Urinary Infections Flashcards
Define a urinary tract infection
An infection to any part of your urinary tract (kidneys, ureter, bladder, urethra).
This is bacteriuria + SYMPTOMS
What is the difference between asymptomatic bacteriuria and a UTI?
Absence of bacterial growth or white cells on a Mid Stream Urine dip is very unlikely to be a UTI.
Bacteriuria is >105 colony forming units/ml on an MSU
How does (the above card) this change management?
You do NOT treat asymptomatic bacteriuria unless:
1) patient is pregnant (risk of preterm labour)
2) prior to urological surgery
Treatment could replace low virulence organisms with something worse.
Uses, contraindications and side-effects of Trimethoprim
Use = 3 days oral for uncomplicated UTI, 7-10 days in complicated
Contra = cannot be used in 1st trimester of preg
Side effects = Diarrhoea, electrolyte imbalance, fungal overgrowth, headache, nausea
Use, contraindications and side-effects of nitrofurantoin
Use = 3 days oral for uncomplicated UTI, 7 days in complicated
Contra = only active in urine so useless in pyelonephritis, not effective in renal failure, cannot use in 1st trimester of pregnancy
Side effects = diarrhoea, nausea, etc
How do you treat Multi-Drug Resistant Gram Negative Organisms? (MGNO)
Trimethoprim/nitrofurantoin if sensitive.
Or Oral fosfomycin.
IV meropenem
Describe some non-antibiotic based strategies for managing recurrent UTIs in women
General:
- exclude structural causes with USS and cystoscopy
- advise fluid intake
- avoid synthetic pants, perfumed soaps, baths
- wiping education?
Recurrent:
- topical oestrogens if post menopausal (best evidence)
- cranberry capsules or D-Mannose
- Methenamine hippurate
What is the clinical presentation of pyelonephritis
usually unilateral flank pain tender on palpation
systemic symptoms like nausea or fever
usually young females due to an ascending UTI
Management:
- oral ciprofloxacin or augmentin for 7-10 days
- if no better then USS to exclude obstruction
- antibiotics
How do you differentiate pyelonephritis from pyonephrosis
in pyonephrosis it is an infected obstructed kidney which must therefore be drained and decompressed first.
What is the difference between acute prostatitis and chronic prostatitis
Acute = rare. patients are unwell and hospitalised on IV antibiotics
Chronic = syndrome of pelvic/perineal pain +/- urinary/sexual dysfunction in men. Referred to as Chronic Pelvic Pain Syndrome (CPPS) due to uncertain aetiology.
What is the clinical presentation of epididymo-orchitis
Acute infection of testis/epididymis.
testicular pain, gross swelling, very tender, red, systemic symptoms eg. fever.
What is the clinical presentation of testicular torsion
commonly sudden onset severe unilateral scrotal pain followed by inguinal/scrotal swelling.
Sometimes also nausea, vomitting.
How do you differentiate epididymo-orchitis from testicular torsion
Torsion occurs mostly in <40 year olds, orchitis doesnt.
Torsion is rapid onset, orchitis isnt.
On examination, high-lying laterally oriented testis suggests torsion.
What is management when testicular torsion is suspected?
- emergency scrotal exploration
- reduction and orchidopexy of torted testis if viable (if non viable then orchidectomy)
- Orchidopexy of contra-latearl testis
What are some common bacterial causes of epididymo-orchitis?
Younger men = chlamydia
Older men = Coliforms
Sometimes viral (mumps) or drug induced (amiodarone) orchitis seen but not common.
What are the principles of treatment of epididymo-orchitis?
- first void urine for Chlamydial PCR
- Mid stream urine
- USS to exclude abscess or tumour
- Oral ciprofloxacin (+ doxazosin in younger men)
- iv antibiotics if septic/ unwell
- 10-14 day course of antibiotics
(doxycycline for STI causes or ciprofloxacin for E.Coli causes)
Describe some antibiotic based strategies for managing recurrent UTIs in women
post coital single dose of antibacterial meds
self start = start antibacterials at first sign of symptoms
low dose continuous prophylaxis (double edged sword = resistance)
What is pyonephrosis?
When pus collects in the renal pelvis, usually results from urinary tract obstruction in the presence of pyelonephritis.
Causes distension of the kidney.
Treat with percutaneous nephrostomy drainage and antibiotics
What is pyelonephritis
Inflammation of the kidney parenchyma and the renal pelvis, usually due to bacterial infection
What are some common infective organisms in a UTI/pyelonephritis?
- Escherichia coli
- Coliform bacteria
- Proteus (associated with staghorn calculi)
- Enterococcus faecalis, Staph aureus, Pseudomonas (catheters)
What are some risk factors for developing pyelonephritis?
Factors that reduce antegrade flow of urine
eg. obstructed urinary tract or spinal cord injury resulting in a neuropathic bladder
Factors promoting retrograde ascent of bacteria
eg. female gender (short urethra), indwelling catheter/ureteric stents/nephrostomy tubes in-situ, structural renal abnormalities
Factors predisposing infection
eg. immunocompromise, DM, HIV, corticosteroids
Factors promoting bacterial colonisation
eg. sex, oestrogen depletion, renal calculi
How would UTI present?
- freq, urgency, dysuria
- haematuria sometimes
- systemic symptoms like fever, nausea
- Leukocytes/nitrates on dip
How would pyelonephritis present?
Triad of fever, unilateral loin pain, nausea/vomiting
May have co-existing LUTS
eg. freq, urgency, dysuria, haematuria
Costovertebral angle tenderness on exam, pyrexia, features of sepsis
What is an important differential to rule out when presenting with back pain, tachycardia and hypotension? What else could it be?
Ruptured AAA
Could also be renal calculi, acute cholecystitis, ectopic pregnancy, PID, diverticulitis, etc.
What investigations would you do for pyelonephritis?
Urinalysis = nitrites and leucocytes, beta hCG
send urine culture if infection
Routine bloods = FBC, CRP (inflammation), U&Es
Renal US scan for evidence of obstruction
Non-contrast CT imaging of renal tract (CTKUB)
How would you manage pyelonephritis?
ABCDE = resuscitation
empirical antibiotics based on local guidelines
IV fluids
analgesia and anti-emetics
CT imaging to check for pyonephrosis or perinephric abscess
