List I - Act Core Conditions Flashcards
1
Q
What is a lower UTI?
A
- Infection of the bladder also known as cystitis, usually caused by bacteria from the GI tract
2
Q
What is an uncomplicated UTI?
A
- UTI caused by typical pathogens in people with a normal urinary tract and kidney function and no predisposing co-morbidities
3
Q
What is a complicated UTI?
A
- UTI with an increased likelihood of complications such as persistent infection, treatment failure and recurrent infection
- RF’s include:
- Structural or neurological abnormalities of the urinary tract, urinary catheters, virulent or atypical infecting organisms and co-morbidities such as poorly controlled DBM or immunosuppression
4
Q
What is an upper UTI?
A
- Infection of the upper part of the urinary tract - ureters and kidneys (pyelonephritis)
5
Q
How is recurrent UTI defined?
A
- Two or more episodes of UTI in 6 months or 3 or more episodes in one year
- More common in women and can be due to:
- Relapse - infection due to the same strain of organism or
- Reinfection - infection due to a different organism
6
Q
What is a catheter associated UTI?
A
- Symptomatic infection of the bladder or kidneys in a person who is catheterised or who has had a urinary catheter in place within the previous 48 hours
- The longer a catheter has been in situ the more likely bacteria will be found in the urine - asymptomatic bacteriuria in non-pregnant women does not routinely need treatment
7
Q
What is bacteriruria?
A
- Presence of bacteria in the urine - the person may or may not by symptomatic
8
Q
What is asymptomatic bacteriuria?
A
- Presence of significant levels of bacteria in the urine in a person without signs or symptoms of UTI
9
Q
What are the main bacteria causing UTI?
A
- E. coli >70% of community acquired, <40% hospital acquired
- Proteus mirabilis 12%
- Staphylococcus saprophyticus/epidermis 8% (30% in young females)
- Entercoccus faecalis 6% (commoner in hospitals)
- Klebsiella aerogenes (commoner in hospitals)
- Enterobacter
- Acinetobacter
- Pseudomonas aeruginosa
- Serratia marascens
- Candida albicans
- Staphylococcus aureus
10
Q
What are the risk factors for UTI?
A
- General
- Immunosuppression (iatrogenic/DM)
- Female
- Urinary tract obstruction
- Catheterised patient
- Congenital malformation
- Acquired fistula
- Sexual intercourse
- Pregnancy
- Exposure to spermicide in females
- Renal calculi
- Menopause
- Cystitis
- Poor bladder emptying
- Urinary stasis/obstruction
- Bladder stones
- Epithelium of bladder damaged in past
- Pyelonephritis
- Preceding cystitis
11
Q
How common is pyelonephritis?
A
- 117 F v 24 M / 100,000
* M:F 1:5
12
Q
How common is asymptomatic bacteriuria?
A
- 30% >65 years
- 50% nursing home residents
- 100% long term catheters (only if costovertebral tenderness, rigors, new onset delirium/fever)
13
Q
What is the pathophysiology of a UTI?
A
- Infecting organisms ascend the urinary tract (if into renal pelvis, calyces and renal parenchyma: pyelonephritis
14
Q
What are the complications of lower UTI?
A
- Lower UTI ascending infection leading to pyelonephritis, renal and peri-renal abscess, impaired renal function, renal failure and urosepsis
- UTI in pregnancy is associated with pre-term delivery and low birth weight
15
Q
What are the risk factors for developing a complicated UTI?
A
- Pregnancy
- Older age (post menopause)
- Healthcare associated UTI
- Presence of symptoms for more than a week before presentation
- Urological instrumentation (including urinary catheter)
- Pre-existing urological conditions such as childhood or recurrent urinary tract infections, neurogenic bladder, polycystic kidney disease, renal transplant, urolithiasis, or urinary obstruction
- DBM and immunosuppression
16
Q
What are the symptoms of cystitis?
A
- Frequency
- Dysuria
- Urgency
- Strangury
- Pyuria
- Haematuria
- Subprapubic pain
17
Q
What are the symptoms of prostatitis?
A
- Few urinary symptoms
- Flu like symptoms
- Low back ache
- Swollen/tender prostate on PR
18
Q
What are the symptoms of pyelonephritis?
A
- High fever
- Rigors
- Vomiting
- Loin pain/tenderness (insidious, constant, does not usually radiate to groins, may be bilateral - usually one worse than the other)
- Haematuria
- Oliguria (if renal failure)
- Frequency
- Dysuria
- Urgency
- Systemic upset (if renal abscess develops (in lumbar triangle)
19
Q
What are the symptoms of UTI in the elderly?
A
- Confusion
- Incontinence
- Nocturia
- Vague systemic upset
- Delirium
20
Q
What are the symptoms of sepsis (uro)?
A
- Fever
- Rigors
- Confusion (off legs)
- Rash
- Vomiting
21
Q
What are the symptoms of genito-urinary TB?
A
- Dysuria
- Flank pain
- Perineal pain
- Scrotal fistula
- Haematuria
22
Q
What are the signs of UTI?
A
General
- Warm peripheries
- Fever
- Tacycardia
Urinary system
- Loin/abdo/suprapubic tenderness
- Foul smelling urine
- Distended bladder (occasionally)
- Enlarged prostate
- Vaginal discharge (non-gonococcal urethritis)
23
Q
What are the worrying signs in a patient with a UTI?
A
- Reduced BP/shock
- Temperature >40c
(elderly patients can be afebrile but very bacteraemic) - New renal impairment
24
Q
What are the differential diagnoses for UTI?
A
- Urethritis
- Cystitis
- Prostatitis
- Pyelonephritis
- Epididymitis
- Chlamydial infection
- Genitourinary TB
- Pelvic inflammatory disease
25
What are the differentials according to MSU/CSU dipstick findings from a urine sample?
* Nitrites - gram -ve UTI (e.coli)
* Leucocytes - from inflammation of the kidneys/urinary tract
- UTI
- Stones
- Trauma
- Neoplasia
- Infection of related structures (prostate, appendix)
- Renal disease
* Blood
* with RBC's on microscopy
- Myoglobinuria
- UTI
- Bladder tumour
- Stones
- Recent catheterisation
- Clotting abnormality
- Prostate hypertrophy
- Glomerulonephritis
- Increased BP
- TB
- Endocarditis
- Sickle cell disease
- Strenuous exercise
- PV bleed
* without RBC's on microscopy
- Haemoglobinuria
- Haemolytic anaemia
- Myositis
- Rhabdomyolysis
- Trauma
- Ischaemia
* Protein - albumin (should not be in urine)
* Glucose - DBM
* Ketones
- DKA
- Fasting
- Low CHO diets
- Acute illness
* pH - normal 4.5-8
- Systemic acidosis/alkalosis
* Specific gravity
26
What are the differentials according to microscopy for urine?
* White cells >10/mm3 is abnormal
* Bacteria - if seen on microscopy - highly suggestive of UTI (still needs to be cultured)
* Red cells >2/mm3 is abnormal
* Casts - hyaline/non-granular (not significant) red cell/epithelial (renal disease), white cell (pyelonephritis)
27
What are the differentials according to urine culture?
* Takes 48 h
* Pure growth >10(5) cfu/ml - UTI likely
* Mixed - suggests contamination of urine
* Sterile pyuria
- TB
- Treated UTI <2wks
- Inadequately treated UTI
- Appendicitis
- Calculi
- Prostatitis
- Bladder Ca
- UTI with fastidious culture requirement
- Papillary necrosis (DM/analgesic excess)
- Tubulointerstitial nephritis
- PCKD
- Chemical cystitis e.g. cyclophosphamide
28
What are the blood investigations for a person with a UTI?
* Culture if systemically unwell - urosepsis
* FBC - WCC neutrophils
* U and E's - increased urea, creatinine, outflow tract obstruction
* CRP - very high and GU TB
* Glucose - DKA/DM, PSA
29
What are the urine investigations for a person with a UTI?
* Dipstick 1st if symtpoms
- 2+ nitrites, leucocytes, blood, protein
- If early morning sample mycobacteria - think GU TB
* MC and S to microbiology
- If +ve for nitrites, leucocytes, blood, protein or -ve despite clinical suspicion of UTI or if male/child/immunosuppressed
* Pure growth of >10 (5)/ml is diagnostic
* Significant is pure growth of <10 (5)/ml but pyruria (WCC >20/mm3)
* Repeat MC and S 1 week post therapy to ensure resolution of infection
30
What imaging can be done to investigate UTI further?
* USS - useful to identify hydronephrosis 2nd to urinary obstruction/renal abscess or drainable collection
- Indications - if child, M, fail to respond to therapy, recurrent UTi >2yrs, pyelonephritis
* Abdominal x-ray
* CT KUB
- Radio-opaque calculi as source of infection
- Unusual organism
- Persistent haematuria
- Evidence of renal impairment
- 6-8 weeks after therapy
* IV urogram/renogram
* Cystoscopy
* DMSA - radio-isotope scan - for children <5 yrs
* Micturating cystourethrogram - if <1yr old
31
What are the principles of management of a UTI in non-pregnant women?
* Trimethoprim or nitrofurantoin for 3 days
* Send a urine culture if
- Aged >65 years
- Visible or non-visible haematuria
* Follow local anti-biotic guidelines if they are available
32
What are the principles of management of a UTI in a pregnant woman?
* Symptomatic
- Urine culture should be sent in all cases
- Treated with an antibiotic
- First line - nitrofurantoin (avoided nearer term)
- Second line - amoxicillin or cefalexin
* Asymptomatic bacteriuria in pregnant women
- Urine culture should be performed routinely at the first antenatal visit
- NICE recommend an immediate prescription of either nitrofurantoin (avoided near term), amoxicillin or cefalexin - 7 day course
- Further urine culture should be performed routinely at the first antenatal visit
* Rationale for treating asymptomatic bacteriuria is the significant risk of progression to acute pyelonephritis
33
What are the principles of treatment for men with a UTI?
* Immediate antibiotic prescription should be offered
34
What are the principles of treatment of a UTI in catheterised patients?
* Do not treat asymptomatic bacteria in catheterised patients
* If the patient is symptomatic they should be treated with an antibiotic
- 7 day rather than a 3 day course should be given
35
What are the principles of management of acute pyelonephritis?
* Hospital admission should be considered
| * Broad spectrum antibiotics - cephalosporin or a quinolone (for non-pregnant women) for 10-14 days
36
What is the prognosis of a UTI?
* Pyelonephritis
- Renal/perinephric abscess (may also be from haematogenous spread)
- Urinary obstruction
- Hydronephrosis
* Recurrent UTI
- Commonly Klebsiella or Proteus mirabilis
* Chronic UTI
- Pyelonephritis
- Prostatitis
- Epididymo-orchitis
- Urethral stricture
* Scarring of urinary tract
- Including kidneys
* Chronic renal failure
Mortality
* Pyelonephritis - in patient 1.7% (M) and 0.7% (F) - most make an uneventful recovery
37
What are the preventative measures/patient education for UTI?
UTI
* Drink >2 L fluid/day
* Void at 2-3 h intervals
* Double voiding before bedtime and after sexual intercourse
* Wipe from front to back after micturation/defecation
Recurrent UTI
* Avoidance of constipation which may impair bladder emptying
* Avoidance of bubble bath or other irritants in bath water
* Abx prophylaxis (trimethoprim/nitrofurantoin continuously/post coital to reduce infection rates in females with recurrent infection
* Cranberry juice/lingo berry juice 200-700ml/day can reduce infection rates by 10/20% as it inhibits adherence of bacteria to uroepithelium - avoid if on warfarin
38
What is acute urinary retention?
* When a person suddenly becomes unable to voluntarily pass urine (over a period of hours)
* Most common urological emergency
39
How common is acute urinary retention?
* Common in men, rare in women
* M:F 13:1
* Mostly occurs in men over 60 years of age and incidence increases with age
* Has been estimated that around 1/3 of men in their 80's will develop acute urinary retention over a 5 year period
40
What are the causes of acute urinary retention?
* In men, acute urinary retention most commonly occurs secondary to benign prostatic hyperplasia - enlarged prostate presses on the urethra which can make the bladder wall thicker and less able to empty
* Other urethral obstructions including urethral strictures, calculi, cystocele, constipation or masses
* Medications such as anticholinergics, tricylic antidepressants, antihistamines, opioids and benzodiazepines
* Less common - neurological cause
* In patients with predisposing causes a UTI can lead to acute urinary retention
* Acute urinary retention often occurs postoperatively and in women post partum - usually secondary to a combination of risk factors
41
What are the presenting features of acute urinary retention?
* Inability to pass urine
* Lower abdominal discomfort
* Considerable pain or distress
42
What are the signs of acute urinary retention?
* Palpable distended urinary bladder either on an abdominal or rectal exam
* Lower abdominal tenderness
* All men and women should have a rectal and neurological examination to assess for the likely causes above
* Women should also have a pelvic examination
43
What investigations are required for acute urinary retention?
* Urine sample which should be sent for urinalysis and culture
* May only be possible after urinary catheterisation
* Serum U and E's and creatinine should also be checked to assess for any kidney injury
* FBC and CRP should be performed to look for infection
* PSA is not appropriate in acute urinary retention as it is typically elevated
44
What is the management of acute urinary retention?
* To diagnose AUR a bladder USS should be performed
* Volume of >300 cc confirms the diagnosis
* AUR is managed by decompressing the bladder via catheterisation
* Catheterisation can be performed in patients with suspected acute urinary retention - volume drained in 15 mins is measured
* Volume of <200 confirms that the patient does not have AUR and a volume over 400 cc means the catheter should be left in place - in between these volumes - depends on the case
45
What is the approach to further investigations for AUR?
* Should target the likely cause
* UTI - treatment of the infection is sufficient and further investigation not necessary
* Men not diagnosed with BPH should be further evaluated by a urologist
* Patients with neurological symptoms should be evaluated by a neurologist and women with gynaecological symptoms by a gynaecologist
* Where no likely cause is identified patients should be evaluated by a urologist for anatomical and urodynamic causes
46
What is the normal/mild raised/moderate and severe range of potassium in the blood?
* Normal - 3.5 - 5 mmol/L
* Mild - 5-6 mmol/L
* Moderate - 6.1-6.9 mmol/L
* Severe >7 mmol/L
* Emergency >6.5 mmol/L or evidence of myocardial hyper-excitability
47
What are the causes of hyperkalaemia?
A WEAKER
* Artefact - haemolysis (difficult venepuncture, patient clenched fist), contamination with K+ EDTA anticoagulant in FBC bottles (do FBC after U and E's), thrombocytopenia (K+ leaks out of platelets during clotting), delayed analysis (K+ leaks out of RBC's), taken from limb infused with IV fluids containing K+
* "Whack" - rhabdomyolysis, trauma, burns, tumour cell necrosis
* Excess K+ therapy - Addisons (or hyperaldosteronism due to NSAID's/ACEi), metabolic acidosis e.g. DKA
* K - K+ sparing diuretics (spironolactone, amiloride), ACEi, suxamthonium, beta-blockers
* Excess blood - massive blood transfusion
* R - Oliguric renal failure
48
What are the ECG findings on a patient with hyperkalaemia?
* Peaked or tall tented T waves (occurs first)
* Loss of P waves
* Broad complex QRS
* Sinusoidal wave pattern
* Ventricular tachycardia
49
What is the approach to the management of a patient with (severe) hyperkalaemia?
* Address precipitating factors - e.g. stop nephrotoxic drugs
* Stabilise the cardiac membrane - IV calcium gluconate (does not lower serum potassium levels)
* Short term shift in potassium from extra-cellular into intra-cellular fluid compartment
- Combined insulin/dextrose infusion
- Nebulised salbutamol
* Removal of potassium from the body
- Calcium resonium (orally or enema)
- Enemas are more effective than oral as potassium is secreted by the rectum
- Loop diuretics
- Dialysis - haemofiltration/haemodialysis should be considered for patients with AKI with persistent hyperkalaemia
50
In terms of hospital care (Leeds Protocol) what is regarded severe hyperkalaemia?
* Potassium K+ = or > 6.5 mmol/L
51
What is the initial management protocol for a patient with severe (K+ > or = 6.5 mmol/L ?
Assessment
* Urgent ECG and cardiac monitoring
* Obtain IV access
* If ECG changes are present treat as severe hyperkalaemia
Management
1) Administer 30ml of 10% calcium gluconate
- IV bolus over 10 minutes
- Repeat every 5 mins if ECG changes are present
- Repeat every 30 mins of K+ still 6.5
* Catheterise if AKI is present
2) Give IV insulin according to bedside capillary blood glucose
- <12 glucose - give 10 units Actrapid in 50 mls of 50% glucose over 10-15 mins
- Followed by 10% glucose infusion (500ml over 12 hrs)
- > or = 12 - give 10 units Actrapid in 50 mls 0.9% sodium chloride over 1--15 mins
- Monitor CBG every 30 mins
- Once blood glucose < 12 give 10% glucose infusion
- Repeat serum potassium (K+) 30 mins after each insulin infusion is completed
3) Consider nebulised salbutamol 10mg stat unless HR >130/min
- 20mg if patient taking regular b-blocker
52
What is the next step after initial management of severe hyperkalaemia (K+ > or = 6.5 mmol/L)?
4) Assess fluid status
- Hypovolaemic - resuscitate with 0.9% sodium chloride
- Euvolaemic - slow IV 0.9% sodium chloride OR sodium bicarbonate 1.26% (e.g. 500mls over 4hrs)
- Hypervolaemic - appropriate diuretic e.g. 100mg IV furosemide
If metabolic acidosis present (HCO3 <16 mmol/L) and ECG changes give sodium bicarbonate 1.26% 250ml over 30 minutes
53
If after the initial treatment for hyperkalaemia the patient develops rebound hyperkalaemia - how should this be managed?
* Peak effect of insulin is after 30 to 60 mins - this may last for 4-6 hrs - rebound may occur after this
* Administer sodium zirconium cyclosilicate in addition to the initial measures
* 10g TDS (orally) for 24-48 hrs
* Monitor potassium regularly and repeat calcium gluconate/IV insulin as above if indicated
* If normokalaemia is not achieved within 48 hrs please discuss with the renal team
54
When should transfer to HDU be considered in a patient with severe hyperkalaemia?
* Hypervolaemia not responding to diuresis
* Hyperkalaemia not responding to initial therapy
* Significant renal failure (AKI or CKD)
55
What is the guidance regarding the long term management of a patient with hyperkalaemia?
* Maintain treatment of the underlying cause of hyperkalaemia as clinically indicated
* All medications which can cause hyperkalaemia should be with-held or stopped
* Oral calcium resonium 15g TDS may be considered in some slow resolving cases and should always be prescribed with lactulose or
* Chronic use of oral sodium ziroconium cyclosilicate is available for limited indications
