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PT > Urinary Tract Infections > Flashcards

Urinary Tract Infections Flashcards

1
Q

what is considered an upper UTI?

A

Pyelonephritis (kidneys)

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2
Q

what is considered an lower UTI?

A

Cystitis (bladder)

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3
Q

when does UTI become prevalent? and what is the reason?

A

with age (more in elderly)

more reasons for retention/obstruction of urine
e.g. BPH in males. and urine incontinence

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4
Q

which route of infection is more common

A

ascending

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5
Q

who is at more risk for an ascending infection?

A

females (shorter urethra, contraceptives (spermicides, diaphragms)

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6
Q

the organisms we can culture if its a ascending infection?

A

Enterobacteriaceae family: E coli, Klebsiella, Proteus

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7
Q

how does one get a descending infection?

A

organism at distant primary site (such as heart valve, bone) –> bloodstream infection (bacteremia) –> urinary tract –> UTI

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8
Q

organisms that can cause descending infection

A

usually non-gut bacteria: S.aureus, Myco TB

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9
Q

factors that determine the development of UTI

A
  1. Host defense mechanism
    - -> bacteria stimulates micturition, increasing diuresis –> emptying bladder

–> anti-bacterial properties of urine and prostate

–> anti-adherence mechanism of bladder; mucosa prevent bacterial attachment

–> inflammatory reponse w polymorphonuclear leukocytes (PMN) –> phagocytosis

  1. Size of inoculum
    - -> increases with greater obstruction/ urinary retention
  2. Virulence/Pathogenicity of microoganism
    - -> bacteria w pili (E coli) adhere to the bladder wall and does not easily washed off
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10
Q

Risk factors of UTI

A

. F > M
. Sexual intercourse
. contraceptives (diaphragms and spermicides)
. abnormalities of the urinary tract (BPH, kidney stones, urethral strictures, vesicourethral reflux)
[ PH and urethral strictures are structural abnormalities ]

. neurologic dysfunction: stroke, diabetes, spinal cord injuries

. diabetes (sugar urine)

. anti-cholinergic drugs or SE of drugs

.pregnancy

. cathether

.genetic association (fam Hx)

. prev UTI

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11
Q

how to prevent UTI

A

. lots of fluid (if can tolerate, no other health condition)
. urinate freq
. urinate after sex
. F: wipe from front to back
. keep area dry; wear cotton
. avoid using diaphragm/spermicide, unlubricated condoms and spermicidal condoms increase irritation and allow bacteria to grow

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12
Q

differences in complicated vs uncomplicated UTI

A

complicated: in men, children, preg woman
- -> complicating factors: functional and structural abnormalities of UT, genitourinary instrumentation, DM, immunocompromised host
- -> increase potential of serious outcomes, risk of therapy failure

  • -> urine culture and urinalysis NEEDED
  • -> MDR common

vs

uncomplicated UTI

  • -> pre-menopausal, non-preg woman with no hx suggestive of abnormal UT
  • -> usually dont need urine analysis/ culture (need for pyelonephritis)
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13
Q

what has to be done to confirm an UTI infection?

A

a. risk factors
b. subjective
c. objective
d. possible site of infection

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14
Q

what are subjective things for lower TI (cystitis), upper TI (pyelonephritis)?

A

cystitis: dysuria, urgency, frequency, nocturia, suprapubic heaviness or pain, gross hematuria (blood in urine
pyelonephritis: fever, headache, N/V, renal punch (costovertebral tenderness), flank pain, abdominal pain, malaise, rigors

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15
Q

what are objective things we can do for UTI?

A

(a) UFEME
- -> WBC >10/mm3: pyuria; indicates present of inflammation but may or may not be due to infection; in sx patients, pyuria correlates with bacteriuria (but if no pyuria means unlikely UTI)

–> RBC (>5 HPF or gross) = hematuria
non-specific; could be due to other things

  • -> microorganism (identify bacteria or yeast via gram stain)
  • -> WBC cast: mass of cells formed in renal tubules (kidney) = indicates upper tract infection

(b) urine analysis (dipstick)
nitrate (10^5/ml): converts into nitrite in gram -ve bacteria (false -ve if + gram bacteria or P.aeruginosa, low urine pH, frequent voiding, dilute urine)

esterase: +ve test means esterase activity of leukocytes in urine
correlates with pyruia (>10 WBC/mm3)

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16
Q

when to take a urine culture

A

no need for uncomplicated UTI

take culture only when:
all male UTI
catheter-assoc UTI
preg women
recurrent UTI (within 2 wks or frequent)
pyelonephritis
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17
Q

most likely microorganisms for community-acquired/uncomplicated UTI (tell the % as well)

A

(a) e coli (85%)
(b) enterococcus faecalis, klebsiella, proteus
(c) stap saprophyticus (5-15%)

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18
Q

how to collect urine for analysis and culture (3 methods)

A

(a) mid stream clean catch (to prevent collecting colonisers)
(b) catherization (ensure new one is used)
(c) suprapubic bladder aspiration

19
Q

most likely microorganisms for hospital-acquired/complicated UTI (tell the % as well)

A

(a) e coli (50%)
(b) enterobacter, kelbsiella, proteus
(c) enterococci
(d) P.aeruginosa

20
Q

what are the healthcare-associated risk factors

A

(1) hospitalization in the last 90 days
(2) current hospitalization for >= 2 days
(3) residence in nursing home
(4) antimicrobial use in last 90 days
(5) home infusion therapy

21
Q

what could be other microorganisms that are not part of UTI infections?

A

stap aureus: causing bacteremia, consider other site of infections

yeast: consider other sides of infections to confirm yeast is the one causing the infection and not just being a coloniser/ could be a possible contaminant as well

22
Q

when do we treat UTI?

A

not to treat for asymptomatic UTI unless
(1) preg: prevent preterm labour and low weight of infant, risk of getting pyelonephritis is higher

(2) invasive urological trauma to mucosa (TURP, cystoscopy with biopsy): prophylaxis to prevent risk of bacteremia; obtain culture and start therapy 12-24h before procedure

23
Q

first line empiric therapy for community-acquired/uncomplicated cystitis in women?

A

(1) Co-TS: 800/160mg bid x 3days
(2) NF 50mg qid x5 days
(3) fosfomycin 3g single dose

24
Q

alternative empiric therapy for community-acquired/uncomplicated cystitis in women?

A

B lactams (3-7 days):

  • cefuroxime 250mg BD
  • cephalexin 500mg BD
  • augmentin 625mg BD

Fluoroquinolones (3 days):

  • ciprofloxacin 250mg BD
  • levofloxacin 250mg daily
25
Q

empiric therapy for complicated cystitis for women

A

treat longer:
Co-TS for 7 days
B lactams for 10-14 days
fosfomycin 3g EOD x 3 doses

26
Q

empiric therapy for uncomplicated/community-acquired pyelonephritis for women

A
    • ciprofloxacin 500mg BD x 7 days
    • levofloxacin 750mg daily x 5 days
  2. Co-TS 800/160mg BD x 14 days
  3. B lactams (10-14 days)
    cephalexin 500mg BD
    Augmentin 625mg TDS
27
Q

therapy for ill patients requiring hospitalisation or unable to take oral drug for uncomplicated/community-acquired pyelonephritis for women

A

IV ciprofloxacin 400mg BD or IV cefazolin 1g 8h or IV augmentin 1.2g q8h and/or IV gentamicin 5mg/kg

switch to oral when patient can take orally

28
Q

protocol for community-acquired UTI for men (cystitis and pyelonephritis)

A
  1. if no indication for prostatitis, and cystitis = regimen same as complicated cystitis in women (longer duration of treatment)
  2. if have indication for prostatitis or pyelonephritis:
    (a) ciprofloxacin 500mg BD
    (b) Co-TS 800/160mg BD
    (and treat for 10-14 days, if got prostatitis confirmed, treat for 6 weeks)
29
Q

definition of nosocomial/healthcare associated pyelonephritis?

A

Nosocomial: onset of UTI >48hours post admission

Healthcare-associated: hospitalisation or underwent invasive urological procedures in last 6 mths

30
Q

empiric therapy for nosocomial/healthcare associated pyelonephritis?

A
  1. IV imipenem 500mg q6h or IV meropenem 1g q8h
  2. IV cefepime 2g q 12h +/- IV amikacin 15mg/kg (1 dose)
  3. levofloxacin 750mg or ciprofloxacin 500mg BD
  4. Co-TS 960mg BD

treatment for all is 7-14 days
(consider 3 or 4 PO for less sick patients; those that can take orally)

31
Q

what are the bacteria encountered in empiric therapy for nosocomial/healthcare associated pyelonephritis?

A

ESBL Ecoli/Kleb/Proteus and P.aeruginosa

thus empiric therapy must be broad-spectrum

32
Q

what is the definition of catheter-associated UTI?

A

presence of sx or signs compatible with UTI with no other identified source of infection;

have 10^3cfu/ml with >= 1 bacterial species in a catheter urine specimen in patient with:

indwelling urethral or suprapubic or intermittent catheter, or mid stream void urine specimen from a patient who had a catheter removed within the previous 48 hours

33
Q

risk factors for CA-UTI?

A
  1. duration of catheterization
  2. colonization of drainage bag, catheter and periureteral segment
  3. DM
  4. female
  5. renal function impairment
  6. poor quality of catheter care, including insertion
34
Q

what are the causative organisms for short or long term catheterization?

A

for short term (<7 days): 85% is a single organism

long term (>28 days): 95% is polymicrobial (2-3 organisms)

35
Q

what is the MM like for CA UTI

A

low risk/unlikely

<10% are febrile episodes, thus symptomatic infection is uncommon

36
Q

what can we do to treat CA UTI (first consideration even before Abx therapy)

A

we can remove the catheter; if a catheter is placed for >2 weeks and its still indicated, catheter has to be replaced to quickly resolve sx and prevent CA-bacteriuria/CA-UTI

37
Q

empiric therapy for CA-UTI

A
  1. IV imipenem 500mg q6h or IV meropenem 1g q8h
  2. IV cefepime 2g q12h +/- IV amikacin 15mg/kg (1 dose)
  3. PO/IV levofloxacin 750mg x 5 days (for mild CA-UTI)
  4. Co-TS 960mg BD x 3 days (for women =< 65yo, and no upper urinary tract sx after indwelling catheter has been removed)

therapy is for 7 days in those with prompt resolution (deferverse/afebrile) within 72hours and 10-14 days for those with delayed response

38
Q

what can we do to prevent CA-UTI?

A
  1. avoid unnecessary catheter use
  2. minimal duration
  3. need to change long-term catheter before a blockage happens
  4. use a closed system
  5. aseptic insertion technique
  6. Prophylactic abx not recommended
  7. topical antiseptic or abx not recommended
  8. chronic suppressive therapy not recommended
39
Q

what is the most common nosocomial UTI?

A

CA-UTI

40
Q

Abx choices for UTI in pregnancy

A
  1. Avoid:
    - FQ: anthropathy
    - Co-TS: first term = defect in neural tubes due to folate antagonism; last term = kernicterus (displace bilirubin into blood); and also G6PD deficiency
  • Nitrofurantoin: G6PD deficiency
  • AGs: 8th cranial nerve toxicity (seen in older gen but careful with new gen)

Safe in preg:
- B lactams (first line treatment)

Treatment:
7 days for asymptomatic bacteriuria or cystitis
14 days for pyelonephritis

41
Q

adjunctive therapy for UTI?

A
  1. pain and fever: paracetamol or NSAIDS
2. urinary symptoms 
for dysuria (pain while urination): phenazopyridine (urogesic): use until dysuria stops, topical analgesic effect, cannot use in G6PD deficiency
ADR: N/V, orange discoloration of urine and stool

or

urine alkalization: to relief discomfort in mild uti

42
Q

other non-antimicrobial options for UTI prevention

A

. cranberry juice: prevent e coli from adhering to UT epithelial cells

. intravaginal estrogen cream: decrease UTI incidence in PMS women; restore normal vaginal flora and protect against e coli colonization

. lactobacillus probiotics: intravaginal lactobacillus reduced recurrence of uncomplicated cystitis, restore normal vaginal flora and protect against e coli colonization

43
Q

Monitoring parameters for UTI

A
  1. sx should resolve within 24-72 hours after abx
    if doesnt resolve with 2-3 days or positive blood/urine culture, need to investigate to exclude resistance, possible obstruction, renal abcess, or other disease
  2. reculture has to be taken for preg women after treatment to ensure clearance
  3. any ADR, allergies

PT (19 decks)

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