TBI 2 Flashcards
Extrinsic or intrinsic mechanical or functional defects
Hydroureter and hydronephrosis
UTO
What to see in Ultrasound in UTO?
postvoid urine
What to see in Voiding cystourethrogram in UTO?
incomplete emptying and bladder neck and urethral pathology
- Flank pain due to the distention of he collecting system or renal capsule
- Pain severity influenced by rate at which distention develops
- Renal colic - supravesical, excruciating and intermittent
- Flank pain with micturition - pathognomonic for VUR
- Obstruction in flow results in an increased int he hydrostatic pressure PROXIMAL to site of obstruction
- Azotemia develops then overall excretory function is impaired
- Always considered in those with UTO or urolithiasis
UTO
Assess UTO
- History of difficulty in voiding, pain, infection or change in urinary volume
- U/S - evaluate renal and bladder size and pelvocalyceal contour (90% specific and sensitive in detecting hydronephrosis)
- Hydronephrosis may be absent on U/S when obstruction is <48 hours or associated with volume contraction, stag horn calculi, retroperitoneal fibrosis or infiltrative renal
disease - CT scan - define site of obstruction, ID and characterize stones, demonstrate dilatation of calyces/pelvis/ureter
- Retrograde or antegrade urography - lesion in ureter or renal pelvis
- complicated by infection - immediate relief of obstruction to prevent sepsis and progressive renal damage
- Elective - urinary retention, recurrent UTI, persistent pain, progressive loss of renal function
- After 8 weeks - recovery is unlikely
- POST OBSTRUCTIVE DIURESIS
+ Relief of bilateral obstruction result tp polyuria
+ Hypotonic urine and natriuresisdue inpart to the correction of ECV expansion increased natriuretic factors and depressed salt and water reabsorption
+ Replace with 0.45%saline
- 2 consecutive voided urnine with isolation of same bacterial strain >100,00cfu/mi
- In men - single clean catch voided specimen
- Screening an dtreatment recommended in those who will undergo genitourinary mania; ation or instrumentation and ALL pregnant women to prevent bacteremia and sepsis
- Culture based treatment for 7 days
UTI
Drugs to treat UTI in Pregnancy
- Cefalexin 500 mg BID
- Cefuroxime 500 ng BID 7 days
- Fosfomycin 3 g single dose.
- Coamoxiclav 625 mg BID x 7 days
- Nitrofurantoin 100 mg QID for 7days.
- Cotrimoxazole 160/800 mg BID x 7 days
RECURRENT UTIIN WOMEN:
Heathy non pregnant
no urinary tract abnormalities with 3 or more episodes of acute uncomplicated cystitis documented by urine culture in 1 year or 2 or more episodes in a 6 month period
RECURRENT UTIIN WOMEN: screening
- no response to appropriate therapy or rapid relapse after therapy
- gross hematuria during UTI or persistent microscopic hematuria,
- obstructive symptoms
- clinical impression of persistent infection,
- infections with urea splitting bacteria,
- history of pyelonephritis,
-history of or symptoms suggestive of urolithiasis, - history of childhood
UTI - elevated crea
All women with recurrent UTI should undergo
- complete history and PE.
-Post void urine should be measured
may be done to screen for urologic abnormalities in recurrent UTI in women
Renal U/S or CT sonogram
frequent of recurrence is not acceptable in terms of level of discomfort or interference with activities of daily living
Prophylaxis
UTI RECURRENT UTIIN WOMEN
post defecation and anal cleansing anterioposteriorly in
women, post coital douche or urination, liberal fluid intake esp after intercourse, avoid tight fitting underwear, alternative form of contraception
Behavioral measures (prevention)
UTI BIOLOGIC MEDIATORS
- Cranberry products - not recommended
+ Daily dose for prevt 300 mi cocktail or 500 mg cap BID
+ Option for those needing long term antibiotic prophylaxis - Probiotic lactobacilli - not recommended
- Hormonal treatments
+ Post menopausal - intravaginal estriol nightly for 2 weeks followed by 2x/week for 8 months OR estradiol releasing silicone vaginal ring for 3 months
Imunoprophylaxis (immune active E coli fractions) in UTI
- recommended; once daily for 3 months
- Longer regimen - OD for 3 months, rest 3 months, 10 days per month for 3 months and rest for 3 months (weak recomendation with moderate quality of evidence)
Prophylaxis UTI
- Continuous prophylaxis -
- Post coital prophylaxis -
- Intermittent -
- Continuous prophylaxis - daily intake of low dose antibiotic for 6-12 months OR
- Post coital prophylaxis - single dose antibiotic innmediately after contact OR
- Intermittent - self treatment with a single antibiotic dose based on need (weak)
Any of the antibiotics for acute uncomplicated cystitis may be used for treatment of individual episodes of UTI
Primary nitrofurantoin 100 mg QID x 5 days and fosfomycin 3 g single dose PO
Breakthrough infections during prophylaxis should be treated empirically with any of the antibiotics recommended for __ OTHER THAN the antibiotic being given for prophylaxis. Order urine C/S and modify treatment accordingly.
uncomplicated cystitis
There is evidence to recommend acupuncture for prevention of recurrent UTI among women when
ANTIBIOTIC PROPHYLAXIS IS CONTRAINDICATED
NO available evidence to recommend ___ in the prevention or treatment of UTI
- coconut juice
- ORAL WATER HYDRATION
- drinking more water and voiding before and after intercourse
significant bacteriuria + clinical symptoms in the setting of functional or anatomic abnormalities in the GUT, presence of underlying disease that interferes with host defense mechanisms and any condition that increases risk of acquiring infection and/or treatment failure
cUTI
ALWAYS obtained BEFORE inititiation of treatment
C/S
imaging for anatomic and structural abnormalities are
suspected (pyelonephritis not responding to treatment, severe PN in high risk groups like DM, recurrent UTI in men )
Ancillary tests
preferred over KUB U/S
CT
- Marked debility and signs of sepsis
- Uncertainty in diagnosis
- Concern about adherence to treatment
- Unable to maintain oral hydration to take oral meds
Hospitalization required
broad spectrum antibiotics and choice would depend on the expected pathogen, results of the gram stain, current susceptibility patterns in the area and risk factors for acquisition of drug resistance
Severely ill
not recommended as empiric choice for severely ill patients due to high rates of resistance locally
FQ
In general, give meds in complicated UTI for
7-14 day
Criteria for OPAT (outpatient parenteral antibiotic therapy)
- Indication for parenteral use in the absence of oral or alternate routes of delivery
- No other clinical indication for hospitalization
- Consent of the patient and/or caregiver to participate (understand benefits, risk economic considerations)
- Safe outpatient environment and adequate to support care
Urine culture should be repeated in complicated UTI
1-2 weeks after completion of antibiotics
