Renal infections

Question 1

Cystitis vs urethritis

Answer 1

Cystitis

• inflammation of the bladder
• **can be infection or generalized inflammation causes
• also presents with frequency and urgency as well as possible suprapubic pain

Urethritis

• inflammation of the urethra
• **strongly consider with younger males with dysuria
• often STI caused (chlamydia/gonorrhea)

both present with dysuria

Question 2

What symptoms are needed to make a diagnosis of a UTI?

Answer 2

Pyuria (presence of white blood cell)

Bacteriuria (presence of bacteria in urine)

Symptoms of infections (fever, sniffles, headache)
- is atypical in elderly or spinal cord injury

Question 3

Dipstick analysis for UTI

Answer 3

Leukocyte esterase
- breakdown of active WBCs

Nitrites

• present when bacteria reduce dietary nitrates
• ***enterobacteriaceae is the most affecting agent showing these

Blood trace on dipstick

• *microscopy looks for WBC/RBC hpf
• pyuria = 10 or > wbc/hfp

need the triad of blood, nitrates and leukocyte esterase on dipstick

Question 4

What types of UTIs are seen in immunocompromised patients, but almost never in normal immune systems?

Answer 4

Gonorrhea, trichomonas, chlamydia

Question 5

What two species of bacteria that produce UTIs dont show leukocyte esterase on dipstick?

Answer 5

Enterobacteriacae
- will show nitrates but no leukocyte esterase

Staphylococcus saprophyticus
- wont show either nitrates or leukocyte esterase

Question 6

What is the classic number of CFUs/mL in order to 100% diagnosis someone with a UTI?

Answer 6

10^5 CFUs/mL

this is starting to drop down to 10^3, but the classic teaching is 10^5

Question 7

Why are male patients almost always complicated UTIs?

Answer 7

Because they hardly ever get them due to longer urethra

Question 8

What types of patients require cultures?

Answer 8

Pretty much everyone who doesnt present with a simple uncomplicated UTI and is symptomatic
- children, men and pregnant women are automatically complicated UTIs

Question 9

How does one make the diagnosis of asymptomatic bacteria?

Answer 9

Is a normal appearing person that lacks typical signs and symptoms of UTI’s
- especially no fever or vomiting

However urinary dipstick shows signs of infection and culture will come back positive with >10^5 with some organism

• lack of treatment does NOT lead to injury to the patient, as compared to pyelonephritis*
• therefore, we DONT treat patients with this as long as they are asymptomatic and are not pregnant!!

if patient is pregnant or the patient is undergoing urologic procedures and can likely bleed, must still treat since it can affect the child

Question 10

What are long term complications of untreated UTI

Answer 10

Renal scarring and GFR dysfunction

HTN (sometimes malignant)

Septic shock

Question 11

Why is it important to ask patients who present with UTI symptoms if they have recently been using antibiotics?

Answer 11

If they say yes, it likely is a resistant organisms you are dealing with

Question 12

Classic presentation of a UTI

Answer 12

A female who presents with:

• Dysuria
• Frequency
• Urgency of urination without vaginal symptoms

even higher chance if they state they have history of UTI/STD in the past

if the patient has all the above, especially the no-vaginal symptoms, then acute lower UTI = 90%

Question 13

First line therapies for uncomplicated UTI and cystitis

Answer 13

Nitrofurantoin (NO in pregnancy)

TMP-SMX (OK in pregnancy outside of the 3rd trimester)

Fosfomycin

Cephalosporins (3rd gen ceftriaxone/cefotaxime or 4th gen cefepime)

second line = fluroquinolones

you don’t need imagining/cultures to diagnosis this and start treatment if the they have the classic triad of symptoms

Question 14

What is 1st line in VRE?

Answer 14

Carbapenems needed to be added

- ertapenem

Question 15

What is added to cover MRSA infections

Answer 15

Vancomycin

Question 16

When should you expect urinary tract infection obstruction with a UTI

Answer 16

If a patient is on appropriate antibiotics and they are not getting better (in fact often get worse)

Question 17

When do you need to consider prostitis with a UTI?

Answer 17

Males who present with febrile UTIs

- requires 4-6 weeks of SMX-TMP or fluroquinolones

Question 18

What is required to diagnosis sepsis?

Answer 18

SIRS criteria (need 2 of the 4) + infection = sepsis 
SIRS criteria:
- temperature > 38.0 C
- heart rate > 90 bpm 
- Respiratory rate > 20 breaths
- WBC > 12,000 

Treatment = start IV fluids. If it doesn’t solve hypotension, then start vasopressors (usually NE 1st)

Question 19

Multiple organ dysfunction syndrome

Answer 19

Progressive organ dysfunction in acutely ill patients
- can be caused by infectious or non-infectious diseases

• *will show multiple organ systems failing which are seen bellow with the respective lab abnormalities
• hematologic = low platelet count/INR
• liver = bilirubin high
• brain = low GCS and AMS
• renal = low creatinine and urine output
• cardiovascular = low blood pressure and height heart rate
• respiratory = oxygen requirements
• cellular metabolism = high lactate

Question 20

What is the #1 compounding risk factor in males that present with febrile UTIs?

Answer 20

Prostatitis

• almost always shows this (90%)
• needs 4-6 weeks of treatment