most common)
  2. Hematogenous spread
    • Secondary infection from extrarenal source of bacteremia e.g. Renal abscess from septic emboli, Genitourinary tuberculosis (TB)…etc
  3. Direct inoculation from neighboring suppurative infections
24
Q

List 7 Lower urinary tract symptoms (LUTS) (Mnemonics: FUN DISH) **

A 
Storage: 
 Frequency, dysuria
 Urgency
 Nocturia
 Urinary incontinence
Voiding: 
 Post-micturition symptoms: Dribbling, retention
 Intermittent and weak stream
 Straining to void
 Hesitance
25
Q

Outline assessments for diagnosis of UTI

A

Clinical: symptoms and signs

Urinalysis (visual + chemical + microscopic)

Microbiological: Urine culture

26
Q

Methods of urine collection and indications

A

Bag urine - urinalysis only

Mid-stream urine (most common) - urinalysis and culture with sensitivity testing

Clean-catch urine - urinalysis and culture with sensitivity testing

Urethral catherization - unable to void, urinalysis and culture with sensitivity testing

Suprapubic aspiration (SPT) - pediatric/ patients with spinal cord injury and paraplegia, urinalysis and culture with sensitivity testing

27
Q

Relative risks/ drawbacks of different methods of urine collection

A

Bag urine - contamination by perineal flora

Mid-stream urine - prone to contamination, not applicable in children

urethral catherization - risk of iatrogenic UTI

Suprapubic aspiration - risk of bowel perforation, bowel injury

28
Q

Outline spectrum of tests in urinalysis

A

Chemical: pH, osmality, specific gravity …etc

Microscopic: Erythrocytes, Leukocytes, Bacteria, Epithelial cells (contamination marker)

Adjunctive: Leukocyte Esterase, Nitrites

29
Q

Indications for radiological evaluation for UTI

A

Persistent infection
* Persistent clinical symptoms after 48 – 72 hours of antibiotic therapy
* Repeated pyelonephritis
* Urosepsis

Altered anatomy
* Renal stones/ mechanical obstructions
* History of urological surgery/ anatomical abnormalities

Weak immune system
* Diabetes mellitus
* Immunosuppression

30
Q

Cause of abnormally alkaline urine pH in UTI

A

Normal urine pH = 5.5 - 6.5

pH >7.5 indicate urease-producing bacterial esp. in presence of stones

e.g. Proteus, Klebsiella, Pseudomonas

31
Q

Bacteria observed in direct microscopy of urine equate UTI. True or False?

A

False

Bacteria only seen in 10^5 CFE/ mL
May be normal flora or contamination
Can be sterile bacteriuria

32
Q

Urinalysis adjunctive tests

Mechanism of action

A

Pyuria: Leukocyte esterase
o Leukocyte esterase is released by lysed neutrophils and macrophages and is a marker for the presence of WBC

Bactiuria: Nitrite test
o Enterobacteriaceae express nitrate reductase which converts urinary nitrate into nitrite
o FN results in Gram +ve or Pseudomonas UTI

33
Q

Define cut-off values for pyuria and bacteriuria

A

Pyuria = > 2 WBC/ high power field (OR) > 10 WBC/mL

Bacteriuria:
≥ 10^3 cfu per ml for female uncomplicated cystitis
> 10^4 cfu/ml in female uncomplicated pyelonephritis
> 10^5 cfu/ml in female or 10^4 cfu/ml in male complicated UTI
Suprapubic aspiration: any bacteria growth is +ve

34
Q

Ddx for sterile pyuria

A

pyuria without bacteriuria

TB
partially treated UTI
urinary tract stones
bladder cancer
inflammatory conditions such as interstitial cystitis and ketamine cystitis
35
Q

Causes of false negative in leukocyte esterase test in urinalysis

Causes of false negative in nitrite test

A 
Leukocyte esterase false negative
High specific gravity/ dehydration 
Glycosuria 
Urobilinogen 
High Vit C 
low WBC: WBC lysis and Neutropenia

Nitrite:
Pseudomonas/ gram-positive UTI
low specific gravity urine

36
Q

Define asymptomatic bacteriuria

A

≥ 10^5 cfu/ml and ≥ 10^3 cfu/ml in women and men urine

without symptoms and signs

37
Q

Recommended screening and treatment of asymptomatic bacteriuria is indicated which patients

A

Pregnant pt: UTI asso with premature birth, LBW

Planned invasive genitourinary surgery with risk of mucosal bleeding

not clinically indicated for DM patients

38
Q

7 loci of UTI

A 
Cystitis 
Pyelonephritis 
Pyonephorsis/ Renal abscess 
Prostatitis 
Epididymo-orchitis 
Urethritis
39
Q

Acute Cystitis:
Classical presentation
Ddx
Treatment

A

Dysuria, frequency, urgency
Haematuria
Foul-smelling urine
No vaginal discharge or systemic upset

Ddx:
Other non-infective cystitis
Vaginosis
Herpes

Tx:

  • amoxicillin-clavulanate (Augmentin)* or Fluoroquinolone (3 days)
  • Nitrofurantoin (7 days)
40
Q

Acute Pyelonephritis:
Classical presentation
Treatment

A 
Fever, chills 
Vomiting
Loin pain
Sepsis 
Haematuria

Treatment:
USG imaging for underlying obstructions, Contrast CT for renal abscess or obstruction after 72h without improvement
14 days Fluoroquinolone or 3rd gen. cephalosporins
Aminoglycosides/ carbapenems for FQ-resistant

41
Q

Indications to investigate male UTI

Empirical treatment for male UTI

A 
Febrile UTI 
Pyelonephritis 
Recurrent UTI (prostatitis?)
AROU/ history of voiding problems 
Persistent microscopic haematuria

7 days augmentin/ fluoroquinolone for male cystitis
2-6 weeks quinolones for prostatitis

42
Q

Risk factors for elderly UTI

A
  • Prostate enlargement **
  • Urinary obstruction e.g. Fecal impaction, Pelvic organ prolapse/ Cystocele
  • Poor perineal hygiene (fecal)
  • Neurologic impairment- Neurogenic bladder, large post void residual volume, drug induced
  • Post-menopausal changes: atrophic vaginitis
43
Q

Prevention measures for UTI

A

Lifestyle modification
• Liberal fluid intake to increase micturition
• Avoid use of spermicide-containing products
• Post-coital voiding

Antibiotic prophylaxis with co-trimoxazole or nitrofurantoin
• Continuous, post-coital, intermittent

44
Q

Manifestation of genitourinary TB

A

Kidneys:

  • Abscess, fibrosis
  • Calcified, non-functional kidney

Ureter strictures

Bladder: cystitis, contracted “thimble” bladder, Golf-hole ureteral orifice

Epididymis, Vas Deferens: abscess, sinus, infertility, discharge

Prostate: Nodules

45
Q

S/S for genitourinary TB

A

Chronic and non-specific:

Frequency, dysuria, loin pain, haematuria, suprapubic pain, fever

Genital:
Scrotal sinus with discharge, epididymal/ prostatic nodules/ vas deferens beading

46
Q

Investigations for genitourinary TB

Treatment

A

AFB smear
Culture: lowenstein-jensen medium
PCR

HREZ therapy

MBBS IV - Junior Clerkship WCS (131 decks)

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