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Renal and Urological Pathology > MI: Urinary Tract Infection > Flashcards

MI: Urinary Tract Infection Flashcards

1
Q

In which situation is asymptomatic bacteriuria clinically significant?

A

Pregnancy - associated with increased risk of complications

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2
Q

What is the difference between uncomplicated and complicated UTI?

A
  • Uncomplicated - infection in a structurally and neurologically normal urinary tract
  • Complicated - infection in a urinary tract with functional or structural abnormalities (includes indwelling catheters and calculi)
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3
Q

In which groups of patients are UTIs considered ‘complicated’?

A
  • Men
  • Pregnant women
  • Children (may have structural abnormality)
  • Hospitalised patients
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4
Q

Which organism most commonly causes UTI?

A

E. coli

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5
Q

List some other organisms that cause UTI.

A
  • Staphylococcus saprophyticus - UTI young healthy women - probably 2nd after E. coli
  • Staphylococcus epidermidis - can cause infection in the presence of prosthesis (e.g. procedures, indwelling catheters)
  • Proteus mirabilis - struvite kidney stones
  • Klebsiella aerogenes
  • Enterococcus faecalis
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6
Q

Which virulence factor allows E. coli to stick to the urinary tract epithelium?

A

P fimbriae

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7
Q

List some antibacterial host defences in the urinary tract.

A
  • Urine (osmolality, pH, organic acids)
  • Urine flow and micturition
  • Urinary tract mucosa (bactericidal activity, cytokines)
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8
Q

What is an ascending UTI?

A

Infection of the lower urinary tract may pass up the ureters into the renal pelvis and parenchyma

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9
Q

List some causes of urinary tract obstruction.

A

Extra-renal

  • Valves, stenosis or bands
  • Calculi
  • BPH
  • External ureter compression (gravid uterus, tumour)

Intra-renal

  • Nephrocalcinosis
  • Nephropathy (uric acid, analgesic, hypokalaemic)
  • Polycystic kidney disease

Neurogenic malfunction

  • Poliomyelitis
  • Tabes dorsalis (demyelinating condition caused by advanced syphilis)
  • Diabetic neuropathy
  • Spinal cord injuries
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10
Q

What is vesicoureteric reflux?

A
  • A condition in which urine can reflux into the ureters
  • It results in a residual pool of infected urine in the bladder after voiding
  • It can result in scarring of the kidneys
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11
Q

Describe how UTI can become established via the haematogenous route.

A

The kidney is a frequent site for abscesses in patients with S. aureus bacteraemia or endocarditis (not really a UTI)

NOTE: Gram negative bacilli like E. coli rarely spreads via the haematogenous route

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12
Q

Outline the symptoms of UTI in:

  1. Neonates and children < 2 years
  2. Children > 2 years
A

Neonates and children < 2 years: (non-specific)

  • Failure to thrive
  • Vomiting
  • Fever

Children > 2 years: (more localised)

  • Frequency
  • Dysuria
  • Abdominal or flank pain
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13
Q

List some symptoms of lower UTI

A
  • Bladder and urethral mucosal irriation - frequent and painful urination
  • Suprapubic pain
  • Haematuria
  • Absence of fever (most of the time)
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14
Q

List some symptoms of upper UTI.

A
  • Fever (and rigors)
  • Flank pain
  • Lower urinary tract symptoms (frequency, urgency, dysuria)
  • At times LUTS preceed the onset of fever and upper tract symptoms
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15
Q

Describe the symptoms of UTI in older patients.

A
  • Mostly asymptomatic
  • Atypical symptoms (e.g. confusion, abdominal pain)

NOTE: classic symptoms such as frequency and dysuria are common in older people and does not necessarily suggest that there is an infection

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16
Q

Would you do a urine dip in suspected UTI in >65 year old and why?

A

No - dipsticks become unreliable in ages >65 due to the increased likelihood of asymptomatic bacturia (which is not harmful)

17
Q

List some investigations for uncomplicated UTI.

A
  • Urine dipstick
  • MSU for urine MC&S
  • Bloods - FBC, CRP, U&E
18
Q

List some further investigations that may be considered in complicated UTIs.

A
  • Renal ultrasound scan
  • IV urography
19
Q

What are nitrites in the urine specific for?

A

They are produced by E. coli

20
Q

What does nitrite-negative leukocyte-positive urine suggest?

A

UTI caused by non-coliform bacteria

21
Q

List some patient groups in whom culture and sensitivities should be performed.

A
  • Pregnancy
  • Children
  • Pyelonephritis
  • Men
  • Catheteristed
  • Failed antibiotic treatment
  • Abnormalities of the genitourinary tract
  • Renal impairment
22
Q

What does the presence of white cell in the urine (pyuria) suggest?

A

Infection

23
Q

What does the presence of sqaumous epithelial cells in the urine suggest?

A

Contamination

24
Q

What is the microbiological definition of UTI?

A

Culture of single organisms >10^5 colony forming units/mL with urinary symptoms

NOTE: this threshold may be reduced for organisms that are known to cause UTI (e.g. E. coli and S. saprophyticus)

25
Q

What number of white cells in the urine represents inflammation of the urinary tract?

A

More than 10^4/mL

26
Q

In which patient groups should screening of the urine for white cells for MC&S NOT be performed?

A

Immunocompromised patients, pregnant women and children

27
Q

List some causes of sterile pyuria (white cells in urine but no culture growth).

A
  • Prior antibiotic treament (MOST COMMON)
  • STIs (e.g. chlamydia)
  • TB
  • Calculi
  • Catheterisation
  • Bladder cancer
28
Q

What type of agar is used for urine culture? What do the colours suggest?

A

Chromogenic agar

  • Pink = E. coli
  • Blue = other coliforms
  • Light blue = Gram-positives
29
Q

List some methods of sampling urine for investigations.

A
  • MSU
  • Catheterisation
  • Suprapubic aspiration (usually in young children)
30
Q

What type of therapy may be needed for patients with UTIs caused by ESBL producing organisms?

A

Outpatient parenteral antibiotic therapy (OPAT)

(ESBL - Extended-spectrum beta-lactamases)

31
Q

Outline the treatment options for:

  1. Uncomplicated UTI in women
  2. UTI in pregnant or breastfeeding women
  3. UTI in men
  4. Pyelonephritis or systemically unwell with a UTI
  5. Catheter-associated UTI
A
  1. Uncomplicated UTI in women
    • Cefalexin 500 mg BD PO for 3 days OR
    • Nitrofurantoin 50 mg POQ QDS for 3 days (check renal function)
  2. UTI in pregnant or breastfeeding women
    • Cefalexin 500 mg BD PO for 7 days
    • 2nd line: co-amoxiclav 625 mg TDS PO for 7 days
  3. UTI in men
    • Cefalexin 500 mg BD PO for 7 days OR
    • Ciprofloxacin 500 mg BD PO for 14 days if suspicion of prostatitis
    • Chronic prostatitis: ciprofloxacin 500 mg BD PO for 4-6 weeks
  4. Pyelonephritis or systemically unwell with a UTI
    • Co-amoxiclav 1.2 g IV TDS
    • Consider adding IV amikacin or gentamicin
    • Penicillin allergy: ciprofloxacin 400 mg IV BD
  5. Catheter-associated UTI
    • Remove catheter (but give stat doses before removal of infected catheter)
    • Gentamicin 80 mg STAT IV/IM 30-60 mins before procedure
      OR
    • Amikacin 140 mg STAT IV/IM 30-60 mins before procedure
32
Q

In which groups of patients is a short course (3-days) of antibiotics not appropriate?

A
  • Women with a history of UTI caused by antibiotic resistant organisms
  • More than 7 days of symptoms
  • Men

i.e. any complex UTI - short course only appropriate for women with uncomplicated UTI

33
Q

In which patients do Candida UTIs tend to occur?

A

Patients with indwelling catheters

34
Q

How should Candida infections due to catheters be treated?

A

Remove the catheter
There is no evidence of oral fluconazole being better than no intervention

35
Q

In which exceptional cases should Candida UTI be actively treated?

A
  • Renal transplant patients
  • Patients waiting to undergo elective urinary tract surgery
36
Q

Which part of the kidney is more susceptible to infection?

A

Renal medulla

37
Q

What is the main treatment option for pylenephritis?

A

IV co-amoxiclav with or without gentamicin

38
Q

Why might imaging be included in the diagnostic workup for pyelonephritis?

A

To see whether there are any structural abnormalities or calculi

39
Q

List some complications of pyelonephritis.

A
  • Perinephric abscess
  • Chronic pyelonephritis - leads to scarring and chronic renal impairment
  • Septic shock
  • Acute papillary necrosis

Renal and Urological Pathology (8 decks)

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