Urinary Tract Infection Flashcards
infection that recurs with a different organism
reinfection
infection where organism persists in the urinary tract despite antimicrobial therapy, same organism
relapse
interleukin involved in UTI
IL8 (pyruria) IL6 (severity of infection, fever)
symptomatic men, cut of in urine culture
10^3
in and out catheter
10^2
more active in acidic urine
penicillin, tetracycline, nitrofurantoin
more active in alkakine urine
aminoglycosides, fluoroquinolones, erythromycin
antibiotic penetrate poorly in the prostate gland because of
no active antibx transport mechanism
antibx that penetrate in the prostate well and remain active
fluoroquinolones and macrolides
cause of cystitis
e. coli
in cystitits, infection occurs via the
ascending route
The pathogenesis of UTI begins with colonization of the vaginal introitus or urethral meatus by uropathogens from the fecal flora, followed by ascension via the urethra into the bladder. Pyelonephritis develops when pathogens ascend to the kidneys via the ureters.
second most frequent isolate and virtually unique to acute cystitis
S. saprophyticus
major risk factor for recurrent cystitis in women of any age
infection at a younger age
stongest association of recurrent acute cystitis in postmenopausal women
history of prior UTI
urine culture in cystitis should be obtained when
- clinical presentation not characteristic
- failure to respond to appropriate empiracal antimicrobial therapy
- early symptomatic recurrence after therapy
mainstay of empirical treatment of acute cystitis
TMP/SMX (3 days)
recommended for women who experience more than 2 episodes in 6 months of UTI
low dose prophylactic antimicrobial therapy
only feasible behavioral intervention for recurrent infection
avoid spermicide use
strongest association to pyelonephritis in premenopausal women
recent sexual intercourse
independent risk factor for pyelonephritis
diabetes
imaging in pyelonephritis is required for
severe symptoms or treatment failure or early post treatment recurrence
initial imaging modality for pyelonephritis
ultrasonography
optimal diagnostic imaging for acute pyelonephritis
contrast enhanced CT
indications for hospitalization
pregnancy, unstable, compliance with oral, medical illness
preferred empirical regimen for pregnant women
ceftriaxone
clinical response after initiation of therapy
48-72 hours
recommended empirical antimicrobial
ciprofloxacin or levofloxacin
duration of treatment pyelonephritis
10-14 days
alternate microbial therapy for pregnant women when cephalosporin cannot be used
gentamicin
risk factors of a poor outcome for pyelonephritis
hospitalization, isolation of a resistant organism, DM, renal stones
major determinant of infection
host impairment
encrusted cystitis or pyelonephritis caused by
corynebacterium urealyticum
urease producing bacterium causing cystitis or pyelonephritis with urolithiasis
u. urealyticum
symptomatic UTI + repeatedly negative urine culture
fastidious organism
alkaline pH + pyuria + negative urine culture
urease producing organism
most frequent isolate in men older than 65
cons
E coli
enterococcus
screening and tx of asymptomatic bacteriuria
pregnant women and traumatic genitourinary tract procedure
when to screen pregnant for asymptomatic bacteriuria
end of 1st trimester
recommended regimen for asymptomatic bacteriuria in pregnant
5 or 7 day course of nitrofurantoid, 7 day course of amox, co-amox or cephalosporin
Urine CS should be done after treatment
monthly
urologic emergency with systemic manifestations
acute bacterial prostatitis
management of acute bacterial prostatitis
- drainage of a urethral or suprapubic catheter
- antibx
first line therapy for acute bacterial prostatitis
- B lactam + aminoglycoside
- FQ 6 weeks
if no clinical response (acute prostatitis)
CT or MRI and transrectal UTZ guided aspiration
diagnosis for chronic bacterial prostatitis
paired culture of midstream + post prostatic massage urine specimens
most common isolates for chronic bacterial prostatitis
enterbacteriacease and p. aeruginosa
first line for susceptible organisms in chronic bacterial prostatitis
ciprofloxacin and levofloxacin
second line drugs for chronic bacterial prostatitis and preferred for gram + infections
doxycycline and macrolides
chronic pelvic pain syndrome + negative culture
4 week trial of antimicrobial
prophylaxis for the 1st 6 months after transplant for UTI
TMP/SMX
occupy the retroperitoneal fat and fascia around the kidney
perinephric abscess
most likely originated with hematogenous spread
s. aureus
preferred imaging modality for abscesses
CT
Cut off size of abscess that responds to antibx without drainage
5 cm
most effective in localizing infected cyst
PET with deoxyglucose F18
optimal duration recommended for infected renal cysts
4 weeks of (cotri, chloramphenicol, quinolones, levox)
acute necrotizing infections characterized by gas formation
emphysematous cystitis and pyelonephritis
most common isolates in emphysematous cystitis
E. coli and K. pneumonia
optimal imaging technique for emphysematous cystitis
CT
destruction and replacement of the renal parenchyma by granulomatous tissue containing histocytes and foamy cells
xanthogranulomatous pyelonephritis
vesicle empyema, purulent fluid collection in a nonfunctioning bladder
pyocystis
early finding in GUTB
erosions of renal calyx, papillary necorsis, hydronephrosis, cavitation
thickened ureteric wall and strictures (distal 3rd)
ureteric TB
reduced bladder volume with wall thickening, ulceration and filling defects
bladder TB
most common finding on CT
renal calcification
diagnosis of GUTB
growth of M. TB in urine or tissue culture
tx for GUTB
HRZE x 2 months then HR 4 months
when is nephrectomy indicated in GITB
intractable pain, untreatable infection proximal to a stricture, uncontrollable hematuria or hypertension or drug resistance
first line treatment for superficial bladder tumors and carcinoma in situ
intravesical vaccine instillation of BCG
bcg bladder instillation followed by local irritative symptoms > 48 hours
BCG infection
treatment of BCG infection
isoniazid for 14 days
when to tx asymptomatic candiduria
neutropenia or before a traumatic urologic procedure
most common fungi growth
candida albicans
treatment of chocie for candida UTI
fluconazole 200-400 mg od x 2 weeks
alternative tx for resistant strains (c. glabrata)
amphotericin 0.3 to 0.6 mkd for 7 days-2 weeks
indicated for treatment of canida uti as a single agent
5-flucytosine
most common viral cause of uti
adenovirus, parvovrus B1, CMV
most common and important parasitic infestation of the urinary tract
schistosoma hematobium
functional abnormality early in the disease of parasitic infestation
obstruction of the bladder neck
risk factor for SCCA of the bladder
s. hematobium infection
thickening of the bladder wall, granulomatous changes, hydronephrosis, bladder or ureteric calcification
s. hematobium
time of maximal egg passage when urine specimen should be collected
1100-1300H
diagnosis of parasitic infections
identification of parasite eggs in the urine or biopsy
treatment of s. hematobium
one dose of praziquantel 40 mk
follow up urine specimen for parasite examination should be done
after 3 months
commonly transmitted sexually
t. vaginalis
tx for t. vaginalis
metronidazole single dose 2 g or tinidazole 2 g
incidental finding of a cyst in the kidneys, ureters, bladder or testes
echinococcus granulosus infestation
recommended for patients with hyatid disease
peioperative albendazole therapy
CS specimen
- clean catch voided specimen with no periurethral cleaning
- transport immediately if not refrigerate 4C
- short term cath: puncture port
- long term cath: replace
major adhesions for ecoli
Type 1 Film H and P fim
found in cystitis, superficial infection
IgA
most frequently isolated organism among premenopausal women causing acute cystitis
e coli
most common post menopausal
K. pneumonia
time dependent antibx
B lactam
Concentration dependent
FQ, aminoglycoside
necessary characteristic for bladder infection
FimH
False positive nitrites
blood urobilunogen dyes
false negative nitrite
non nitrate bacteria or short dwell time
for esbl organisms
carbapenems
marker for bacteremia, not predict outcome
procal
Associated with prolonged hospitalization and post discharge recurrence
crp
most impt rf for fungal uti
In dwelling cath/uro device
broad spectrum antibb
dm
tx for fungus balls
Surgery
remove devices when possible
Tx for cmv uti
Ganciclovir or foscarnet
tx for adenocirus
cidofovor vidarabine ganci rinbavirin
adverse effect of nitrofurantoin
peripheral neuropathy
major risk factor in home care
functional impairment
most common organisms in stones
p. mirabilis
most common lesion location of gi tb
distal 3rd ureter
prostatitis syndrome class I
acute bacterial prostatitis
class 2 prostate
chronic bacterial prostatitis
Class III
chronic pelvic pain syndrome
Class IIIa
inflammatory cpps
leukocytes in semen, in urine after prostate massage or in expressed prostate secretions
Class IIIb
noninflammatory cpps
absence of leukocytes in specimens
Class IV
Asymptomatic inflammatory prostatitis, leukocytes with no symptoms
multiple bilateral and cortical abscesses cause
hematogenous route
risk factors for abscesses
dm, aki, wbc >20k
tx for emphysematous pyelo
percutaneous aspiration or open drainage vs partial nephrectomy
tx for xanthogranulomatoys pyelo
Nephrectomy
Cause of xanthogranulomatous pyelo
P. mirabilis, e coli
histiocytes and foamt cells
xanthogranulomatous pyeloneph
chyluria and lymphatic obstruction
filiarisis, w. bancroftu
hyatid cyst in the kub
echinococcus
tx for hyatid cyst
surgery
cintilografia renal estatica DMSA
avalia a função tubular e a estrutura anatômica do córtex renal. É um método confiável e acurado para o diagnóstico e acompanhamento de cicatrizes renais.
Cintilografia Renal Estática (DMSA)
avalia a função tubular e a estrutura anatômica do córtex renal. É um método confiável e acurado para o diagnóstico e acompanhamento de cicatrizes renais.
Acute simple cystitis*
Acute UTI that is presumed to be confined to the bladder
There are no signs or symptoms that suggest an upper tract or systemic infection (refer to below)
Acute complicated UTIAcute UTI accompanied by signs or symptoms that suggest extension of infection beyond the bladder:
Fever (>99.9°F/37.7°C)¶
Chills, rigors, significant fatigue or malaise beyond baseline, or other features of systemic illness
Flank pain
Costovertebral angle tenderness
Pelvic or perineal pain in men
Special populations with unique management considerations
Pregnant women
Renal transplant recipients
We categorize UTI as either acute simple cystitis or acute complicated UTI based on the extent and severity of infection. This categorization informs management and differs somewhat from other conventions. Specifically, cystitis or pyelonephritis in a nonpregnant premenopausal woman without underlying urologic abnormalities has traditionally been termed acute uncomplicated UTI, and complicated UTI has been defined, for the purposes of treatment trials, as cystitis or pyelonephritis in a patient with underlying urologic abnormalities or other significant comorbidities. Individuals who do not fit into either category have often been treated as having a complicated UTI by default. Rather than use this convention, we favor an approach to treatment based on the presumed extent of infection and severity of illness. Patients categorized as having acute uncomplicated cystitis according to traditional definitions would fall under the category of acute simple cystitis that we use here.
What are independent risk factors for early urinary tract infections in renal transplants?
- Female Gender
- Prolonged use of foley
- Stent use
- Older age
- Delayed Graft function.
tto cistite
Duration 3 days therapy is as effective as 5-10 days treatmentFirst Line Antibiotics1. Trimethoprim 200 mg bd or cotrimoxazole 960 mg bd(Nice Guidelines)Longer course 7-10 days therapy1. Nitrofurantoin 100 mg bd (not in renal impairment)Second line drugs 1. Fluoroquinolones such as ciprofloxacin 500 mg bd or levofloxacin250 mg bd2. Fosfomycin 3 g single dose
(Avoid ampicillin not effective in eradicating vaginal and periuretheral colonization)
•
Encourage Fluid intake>2 L/da
E Coli77%56%69%
Proteus
4%6%3%
Klebsiella sp4%7%9%
Enterococcus4%9%6%
Pseudomonas2%4%-
S Saprophyticus
4%–
Staph aureus
-2.5%-
catheter-associated bacteriuria as follows
Symptomatic bacteriuria (urinary tract infection [UTI]) – Culture growth of ≥103 colony forming units (cfu)/mL of uropathogenic bacteria in the presence of symptoms or signs compatible with UTI without other identifiable source in a patient with indwelling urethral, indwelling suprapubic, or intermittent catheterization. Compatible symptoms include fever, suprapubic or costovertebral angle tenderness, and otherwise unexplained systemic symptoms such as altered mental status, hypotension, or evidence of a systemic inflammatory response syndrome.
●Asymptomatic bacteriuria – Culture growth of ≥105 cfu/mL of uropathogenic bacteria in the absence of symptoms compatible with UTI in a patient with indwelling urethral, indwelling suprapubic, or intermittent catheterization.
Patients who are no longer catheterized but had urethral, suprapubic, or condom catheters within the past 48 hours are also considered to have catheter-associated UTI or asymptomatic bacteriuria if they meet these definitions.
Because periurethral contamination is less likely in catheterized specimens, a relatively low threshold for bacteria growth in a symptomatic patient is likely to represent true bladder bacteriuria. Although the IDSA guidelines acknowledge that growth as low as 102 cfu/mL has been associated with bladder bacteriuria in the setting of symptoms, the threshold of 103 cfu/mL was chosen since many labs do not quantify growth below that threshold.
itu cateter
The duration of catheterization is an important risk factor for catheter-associated bacteriuria and UTI and is a major target of prevention efforts [11,12]. (See ‘Prevention’ below.)
Other risk factors include [13-15]:
●Female sex
●Older age
●Diabetes mellitus
●Bacterial colonization of the drainage bag
●Errors in catheter care (eg, errors in sterile technique, not maintaining a closed drainage system, etc.)
pathologia itu cateter
Urinary tract infection (UTI) associated with catheterization may be extraluminal or intraluminal. Extraluminal infection occurs via entry of bacteria into the bladder along the biofilm that forms around the catheter in the urethra [16-19]. Intraluminal infection occurs due to urinary stasis because of drainage failure, or due to contamination of the urine collection bag with subsequent ascending infection. Extraluminal is more common than intraluminal infection (66 versus 34 percent in one study) [20].
Rarely, there can be purple discoloration of the urine, collecting bag, and tubing (the purple urine bag syndrome) [21]. The purple color of the urine is due to metabolic products of biochemical reactions formed by bacterial enzymes in the urine. Gastrointestinal tract flora break down the amino acid tryptophan into indole, which is subsequently absorbed into the portal circulation and converted into indoxyl sulfate. Indoxyl sulfate is then excreted into the urine, where it can be broken down into indoxyl if the appropriate alkaline environment and bacterial enzymes (indoxyl sulfatase and indoxyl phosphatase) are present. The breakdown products, indigo and indirubin, appear blue and red, respectively [22,23]. Bacteria capable of producing these enzymes include Providencia spp, Klebsiella, and Proteus.
