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Urinary System > Urinary Tract Infection > Flashcards

Urinary Tract Infection Flashcards

1
Q

Name infection of kidney

A

Acute or chronic pyelonephritis

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2
Q

Name infection of the bladder

A

Cystitis

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3
Q

Name infection of the urethra

A

Urethritis

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4
Q

Name infection of prostate

A

Prostatitis

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5
Q

Name infection of the epididymis/Testis

A

Epididymo-orchitis

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6
Q

What are the two classifications of UTIs?

A
  • Uncomplicated: normal renal structure + function

* Complicated: structural/functional abnormality of urinary tract

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7
Q

What are general predisposing factors which makes an individual more susceptible to UTI (or other infection)?

A
  • Immunosuppression
  • Steroids
  • Malnutrition
  • Diabetes
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8
Q

What are predisposing factors specific to the urinary tract?

A
  • Female sex (short urethra)
  • Sexual intercourse and poor voiding habits
  • Congenital abnormalities e.g. duplex kidney, PUJ obstruction
  • Stasis of urine e.g. due to poor bladder emptying
  • Foreign bodies eg catheters, stones
  • Oestrogen deficiency in postmenopausal women
  • Fistula between bladder & bowel
  • Renal cysts
  • Pre-existing renal parenchymal damage (i.e. recurrent pyelonephritis)
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9
Q

What is acute pyelonephritis?

A

Infection of upper urinary tract involving the kidneys/renal pelvis

• Commonly women of child bearing age

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10
Q

What is chronic phyelonephritis?

A

Pathological condition with renal scarring and potentially loss of renal function. Infection may be a contributory cause but the term does not necessarily imply ongoing infection. Other factors which may contribute include diabetes, vesico-ureteric reflux and urinary obstruction

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11
Q

What are the common causative organisms?

A

Usually anaerobes and gram-negative bacteria from bowel and vaginal flora.

  • E coli (commonest)
  • Proteus
  • Klebsiella
  • Enterococcus
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12
Q

What is sterile pyuria?

A

Urine is negative on culture but significant numbers of pus cells are present.

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13
Q

Describe different routes for bacteria to enter the urinary tract (usually sterile)

A

Transurethral:
• Periurethral area contaminated (recurrent UTI, diaphragms)
• Urethra to bladder (intercourse, catheterisation)
• Bladder (and u ureters)

  • Blood stream
  • Lymphatics
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14
Q

What are general clinical features for UTIs in children?

A 
Diarrhoea	
Excessive crying
Fever
Nausea and vomiting
Not eating
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15
Q

What are general clinical features for UTIs in adults ?

A 
Flank pain
Dysuria
Cloudy offensive urine
Urgency
Chills
Strangury
Confusion (very old people)
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16
Q

What is strangury?

A

Condition caused by blockage or irritation at the base of the bladder, resulting in severe pain and a strong desire to urinate.

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17
Q

What are the clinical features of acute pyelonephritis?

A 
Pyrexia
Poor localisation
Loin tenderness (renal angle)
Signs of dehydration
Turbid urine (cloudy)
Vomiting

In severe cases, bacteria spreads to blood stream -> bacteraemia causing sepsis:
• Rigors
• N+V

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18
Q

What are the clinical features of cystitis?

A 
Frequency 
Dysuria 
Urgency 
Suprapubic pain 
Polyuria (large volume)
Haematuria
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19
Q

What investigations are carried out for women?

A

• Mid-stream sample of urine.
• Dipstick: Blood, leucocytes, protein and
nitrites

Microbiology In lab:
• Microscopy and Gram staining
• Bacteruria >105 CFU /ml
• Culture and sensitivity

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20
Q

What is the typical presentation of acute cystitis or lower tract infection in adult women?

A 
Variable combinations of:
• Dysuria 
• Frequency 
• Urgency 
• Suprapubic 
• Polyuria 
• Haematuria
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21
Q

What is the management for a women with mild or only 2 symptoms?

A

MSU

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22
Q

What is the management for a women with >= 3 symptoms of cystitis and no vaginal discharge?

A

Treat empirically* with no further test, usually 3 days.

*Therapy begun on the basis of a clinical “educated guess”

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23
Q

What can contaminate MSU and how are samples made sterile?

A

Urine contaminated by urethral contents (from vaginal/labial organisms moving up)

  • Take midstream sample
  • Wash/swab with sterile saline in advance
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24
Q

What is tested for in dipstick urinalysis?

A
  • Nitrate (metabolic product of bacteria)
  • Protein (shouldn’t be in urine - inflammation and renal pathology indicated)
  • Leucocytes (marker of inflammatory response)
25
Q

Is cloudy urine indicative of UTI is women?

A

Makes it unlikely to be UTI

26
Q

Describe dipstick results of a UTI

A

If all 3 are negative, it’s unlikely that Pt has UTI.

If all three positive -> empirical therapy

• Positive leucocytes esterase doesn’t diagnose of exclude, need to carry out urine culture. Same if protein just positive.

27
Q

In men, why do UTIs increase with age?

A

Secondary to obstruction cause by prostatic hypertrophy

28
Q

What condition is recurrent UTIs in men a presenting feature of?

A

Prostatitis

29
Q

What is the causative bacteria of prostatitis in men?

A
  • Coliform organisms in older patients

* In younger males, sexually transmitted organisms; chlamydia trachomatis and Neisseria gonorrhoea

30
Q

What investigations should be carried out for children, men or frequent UTIs?

A
  • USS or IVU

* Isotope studies to rule out reflux and scarring

31
Q

What are the principles of management?

A
  1. Identify organisms and start treatment

2. Identify predisposing factors and treat if possible

32
Q

What is the management of acute pyelonephritis?

A
  • Urine culture
  • Blood culture is systemically unwell
  • Immediate antibiotic treatment, more aggressive over 7 days
  • Recurrent episode investigated for calculi etc.
33
Q

What is the management of catheter-related infection?

A

Long-term catheters mean bacteria will be present, does not mean they have a UTI, so no indication for urine culture or treatment if no symptoms or signs of UTI

Culture and antibiotics if Pt symptomatic and has signs of infection, and catheter should be changed prior to any treatment.

34
Q

Do you treat asymptomatic bacteria?

A

No

Unless they’re pregnant or undergoing urological surgery or surgery involving implantation of artificial prosthesis

35
Q

What is the effect of asymptomatic bacteria in pregnancy?

A

Increases risk of pyelonephritis and premature delivery

So common to screen with MSU culture and treating those wit significant bacteria

36
Q

What are causes of sterile pyuria?

A
  • Renal tuberculosis
  • Chlamydia trachomatis in the sexually active
  • Non-infective; stone, interstitial cystitis, malignancy, chronic prostatitis etc (causes recurrent sterile pyuria)
37
Q

What is the investigation of suspicion of renal tuberculosis (cause of sterile pyuria)?

A

Three early morning urine samples for a ZN stain and TB culture

38
Q

Why is it important to identify children with vesicle-ureteric reflux?

A

Can lead to renal scarring in later life

• So need to follow up and treat UTI in children

39
Q

What is the clinical presentation of chronic pyelonephritis?

A
  • Vague abdominal discomfort
  • Hypertension
  • Sterile urine, but contains pus cells
  • IVP changes; clubbing of calyces with scarring or cordial parenchyma
  • If ureters dilated -> carry out micturating cystogram to detect VU reflux
40
Q

What are the features of uncomplicated UTIs?

A
  • Health, sexually active young women
  • E coli or skin commensals (staph. aprophyticus)
  • No extra investigations
41
Q

What are the features of complicated UTIs?

A

• Any UTI in children, men, patients with abnormal renal tract (PUJ obstruction), immunosuppression, foreign body in renal tract (catheter), bladder tumour, chronic urinary retention and abnormal bladder outflow tract (urethral stricture)

Investigations including:
• USS or CT of upper renal tract
• Cystoscopy and post-vois bladder scan
• Urinary flow studies

42
Q

In what circumstances should cultures be undertaken?

A
  • Women < 2 symptoms
  • Men
  • Suspected acute pyelonephritis
  • Pregnancy or screening
  • Failed antibiotic treatment or persistency
  • Recurrent UTI (> 2 with 6 months or 3 in a year)
  • Children
43
Q

Where should catheter specimens be taken from?

A

Sampling port, not collection bag

44
Q

What is an alternative method to MSU if there is a delay in specimens reach lab?

A

Dipslide:
Plastic holder coated in agar which is dipped into urine immediately after collection. Organisms in urine are inoculated on agar and will grow in quantities proportional to their collections.

45
Q

How are MSU samples stored before delivery to labs?

A

?Refrigerated or collected in containers with boric acid to prevent bacterial overgrowth

46
Q

How are urine samples collected in children?

A

Clean catch sample
• If not possible, use urine collection pads
• If non-invasive methods not possible, use a catheter smoke or suprapubic aspiration

47
Q

What is the process of urine cultures?

A

Measured amount of urine plated out and number of colonies which grow is proportional to number of organisms in the original sample (organisms/ml)

48
Q

What are the causative organisms of UTIs?

A 
Ecoli 
Proteus 
Enterococcus faecalis 
Klebsiella 
Pseudomonas 
Staph. Saprophyticus
49
Q

Describe E coli

A

Most common cause of UTI and strain have specialised projections call P fimbriae which are adherent to eruepithelium (more likely to cause upper urinary infection (pyelonephritis))

50
Q

Describe Staph. Saprophyticus

A

Coagulase negative staph which causes UTI particularly in sexually active women

51
Q

Describe proteus

A

Produces enzyme urease which splits urea to release ammonia, making urine alkaline and encouraging stone formation

52
Q

Describe Enterococcus faecalis, Klebsiella and Pseudomonas spp.

A

Often found in hospital patients, associated with catheters or instrumentation of urinary tract.

More antibiotic resistant (pseud.) and associated with stone formation (proteus or kleb.) so should always investigation upper renal tract imaging

53
Q

What is the use of microscopy for investigations?

A

Determine whether or not there are cells, casts or organisms present
• >10 WBC/mm3 in uncentrifuged urine -> significant pyuria

54
Q

What is the treatment for lower UTI in non-pregnant women (simple cystitis)?

A

Use antibiotics not used for treatment of other serious infections (prevent resistant bacteria)
• Trimethoprim 3 days
• Nitrofurantoin

55
Q

What is the treatment for lower UTI in men?

A

Longer antibiotic cours; 14 days quinolone (i.e. ciprofloxacin) to cover possibility to prostatitis

7 days of nitro. or trimethoprim is infection appears uncomplicated.

56
Q

What is the treatment for acute pyelonephritis?

A

7 days ciprofloxacin

Reviewed after results of urine cultures and sensitivity tests known

Resolution checked by urine sample 1-2 weeks after cessation of antibiotic therapy

57
Q

What treatment should be used in pregnant women?

A

Nitrofurantoin safe but can cause neonatal haemolysis if used at term

Cephalexin safe but should be guided by sensitivities

58
Q

What is the management of recurrent infections?

A
  • Drink plenty fluids
  • Empty bladder after sexual intercourse
  • Personal hygiene
  • Gynaecological exam and IVP
  • Long term prophylaxis: one tablet of trimethoprim or nitro. per night up to 1 year
  • For recurrent uncomplicated UTI, prophylactic antibiotic immediately after intercourse

Urinary System (31 decks)

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