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Infectious Diseases > Therapeutics - Urinary Tract Infections > Flashcards

Therapeutics - Urinary Tract Infections Flashcards

1
Q

Why are males more protected than females for UTIs?

A

Males have a significantly longer urethra, so longer distance for bacteria to travel

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2
Q

What are uncomplicated UTIs? Examples?

A

Infections in otherwise healthy women ex.

  • acute cystitis in women
  • acute pyelonephritis in women
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3
Q

What are complicated UTIs? Examples?

A

Infections complicated by other factors ex.

  • infections in men (all)
  • obstruction - Prostatic hypertrophy, anatomical abnormalities, nephrolithiasis, metastatis cancers
  • Neurological abnormalities
  • catheters
  • diabetes
  • Symptoms >7days
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4
Q

What are predisposing factors for women for recurrent UTIs?

A
  • Perineal length <4.5cm
  • Mother with UTIs
  • Sexual activity with a new sexual factor (not in menopausal women)
  • First UTI at 15 years old or younger
  • Diaphragm/spermicide or condom with spermicide
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5
Q

What are not risk factors for UTI?

A
  • BC pills
  • condoms without spermicide
  • postcoital voiding
  • type of underwear
  • personal hygiene after voiding or defecating
  • bath rather than shower
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6
Q

Symptoms of Acute Uncomplicated Cystitis in Women

A
  • Acute dysuria
  • urgency
  • frequency
  • suprapubic pain/tenderness
  • low back pain
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7
Q

What sx have a 90% predictive value for acute cystitis?

A
  • frequency
  • dysuria
  • urgency
  • no vaginal discharge or pain
  • onset of increased incontinence in older women common
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8
Q

What are symptoms of urethritis?

What are common pathogens of urethritis?

What condition group usually accompanies this?

A
  • dysuria
  • urethral discharge
  • vaginal symptoms
  • N. gonorrhoeae
  • C. trachomatis
  • Herpes simplex

-an STI

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9
Q

Pathogens implicated in UTIs

A
  • E. coli
  • S. saprophyticus

Occasionally:

  • Group B Strep (pregnant or diabetic)
  • Enterobactericiae - Proteus mirabilis, Klebsiella
  • Enterococci
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10
Q

What are the bacterial virulence factors that lead to UTIs?

What bacteria may circulate in household members?

A
  • Type 1 mannose sensitive fimbriae which attach to receptors on uroepithelial cells
  • adhesins
  • transport systems allowing growth in urine
  • urease
  • Uropathogenic E.coli may circulate among household members
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11
Q

How does an infection originate?
Why may recurrent UTIs occur so much?
What can facilitate the infection?

A

Uropathogenic E.coli colonize vagina and periurethral region by replacing hydrogen peroxide producing lactobaccilli (which maintain normal acidic environment)

  • E.coli may persist as a resorvoir in vagina
  • Spermicide use facilitates these changes
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12
Q

What lab tests are routinely required for UTIs? Which are not?

What test can test for particular group of bacteria?

A
  • Just a pyuria test - Leukocyte esterase test (>5-10 WBC/HPF)
  • Hematouria occasionally
  • NOT a symptomatic C&S,

-Greiss Nitrate Reduction Test: detects reduction of nitrate to nitrite in urine by G-organisms (false negatives with S. saprophyticus)

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13
Q

What was a recent FDA warning that restricted an abx group in use of uncomplicated URIs?

A

-Fluroquinolones, because they can lead to disabiling and potentially permanent side effects involving tendons, muscles, joins, nerves, CNS

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14
Q

What is a main issue of UTIs in LTCFs and community hospitals?

A

Overuse of TMP/SMX and ciprofloxacin has lead to very high E. coli resistance rates that render both of them not feasible for treatment of UTIs

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15
Q

First line treatment of UTIs in young healthy non-pregnant women in community

A

Nitrofurantoin 50-100 mg qid x5 days (MacroBID: 100mg bid x 5 days)

Fosfomycin 3 g once

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16
Q

When are symptoms expected to resolve with treatment?

A

50% improve within 6 hours
87% by 24 hours
91% by 28 hours

17
Q

What do you do if failure to respond?

How to tell difference between relapse and reinfection and how do you treat each?

A

Failure to response after 48h therapy
-C&S and treat as pyelonephritis

Relapse: <2 weeks after completion of therapy - treat as pyelonephritis
Reinfection (different organism): usually 2-4+ weeks - treat was cystitis

18
Q

What are the criteria for multiple recurrences of UTI?
Should be documented with what?

Prophylaxis for recurrent episodes (3 or more per year)

A

2-3 UTIs/year
Should be documented with C+S at least once

Prophylaxis

Related to intercourse:
Pericoitally
-TMP/SMX i SS
-Nitrofurantoin 50-100 mg po qhs

Not related to intercourse:
-TMP/SMX i SS 3x/week x6 months
OR
-Trimethoprim 100mg qhs x 6 months

19
Q

What are three culture sparing techniques?

A
  1. Office Visits without culture
  2. Telephone Management: women have no hx of complicated UTIs or pyelonephritis
  3. Patient initiated therapy
20
Q

What are criteria for telephone management of UTI?

A
  • Acute onset <7-10 days with at least 1 of dysuria, frequency, urgency or gross hematuria
  • Able to urinate in last 4 h
  • Able to take po
  • NO: flank pain, fever, pregnant, comorbidities, voiding abnormalities, hx of STI or a new sex partner, vaginal symptoms, UTI in past 4-6 weeks, urological procedure
21
Q

What are symptoms of pyelonephritis?

A

Symptoms of LUTI:
Dysuria, frequency, urgency, suprapubic pain, lower back pain

AND/OR

Symptoms of UUTI:

  • CVA pain, flank pain
  • fever, chills, rigours
  • N/V
  • Possibly bacteraemia or septicaemia (urosepsis) if severe
22
Q

How do you diagnose pyelonephritis?

A
  • hx and physical
  • Urinalysis: pyuria, RBCs, WBC casts, significant bacteruria
  • Urine for C+S
23
Q

First line Outpatient Pyelonephritis treatment

A

Initial parenteral dose:
Ceftriaxone 1-2g IV/IM once
OR
Gentamicin 5-7mg/kg IV/IM once

then
Oral therapy:
Cefixime 400mg po daily x10 days
OR
Amoxi-clav 875mg po bid x10 days
OR
Ciprofloxacin 500mg bid or 1 XL daily x7days
OR 
TMP/SMX i DS bid x14 days
24
Q

Pyelonephritis Response to therapy

Risk factors for poor outcome

A

Majority of women will be afebrile by 48-72 hours
If not, needs investigation

  • Hospitalization
  • Resistant organisms
  • Diabetes
  • Hx renal stones
25
Q

Follow-up for pyelonephritis if

  • asymptomatic
  • relapse occurs
A

-Follow-up urine cultures not recommeneded in asymptomatic women

  • If relapse occurs:
  • 2 wk treatment guided by C+S followed by repeat cultures
  • Further relapse: 4-6 weeks Rx guided by C+S
  • Future studies may be warranted for structural abnormalities
26
Q

When should you treat asymptomatic bacteruria?

A

Pregnant women or patients undergoing urologic surgery should be treated

27
Q

Why are pregnant women predisposed to bacteria UTI?

A
  • weight of uterus/baby on bladder means incomplete emptying and reflux into ureters
  • Hormonal changes: dilation of ureters and renal pelvis; decreased peristalsis of ureters; decreased bladder tone; increased incidence of urine reflux
28
Q

Why is bacterial UTI such a concern in pregnant women?

A
  • Symptomatic bacteriuria in 1st trimester predisposes women to get UUTI in 2nd and 3rd trimester
  • Pyelonephritis in third trimester may induce premature labour
29
Q

First line treatment for UTI in Pregnant Women

A 
Nitrofurantoin 50-100 mg qid (MacroBID: 100mg bid) x 7 days
OR
Cephalexin 250-500mg qid x7days
OR
Cefixime 400mg daily x7days
OR
Fosfomycin 3g once
30
Q

When does bacterial prostatitis usually occur for men?
What are symptoms of acute bacterial prostatitis?
Why does chronic prostatitis occur?

A

> 30years
Sx: severe with fever, UTI sx, may be associated with bacteraemia, sepsis
Chronic prostatitis results from relapse due to incomplete eradication or organism in prostate or may be a non-infectious inflammatory syndrome

31
Q

How to treat mild/mod acute prostatitis? Severe?

A

Ciprofloxacin, Ofloxacin, TMP/SMX, Ampicillin+Gentamicin

Pip/tazo

32
Q

What is the evidence for estrogen tx for recurrent UTI in elderly women?

A
  • exogenous estrogen reverses GU mucosal atrophy and restores normal environment in vagina
  • Fewer UTIs only with exogenous and ring estrogen
  • oral estrogen no benefit
33
Q

What is the evidence for cranberry to prevent recurrent UTIs?

A

Prior to Cochrane review, thought to be effective. However, recent reviews show no effectiveness of juice, tablets or capsules.

Infectious Diseases (9 decks)

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