TB and UTIs Flashcards
What factors are necessary for a ≥ 5 mm induration to be positive on a PPD skin test?
- HIV co-infxn
- recent TB contact
- classic x-ray Δ’s
- organ transplant
Treatment for cath-associated UTI?
- D/C or change cath
- Get UA w/ C/S first
- Then 7-14 days of ABX therapy
What should initially be done for acute pyelonephritis?
- UA w/ C/S and Gm stains
- Initiate empiric therapy
- f/u w/ directed therapy on basis of infecting pathogen
What factors are necessary for a ≥ 10mm induration to be positive on a PPD skin test?
- immigration from endemic area w/in 5 yrs
- IVDU
- high-risk congregate setting
- microbio lab workers
- CKD/DM/cancer
What are some common risk factors for developing UTIs?
- Female gender
- ↑ age
- obstruction
- calculi, BPH
- ↓ flow
- Anti-Ach Rx, neuro Dz
- Catheters/Instruments
- Diaphrams
What is the initial Rx therapy for active TB infxn?
Intensive phase (all 4 Rx, no abbrev.)
- rifampin + isoniazid + pyranizamide + ethambutol
- for 2 months
What Sx do we look for when hepatotoxicity is a concern on TB agents?
- anorexia
- fatigue
- jaundice
- scleral icterus
How do we administer the “rif” 1st line TB agents?
- Must take it on an empty stomach (food ↓ absorption)
- take 1 hr before or 2 hrs after meals
What are the risk factors for contracting/communicating TB
- Foreign travel/residence
- Immune weakness
- IVDU
- Close contact
What is a clinical pearl associated with moxifloxacin?
will cover E. coli, Ø concentrated in urine
Why are there a lot of Rx interactions w/ 1st line TB agents, and what are some interaction examples?
- Potent inducer of CYP-450
- oral contraceptives
- anti-retrovirals
- anticonvulsants
Why is latent TB treated w/ Rx therapy?
- to reduced lifetime risk of reactivation from 10% to 1% for non-HIV+ patients
Which asymptomatic patients should you NOT screen for UTI and why?
- Groups Ø to screen:
- DM
- elderly
- spinal cord injuries
- indwelling catheters
- Likelihood of finding MO’s high but risk of complication extremely low
- want to avoid unnecessary treatment
What is a clinical pearl associated with Sulfonamides?
Avoid after 32 wks of pregnancy if possible
What is the treatment for culture positive, pan-susceptible TB during the contiuation phase?
- rifampin + isoniazid for 4 additional mo
- q day, q 5x/wk, or q 3x/wk
What are things that need to be considered when treating UTIs?
- Regional ABX resistance (antibiogram)
- Uncomplicated vs Complicated
- That drugs make it to kidneys
- excretion, urine [Rx], molecular size/protein binding
What are the latent TB infxn treatment options?
- isoniazid 300mg q day for 9 mo
- typically Ø done b/c it’s 9 months
- isoniazid 900mg + rifapentine 900mg q weekly for 3 mo
- most common and DOT
- rifampin q day for 4 mo
- Ø tolerate INH, or…
- exposed to INH resistant TB
What Rx treatment approach is taken for TB relapse?
- six agent minimum for re-treatment
- RIPE + fluoroquinolone + aminoglycoside
- Why is asymptomatic bacteriuria in pregnancy treated differently?
- How is it treated?
- b/c likelihood of developing pyelonephritis with bacteriuria during pregnancy is significantly higher
- treat like symptomatic bacteriuria
What is unique about the SE profile of Ethambutol?
- can cause retrobulbar neurtitis
- least hepatotoxic of 1st line agents
What are the two primary reasons why TB relapse occurs?
- Self admin therapy
- non-rifampin containing regimen
What are the greatest risks for reactivation of TB?
- HIV coinfection
- Infected contact
- Corticosteroid use
- CKD/DM
- Smokers
What is the treatment process for uncomplicated UTI?
- Get a UA
- Get antibiogram
- Treat
- Nitrofurantoin monohydrate
- Trimethoprim-Sulfamethoxazole
- Fosfomycin tromethamine
What is multi-drug resistant TB?
resistant to isoniazid and rifampin
What is a clinical pearl associated with Nitrofurantoin?
Ø concentrates in urine adequately if CrCl <60mL/min
How can hyperuricemia be distinguished from non-gout polyarthralgia w/ pyrazinamide use? What does this mean for SE treatment?
- hyperuricemia typically in one joint, polyarthralgia in many joints
- anti-gout Rx for one and anti-inflammatory Rx for the other
What are the SE of the rifampin 1st line TB agents?
- rash/mild GI discomfort
- discoloration of all bodily fluids
- hepatotoxicity
- pseudomenbranous colitis
What is the purpose of RNA amplification?
- rapid TB detection
- diff btw TB and non-TB mycobacterium
- can detect rifampin-resistant genes
What 3 factors does duration of therapy of the intensive phase depend on?
- culture results
- 6 to 8 wks to finalize
- 90-95% should be neg at 3 mo
- Cavitary dz (abscess)
- Resistance profile
- rifampin resistance or detection of other resistance
Why do we use the TB two-step (TST) process?
- to identify anyone with a booster phenomena and avoid falsely labeling TB conversion (from - to +)
- initial test stim body to react → (+) rxn to subsequent TST
How are severely ill acute pyelonephritis patients treated?
- Go to the hospital
- IV antimicrobal agents for first 48-72 hr then 7 days oral therapy
- Use C/S results to tailor therapy once received
What are the additional symptoms that can help differentiate upper UTI (pyelo) from lower UTI (cystitis)?
- flank pain
- fever, malaise
- N/V
- What initial steps are taken to treat symptomatic abacteriuria?
- What is done if Pt reports recent sexual activity?
- Treat with 3 day course of TMP-SMX
- if ineffective, get culture
- Recent sexual activity possible Chlamydia trachomatis
- Ø see Clap on UA
- Azithromycin 1 gram x 1 day + Doxycycline 100 mg BID x 7 days
How are recurrent UTI infxns treated?
- < 3 episodes/yr
- short course therapy
- ≥ 3 episodes/yr
- suppressive at home/PPX therapy
- TMP-SMX 160mg/800mg PO q day 1/2 DS tab x 6 mo
- Levofloxacin 500 mg PO q day x 6 mo
- Nitrofurantoin 50-100 mg PO q day x 6 mo
- suppressive at home/PPX therapy
- Indefinite cont therapy available if needed
- What two criteria would extend the continuation phase to 7 mo+?
- How many total months would treatment be?
-
Two Criteria
- initial CXR shows cavitary dz
- cultures drawn at 2 mo are positive
- 9 months
What are the general ADRs with isoniazid?
- peripheral neuropathy
- results from ↓ B6
- hepatotoxicity
- hyperglycemia
What are the ADRs associated with pyrazinamide?
- hepatotoxicity
- GI
- hyperuricemia/gout
- non-gout polyartheralgia
What are the different types of cystitis?
- uncomplicated
- complicated
- recurrent
- relapse
- What is asymptomatic bacteriuria defined as?
- What does this typically mean?
- Consecutive UA w/ > 105 CFUs/mL of same organism w/ Ø Sx
- Usually represents COLONIZATION, not infxn
- Can attempt to eradicate once
What 3 different patient presentations occur with UTIs?
- asymptomatic bacteriuria
- technically Ø an infxn
- symptomatic abacteriuria
- symptomatic bacteriuria
How are complicated UTIs treated?
- treat as mild-moderate pyelonephritis
What are the elderly Sx associated with UTIs?
- AMS
- GI symptoms
- Δ eating patterns
What is a clinical pearl associated with Trimethoprim?
Should be avoided in 1st trimester or pregnancy
What are the 3 types of TB?
- Latent TB
- Active pulmonary TB
- Extra-pulmonary TB
What are the Sx of active TB
- fever
- weight loss
- night sweats
- productive cough
- hemoptysis
- fatigue
What is the treatment for chronic bacterial prostatitis?
- Initial Therapy
- TMP-SMX for 4-12 wks
- Quinolone for 4-12 wks
- Suppressive therapy
- 3/wk dosing
- Ciprofloxacin
- TMP-SMX reg str
- Nitrofurantoin 100 mg q day
- 3/wk dosing
What are the Rx, doses, and admin instructions for the 3 Rx’s used to treat uncomplicated UTIs?
- Nitrofurantoin monohydrate 100mg PO BID x 5 days
- Ø if early pyelon is suspected
- Trimethoprim-Sulfamethoxazole 160mg/800mg (DS) PO BID x 3 days
- Ø if resistance > 20%
- Ø if used to treat UTI in last 3 mo
- Fosfomycin tromethamine 3 gram powder PO x once
- ↓ efficacy
- Ø if early pyelo suspected
- What should never be done to a failing TB regimen and why?
- What should be generally done?
- Never add a single Rx to a failing regimen b/c all TB considered resistant
- Always add 2 Rx to a regimen
What is extensively drug-resistant TB?
resistant to isoniazid + rifampin + at least 2 other Rx
What defines a TB regimen failure?
- positive cultures after 4 mo of treatment
- never got negative result
What minimum regimen must HIV+ Pts be on during continuation phase?
≥ 3x/wk or more
What is the UA gold standards for C/S?
- > 105 CFU/mL → reasonably assume infectious
- can still have cystitis w/ < 105 CFU/mL
- just can’t say 100% positive UTI
- can still have cystitis w/ < 105 CFU/mL
What factors make Mycobacterium tuberculosis (MTB) unique?
- aerobic bacilli w/ thick, waxy cell wall
- very slow growing
- > 15 hr generation time
What are important things we should be doing and/or monitoring for while on TB therapies?
- HIV test (if status unknown)
- Pregnancy test
- LFTs
- initial and q month if baseline abnml
- visual acuity if on ethambutol
- initial and q month
- culture results every 2 mo
- positive at 4 mo = failure
What steps are taken if high suspicion of TB but all diag tests are negative?
- Initiate RIPE (must spell out) therapy
- Assess response and culture results at 2 months
Following treatment of highly suspicious TB for 2 months, what criteria is needed to:
- d/c therapy
- cont therapy (how long?)
- neg culture and no change in CXR/clinical picture
- then → d/c therapy
- neg culture and positive response to therapy
- then → cont for 4 additional mo
Why do we treat UTIs?
- Treat symptoms - don’t like Sx and want them to go away
- Don’t want infxn to travel
- to blood → urosepsis
- to kidney → pyelonephritis
What’s the difference btw each of the “rif” 1st line TB agents?
- rifampin = most common in US
- rifabutin = ↓ Rx interactions (common in HIV+ Pts)
- rifapentine = longer DoA (weekly regimens)
What is the first-line rifampin Rx therapy choice for TB?
- rifampin
- rifabutin
- rifapentine
What are some Rx alternatives to uncomplicated UTIs?
- Urinary fluoroquinolones x 3 days
- cipro-, o-, levofloxacin
- ↑ resistance d/t overuse, so need good reason to use
- β-Lactams
- amoxicillin-CA, cefdinir, ceflacor, cefpodoximine x 3-7 days
- used when others can’t
- amoxicillin-CA, cefdinir, ceflacor, cefpodoximine x 3-7 days
- What is the recommended treatment for mild-to-moderate symptomatic acute pyelonephritis?
- What are alternative Rx options?
- Treat as outpatient
- Recommended therapy
- ciprofloxacin 500 mg PO BID x 7 days
- ok if resistance < 10%
- TMP-SMX 160 mg/800 mg BID x 14 days
- ciprofloxacin 500 mg PO BID x 7 days
- Recommended therapy
- Alternative Rx’s = q day
- Ciprofloxacin 1000 mg x 7 days
- Levofloxacin 750 mg x 5 days
Why is the first-line therapy Rx considered 1st line?
Because all other Rx therapies for TB take longer to work
What is the treatment for acute bacterial prostatitis?
- Oral
- TMP-SMX or quinolones for 4-6 wks
- IV
- rarely needed
- IV → PO
- if afebrile for 48hr, or
- after 3-5 days of IV ABX
What are some additional clues to help validate a UA sample?
- Non-specific findings:
- pyuria, hematuria, proteinuria
- Specific findings:
- nitrite from Gm (-) organisms
- leukocyte esterase (WBCs present)
What are the Sx we are monitoring for when looking for hepatoxicity?
- jaundice
- scleral icterus
- ABD pain
- nausea
- fatigue
- ↓ appetite (mentioned in lecture)
- What LFT results would lead to d/c’ing therapy?
- How is therapy then restarted?
- D/C all agents if LFTs
- >5x ULN or
- >3x ULN w/ Sx
- then restart agents one at a time
- rifampin +/- ethambutol 1st
- add isoniazid if LFTs remain nml x1 wk
What steps are taken to distinguish btw active vs latent TB?
- good history
- CXR
- 3 AFB smears/cultures taken ≥ 8 hrs apart
- RNA amplification and C/S
