Lecture 7: UTI & STD Flashcards
22 year old woman
• Develops frequent urination with burning
• Mild suprapubic tenderness
• 1 day later has fever 387 C, new onset flank pain • Nausea and vomiting, malaise, chills
– Presents to physicians office
• Additional history
– Sexually active, long standing partner for 1 year – Last normal menstrual cycle finished 1 week ago – Prior history of UTI as child
- HR 95, BP 105/60, Temp 381 C • Dry mucous membranes
- Right flank pain on percussion
Dx: UTI
UTI: 2 levels of infection
Cystitis and pyelonephritis
– Divided into complicated and uncomplicated infections in terms of management
• Adults uncomplicated infection
– nonpregnant otherwise healthy young woman.
– Complicated infection occurs in anyone else.
• In children, uncomplicated cystitis occurs in
– child over 2 years of age
– adolescent with normal anatomy and no underlying medical problems and infection does not enter the upper urinary tract.
UTI: Risk factors
Bacterial factors
– adhesins, pili and flagella give some bacteria selective advantage
– E. coli, Proteus mirabilis
Genetic host factors also involved
– White children 2 – 4 X higher prevalence of UTI than black children
– First degree relative of child with UTI more likely to have had UTI’s
Anatomic factors
– Catheters
– Incomplete emptying (urinary obstruction)
– Vesicoureteral reflux (children)
– Lack of circumcision (males under 1 year)
Behavioral
– Sexual intercourse increases the risk
Underlying condition
– Diabetes
– Pregnancy
– Immunosuppression
– Renal transplant
UTI: Common organisms
Uncomplicated
- E. coli across all ages (75 to 90%). Pink colonies on MacConkey agar. Does not split urea
- Proteus mirabilis common as well. Splits urea and can give rise to struvite stones
- Klebsiella pneumoniae less common but also splits urea
- Staphylococcus saprophyticus in young women (Honeymoon cystitis)
Complicated
• Hospitalization and catheters, prior antimicrobial therapy change the
organisms.
– Above gram negatives still occur but susceptibilities change. E.coli remains the most common overall
– Enterococcus,Pseudomonas,Enterobacter,Serratia
– Candida species
– Staphylococcus aureus is not a common cause of ascending UTI. If present think bacteremia and where did it come from.
– Neonates
• Group B strep, E.coli, other enteric gram negatives
UTI: Dx
- Determined in young women with cystitis
- Consider clinical context raising suspicion of UTI
- Urinalysis for pyuria. > 10 WBC/uL
- Standard for positive urine culture is ≥ to 105 of a single organism
- Cut off for colony count in symptomatic patient (dysuria and frequency) with pyuria is ≥ 103 cfu/ml. (colony forming unit)
- The only indication for screening for asymptomatic bacteruria with a catheter is in pregnant women or for urologic procedures that cause mucosal bleeding.
Dipstick tests
- Predominantly used in primary care settings
- Nitrite positive if urine in bladder for 4 hours with nitrite producing bacteria (Enterobacteriaceae) Does not apply to Enterococcus, S. saprophyticus, Pseudomonas
- Can pick up leukocyte esterase indicating pyuria
- Sensitivity and specificity depend on patient group and
- clinical practice.
- Best for screening patients with symptoms specific to urinary tract (dysuria, frequency, suprapubic pain, flank pain)
UTI: Dx Additional tests
Blood cultures in suspected upper tract disease
– Imaging of urinary tract for symptoms persisting beyond 48 hours on appropriate therapy,
- suspected renal colic or prior renal stones
- diabetics
- Immunosuppression
- Priorurologicsurgery
- Urosepsis including but not restricted to positive blood cultures
– Imaging test of first choice non-contrast CT scan. Contrast required to demonstrate renal perfusion
– Ultrasound used in neonates, others where CT contraindicated
UTI Management
Depends on complicated vs. uncomplicated disease and whether upper or lower tract
Neonates
- Weight based ampicillin and gentamicin
- Vancomycin may be substituted for ampicillin
- Choice will depend on local hospital resistance patterns
Children
– Oral therapy in child who is not vomiting.
– Aim at E. coli. Get susceptibilities!
– IV therapy for resistant organisms or child who can’t take oral therapy
– Switch to oral when afebrile and taking meds ok by mouth
– Duration 7 to 10 days if febrile and 3 to 5 days if afebrile
Adults
- Uncomplicated cystitis.
- Duration dependant on antibiotic choice
- – Nitrofurantoinx5days
- – Septrax3days
- – Ciprofloxacinx3days
- – Levofloxacinx3days
- – Reserve quinolones for complicated disease or resistant organisms
- – Betalactamsfor7days
- – Fosfomycin single dose. Use for Extended spectrum B-lactamase producers
– Uncomplicated Pyelonephritis
- Don’t use nitro furantoin or fosfomycin (inadequate blood levels)
- Ciprofloxacinx7days
- Levofloxacin x 7 days
- IV therapy for resistant organisms or inability to keep down oral meds
UTI pregnancy management
- 1st visit screen of urine sufficient in otherwise low risk woman.
– 3 day regimens usually sufficient. May need to go to 7 days.
- Trimethoprim/sulfamethoxazole (TMP/SMX) should not be used close to term.
- Quinolones contraindicated (only when organism is susceptible)
- Amoxicillin/calvulin, cephalosporins, nitrofurantoin OK.
Male HIV+ Pt
- Presents to family doctor in September with lymphadenopathy, malaise, sore throat
- Treated with oral penicillin. No improvement
- Develops rash on body and feet, mouth lesions
- Additional complaints of ringing in ears and blurry vision
Physical
- No weight loss
- Generalized lymphadenopathy 1 cm size
- Mucosal lesions on palate
- Fundi normal, no cranial nerve deficits
- Rash on soles of feet
- No genital lesions
Labs
- Prior VDRL negative 1 year ago
- CD4 > 500, viral load still undetectable
- VDRL repeated Titer >1:16, positive confirmatory test
Dx: syphillis
Syphilis: Stages of Infection
Early
- During first year
- Includes primary, secondary and early latent disease
- Latent stage disease: + serology , no findings
Late
- Neurologic
- Cardiac
- Gummatous
Congenital
STD: Neisseria gonorrhoeae in women
Urethritis: dysuria main symptom
- Anorectal infection. Asymptomatic. Usually associated with cervicitis or urethritis
- Oropharyngeal infection.
- – Usually asymptomatic.
- – Associated with oral sex, pregnancy, sexual partner with gonorrhea
- PID
- – 10 to 40% of women with cervical gonorrhea
- – Scarring, inflammation with dyspareunia, pelvic abdominal pain
- – Perihepatitis of Fitz-Hugh Curtis syndrome (RUQ pain and tenderness)
STD: N. gonorrheoae disseminated infection
- Tenosynovitis, dermatitis, polyarthralgia syndrome
- – Fever, chills at outset
- – Multiple inflamed tendons (Finger, ankles, toes tenosynovitis)
- – Painless pustular / vesiculopustular lesions 2 to 10 in number, resolve spontaneously
- Purulent arthritis without rash
- – Usually afebrile
- – Knees, wrists and ankles
- – Multiple joints, asymmetric
- Diagnosis by history, exam for rash, purulent synovial fluid analysis (50,000 WBC/mm3) Blood and mucosal (rectal, genital, pharyngeal) may be positive
- Rx 7 days. Purulent arthritis requires joint drainage
STD: Chlamydia trachomatis
- Mucosal infection leads to local inflammatory response with lymphocytes and monocytes; Not as severe as gonorrhea (mucopurulent discharge), whereas chlamydia is more watery
- Heat shock proteins and LPS in cell wall contribute to pathogenesis
