Lecture 22/23 UTIs Flashcards
What is the epidemiology of UTIs?
approx 12% annually for females
50% of women report to have one by age 32
significantly less common in males, incidence increases with age
recurrence occurs in 25% of women within 6 months of 1st UTI (increases when >1 prior UTI experienced)
is the 8th most common reason for ambulatory clinic visits and 5th most common for ER visits in Canada
What is a UTI?
is a bacterial infection of urinary tract ⇒ involves cystitis (lower), pyelonephritis (upper)
S&S: cystitis - dysuria +/- frequency, urgency, suprapubic pain, hematuria
pyelonephritis - fever, chills, flank pain/tenderness, +/- typical cystitis S&S
What is asymptomatic bacteriuria (ASB)?
bacteria in urine in quantitative counts consistent with growth in bladder/kidneys without S&S referable to the urinary tract
usually tx of this is unnecessary
What are predisposing factors for UTIs in women and men?
Women: sexual intercourse, spermicide use, new sexual partner within last year, previous UTI, FHx of UTI in first degree relative, menopause, diabetes and other complicating factors
Men: BPH, previous urinary tract surgery, recent procedures (including cystoscopy, catheterization, prostate biopsy), anatomic or physiologic abnormalities (incomplete bladder emptying), age >65, uncircumcised, immunocompromised, engaging in sex with infected female or engaging in anal intercourse
What S&S should be covered in questioning regarding UTIs?
SHUDF - Suprapubic pain, hematuria, urgency, dysuria, frequency
DOPP - vaginal Discharge, odour, pruritus, painful intercourse (vaginitis more likely when these are present especially if no urinary frequency or urgency)
flank pain/tenderness, fever/chills, N/V
What are complicating factors for UTIs?
male sex, chronic obstruction, diabetes (poorly controlled), indwelling urinary catheter, nephrolithiasis, immunosuppression, pregnancy
if pt presents with one of these it indicates complicated UTI, in absence of these its considered uncomplicated UTI
What are the usual pathogens involved with UTIs?
E. coli - up to 95% of uncomplicated UTIs
Others: K. pneumoniae, P. mirabilis, enterobacterales, S. saprophyticus, P. aeruginosa, enterococcus spp, S. agalactiae (if pregnant or diabetic)
What are lab investigations that may be involved in UTIs, what are they, and when might they be used vs not used?
Urine Culture: not generally recommended IF asymptomatic
if uncomplicated ⇒ not usually necessary unless: early recurrence of infection, recent travel outside Canada/US or recent hospitalization, atypical presentation, pyelonephritis
if complicated ⇒ its recommended (ir catheter in place >/= 2 weeks it should be discontinued or changed before collection)
Blood Culture: recommended if pt febrile, hemodynamically unstable, pyelonephritis, immunocompromised,, Pyuria: via urinalysis or dipstick
doesn’t identify symptomatic infection, high NPV particularly in elderly
Nitrites: via urinalysis or dipstick, reduction of nitrates to nitrites by Gram (-), not helpful
What is the recommended treatment for CYSTITIS UNCOMPLICATED UTIs?
First-Line: Nitrofurantoin monohydrate/macrocrystals 100 mg PO BID F5D,, Fosfomycin 3 g PO x 1 dose
Alternatives: no antibacterial exposure within last 6 months: cephalexin 250-500 mg PO QID F5-7D
TMP/SMX i DS tab PO BID F3D (can use TMP 100 mg PO BID F3D if sulfa allergy)
Other: cefixime 400 mg PO QD F5-7D
fluoroquinolone F3D (only if no other options, due to serious AEs on tendons, muscles, joints, nerves, and CNS)
What is the recommended treatment for PYELONEPHRITIS UNCOMPLICATED UTIs?
Outpatient: IV/IM - Ceftriaxone 1-2 g IV/IM x 1 dose followed by PO tx,, Gentamicin 5-7 mg/kg IV/IM x 1 dose followed by PO tx, Oral - Cefixime 400 mg PO QD F7-10D
amox/clav 875 mg PO BID F7-10D,, fluoroquinolone F7-10D
TMP/SMX i DS tab PO BID F7-10D
Hospitalized/Septic: Ceftriaxone 1-2 g IV Q24H F7D
Gentamicin 5-7 mg/kg IV Q24H
What is the recommended treatment for COMPLICATED UTIs?
Cystitis with no systemic: Cefixime 400 mg PO QD F7-10D,, amox/clav 875 mg PO BID F7-10D
fluoroquinolone F7-10D
TMP/SMX i DS tab PO BID F7-10D, if rapid response (within 2 days) treat for 7 days, if delayed response or structural abnormality treat for 10 days
Pyelonephritis and/or systemic features: Ampicillin 1-2 g IV Q6H + (Ceftriaxone 1-2 g IV Q24H OR Gentamicin 5-7 mg/kg IV Q24H) F7D
Septic/Hemodynamically Unstable: Piperacillin/tazobactam 3.375 g IV Q6H +/- Gentamicin 5-7 mg/kg IV Q24H F7-10D
What is the recommended treatment for UTIs in PREGNANT women?
Cystitis: Nitrofurantoin 50-100 mg PO QID (or Macrobid 100 mg BID) F7D (not to be used in 3rd trimester)
Cephalexin 250-500 mg PO QID F7D
Cefixime 400 mg PO QD F7D
Fosfomycin 3 g PO x 1 dose
TMP/SMX i DS tab PO BID F7D (not to be used in 1st or 3rd trimester)
Pyelonephritis: Ceftriaxone 1-2 g IV Q24H F7D (may be able to switch to oral depending on response)
Ampicillin 2 g IV Q6H + Gentamicin 7 mg/kg IV Q24H F7D (may be able to switch to oral)
post tx (1 week) urine culture recommended followed by monthly follow up cultures during remainder of pregnancy
What is the difference between relapse and reinfection in UTIs?
Relapse ⇒ same organism, typically within 2-4 weeks after tx completion
consider investigation for pyelonephritis or renal abscess
Reinfection ⇒ same or different organism, over 90& of recurrences are due to this
What are some tips to preventing recurring UTIs?
avoid use of spermicides or spermicide-coated condoms
adequate hydration (ex. additional 1.5L water daily)
post-coital voiding
cranberry products (conflicting evidence, little harm)
topical vaginal estrogen (postmenopausal)
What is the treatment for recurrence of infection for UTIs?
defined by females with frequent recurrences (>/= 3 episodes per year or >/=2 episodes in 6 months)
may consider prophylactic antibacterials but should confirm eradication with negative urine culture 1-2 weeks post-tx before initiating prophylaxis
Pericoital Prophylaxis: TMP/SMX i SS tab PO (or TMP 100 mg PO)
Nitrofurantoin 50 mg PO (or Macrobid 100 mg PO)
Cephalexin 125-250 mg PO
Continuous Prophylaxis: TMP/SMX i SS tab (or TMP 100 mg) PO HS (or 3x/week) x 6 months
What is prostatitis and what are pathogens involved?
15% of men will have this in lifetime, effective antibacterials are limited and need to be given for prolonged periods
significant failure rates (up to 75%)
Acute Bacterial: urinary sx and pain (may be suprapubic, perineal, rectal, external genitalia), may include fever and urosepsis
Chronic Bacterial: lasting > 3 months
Pathogens: E. coli, other enterobacterales (ex. Klebsiella, Proteus spp, etc), enterococcus, Pseudomonas, staphylococci and streptococci (rare), STIs less common cause
What is recommended treatment for bacterial prostatitis?
Acute: Mild-Moderate - Ciprofloxacin 500-750 mg PO BID F10-14D
TMP/SMX i DS tab PO BID F2-4W
Ceftriaxone 1-2 g IV QD (switch to PO when improved to complete 10-14D), treat for 4 weeks if pt remains symptomatic at 2 weeks or prostatic abscess
Severe - Piperacillin/tazobactam 4.5 g IV Q6H (switch to PO once improvement to complete 4 weeks)
Chronic: Ciprofloxacin 500-750 mg PO BID F4W
TMP/SMX i DS tab PO BID F6W
Doxycycline 100 mg PO BID F6W
if no response in 4 weeks consult urologist
