Therapeutics - Urinary Tract Infections Flashcards
Why are males more protected than females for UTIs?
Males have a significantly longer urethra, so longer distance for bacteria to travel
What are uncomplicated UTIs? Examples?
Infections in otherwise healthy women ex.
- acute cystitis in women
- acute pyelonephritis in women
What are complicated UTIs? Examples?
Infections complicated by other factors ex.
- infections in men (all)
- obstruction - Prostatic hypertrophy, anatomical abnormalities, nephrolithiasis, metastatis cancers
- Neurological abnormalities
- catheters
- diabetes
- Symptoms >7days
What are predisposing factors for women for recurrent UTIs?
- 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
What are not risk factors for UTI?
- BC pills
- condoms without spermicide
- postcoital voiding
- type of underwear
- personal hygiene after voiding or defecating
- bath rather than shower
Symptoms of Acute Uncomplicated Cystitis in Women
- Acute dysuria
- urgency
- frequency
- suprapubic pain/tenderness
- low back pain
What sx have a 90% predictive value for acute cystitis?
- frequency
- dysuria
- urgency
- no vaginal discharge or pain
- onset of increased incontinence in older women common
What are symptoms of urethritis?
What are common pathogens of urethritis?
What condition group usually accompanies this?
- dysuria
- urethral discharge
- vaginal symptoms
- N. gonorrhoeae
- C. trachomatis
- Herpes simplex
-an STI
Pathogens implicated in UTIs
- E. coli
- S. saprophyticus
Occasionally:
- Group B Strep (pregnant or diabetic)
- Enterobactericiae - Proteus mirabilis, Klebsiella
- Enterococci
What are the bacterial virulence factors that lead to UTIs?
What bacteria may circulate in household members?
- 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
How does an infection originate?
Why may recurrent UTIs occur so much?
What can facilitate the infection?
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
What lab tests are routinely required for UTIs? Which are not?
What test can test for particular group of bacteria?
- 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)
What was a recent FDA warning that restricted an abx group in use of uncomplicated URIs?
-Fluroquinolones, because they can lead to disabiling and potentially permanent side effects involving tendons, muscles, joins, nerves, CNS
What is a main issue of UTIs in LTCFs and community hospitals?
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
First line treatment of UTIs in young healthy non-pregnant women in community
Nitrofurantoin 50-100 mg qid x5 days (MacroBID: 100mg bid x 5 days)
Fosfomycin 3 g once
When are symptoms expected to resolve with treatment?
50% improve within 6 hours
87% by 24 hours
91% by 28 hours
What do you do if failure to respond?
How to tell difference between relapse and reinfection and how do you treat each?
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
What are the criteria for multiple recurrences of UTI?
Should be documented with what?
Prophylaxis for recurrent episodes (3 or more per year)
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
What are three culture sparing techniques?
- Office Visits without culture
- Telephone Management: women have no hx of complicated UTIs or pyelonephritis
- Patient initiated therapy
What are criteria for telephone management of UTI?
- 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
What are symptoms of pyelonephritis?
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
How do you diagnose pyelonephritis?
- hx and physical
- Urinalysis: pyuria, RBCs, WBC casts, significant bacteruria
- Urine for C+S
First line Outpatient Pyelonephritis treatment
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
Pyelonephritis Response to therapy
Risk factors for poor outcome
Majority of women will be afebrile by 48-72 hours
If not, needs investigation
- Hospitalization
- Resistant organisms
- Diabetes
- Hx renal stones
Follow-up for pyelonephritis if
- asymptomatic
- relapse occurs
-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
When should you treat asymptomatic bacteruria?
Pregnant women or patients undergoing urologic surgery should be treated
Why are pregnant women predisposed to bacteria UTI?
- 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
Why is bacterial UTI such a concern in pregnant women?
- Symptomatic bacteriuria in 1st trimester predisposes women to get UUTI in 2nd and 3rd trimester
- Pyelonephritis in third trimester may induce premature labour
First line treatment for UTI in Pregnant Women
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
When does bacterial prostatitis usually occur for men?
What are symptoms of acute bacterial prostatitis?
Why does chronic prostatitis occur?
> 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
How to treat mild/mod acute prostatitis? Severe?
Ciprofloxacin, Ofloxacin, TMP/SMX, Ampicillin+Gentamicin
Pip/tazo
What is the evidence for estrogen tx for recurrent UTI in elderly women?
- exogenous estrogen reverses GU mucosal atrophy and restores normal environment in vagina
- Fewer UTIs only with exogenous and ring estrogen
- oral estrogen no benefit
What is the evidence for cranberry to prevent recurrent UTIs?
Prior to Cochrane review, thought to be effective. However, recent reviews show no effectiveness of juice, tablets or capsules.
