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PR3124 > Urinary Tract Infections > Flashcards

Urinary Tract Infections Flashcards

1
Q

How does prevalence of UTI vary with age & gender?

A

0-6mths: Males >
- Higher rate of structural/functional abnormalities

1-adult: Females >
- Shorter urethra, easier access for bacteria; Males have extra protection from antibacterial secretions from prostate

Elderly: Equal
- Comorbidities, increased usage of cahether

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2
Q

Normal host defense mechanisms

A
  • Bacteria in bladder stimulates micturitoin -> Increases diuresis -> Increased emptying of bladder
  • Antibacterial properties of urine & prostatic secretion
  • Anti-adherence mechanism -> Prevent bacterial attachment
  • Inflmm response with polymorphonuclear leukocytes (PMNs) -> Phagocytosis -> Prevent/control spread
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3
Q

Different types of UTIs?

A

Pyelonephritis, Cystitis, Catheter-associated, Urethritis, Prostatitis, Epididymitis

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4
Q

Pathogenesis (Routes of Infection)

A

1) Ascending
- colonic/fecal flora colonise periurethra/urethra & ascend to bladder/kidney (eg. E.coli, Klebseilla, Proteus)
- Females > risk (shorter urethra)

2) Descending (< common)
- Organism at distant primary site -> Bloodstream -> Urinary Tract -> UTI
- Eg. Staph aureus, mycobacterium tuberculosis

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5
Q

Factors affecting developement of UTI

A

1) Competency of host defense mechanism
2) Size of inoculum
3) Virulence/Pathogenicity

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6
Q

Risk factors for UTI

A
  • Females
  • Sexual intercourse (Incr colonisation of bacteria @ vaginal site)
  • Abnormalities of urinary tract (Incr urinary retention)
  • Neurologic dysfunctions
  • Anti-cholinergic drugs
  • Catheterization/ Other mechanical instrumentation (can harvest bacteria in medical devices)
  • Diabetes (Neuropathy, can have urinary retention)
  • Pregnancy
  • Use of diaphragms/spermicides (Can alter flora of periurethra area)
  • Genetic association
  • Previous UTI
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7
Q

Non-pharmacological interventions for UTI

A
  • Drink lots of fluid (6-8 glasses/day)
  • Urinate frequently whenever you feel the urge
  • Urinate shortly after sex
  • Wipe from front to back especially after bowel movement (Females)
  • Wear cotton underwear & loose-fitting clothes, keeo area dry
  • Modifying birth control method (Soermicidal & unlubricated condoms can increase bacterial growth)
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8
Q

Non-pharmacological interventions for UTI

A
  • Drink lots of fluid (6-8 glasses/day)
  • Urinate frequently whenever you feel the urge
  • Urinate shortly after sex
  • Wipe from front to back especially after bowel movement (Females)
  • Wear cotton underwear & loose-fitting clothes, keep area dry
  • Consider modifying birth control (Unlubricated/Spermicidal condoms increase irritation, may help bacteria grow; Diaphragm/Spermicide can increase bacteria growth)
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9
Q

Classification of UTI

A

1) Complicated
- Potential for serious outcomes, risk for therapy failure
- Presence of complicating factors

2) Uncomplicated
- Healthy, premenopausal, non-pregnant women with no hx suggesting abnormal urinary tract

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10
Q

Symptoms of lower UTI (Cystitis)

A
  • Dysuria, urgency, frequency, nocturia, gross hematuria, suprapubic heaviness or pain
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11
Q

Symptoms of upper UTI (Pyelonephritis)

A
  • Costovertebral tenderness (Renal punch)
  • Flank pain
  • Fever, reigors, HA, N/V, Malaise

Note: Elderly may not present specific urinary symptoms instead just more drowsy, less alert, general GIT symptoms

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12
Q

Methods to collect urine

A

1) Midstream clean-catch
2) Catheterization
3) Suprapubic bladder aspiration

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13
Q

Microscopic analysis of UFEME

A
  • WBC: > 10 WBCs/mm3 = pyuria
  • > Signifies presence of inflmm (no pyuria = unlikely UTI)
  • Presence of RBC (Hematuria) (frequent but non-specific)
  • Identify bacteria/yeast using Gram stain
  • WBC casts indicate upper tract infection/disease
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14
Q

What does chemical urinalysis (dipstick) test for?

A

Nitrite

  • Positive test detects for Gram (-) bacteria (at least 10^ bacteria/mL)
  • False -ve: Gram (+), P.aeruginosa, frequent voiding, dilute urine

Leukocyte esterase

  • Positive test detects esterase activity of leukocytes in urine
  • Correlates with significant pyuria
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15
Q

Pathogen for Uncomplicated Cystitis

A
  • E. Coli (Most common)
  • Staphylococcus Saprophyticus
  • Enterococcus, Klebsiella, Proteus
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16
Q

Pathogen for Complicated/ Healthcare-associated Cystitis

A
  • E. Coli (Most common)
  • Enterococci
  • Proteus, Klebsiella, Enterobacter, P. aeruginosa
17
Q

Unlikely pathogens for UTI

A

S. Aureus: Bacteremia, to consider other primary sites of infection
Yeast/Candida: Possible contaminant

18
Q

Exceptions to treat asymptomatic UTI

A

1) Pregnancy
- Reduces developement for pyelonephritis, risk of preterm labour & low birth weight infant

2) Invasive urologic procedures with mucosal trauma
- Antibioitics given as prophylaxis to prevent postoperative bacteremia & sepsis
- Obtain culture, start based on culture & sensitivity 12-24hrs BEFORE procedure

19
Q

Empiric antibiotics for uncomplicated cystitis in women (community-acquired)

A

1st line:

  • PO Cotrimoxazole 800/160mg BD x 3d
  • PO Nitrofurantoin 50mg QID x 5d
  • PO Fosfomycin 3g single dose
  • PO Beta-Lactams x 3-7days
  • -> Cefuroxime 250mg BD/ Cephalexin 500mg BD/ Augmentin 625mg BD
  • PO Fluoroquinolones x 3days [not recc]
  • -> Ciprofloxacin 250mg BD/ Levofloxacin 250mg daily
20
Q

Empiric antibiotics for complicated cystitis in women

A
  • Same as uncomplicated cystitis -
  • Longer: 7-14days
  • Fosfomycin: PO 3g EOD x 3 doses
21
Q

Adverse effects of Cotrimoxazole

A
  • Photosensitivity
  • Hemolytic anemia (G6PD Deficiency)
  • Megaloblastic anemia, leukopenia & theombocytopenia (Give folinic acid)
  • N/V
  • Rash

Caution in 1st & last trimester of pregnancy

22
Q

Empiric antibiotics for community-acquired Pyelonephritis in women

A

1st line:
- PO Fluoroquinolones
–> Cipro 500mg BD x 7days/
Levo 750mg OD x 5days

  • PO Cotrimoxazole 160/800mg BD x 14days
  • PO Beta-lactam x 10-14 days
    –> Cephalexin 500mg BD/
    Augmentin 625mg TDS

Severely ill requiring hospitalization/ Unable to take oral drug:
- IV Ciprofloxacin 400mg BD
- IV Cefazolin 1g Q8h
- IV Augmentin 1.2g Q8h
ADD/or IV/IM Gentamicin 5mg/kg for ESBL-producing E.Coli coverage

23
Q

Empiric antibiotics for community-acquired UTI in men

A
  • Same as complicated cystitis but for LONGER DURATION -
24
Q

Empiric antibiotics for prostatitis/ pyelonephritis in men

Prostatitis: Localised pain/ pain on ejaculation

A
  • PO Ciprofloxacin 500mg BD
  • PO Cotrimoxazole 800/160mg BD

Duration: 10-14 days, longer duration if prostatitis confirmed (6 weeks)

25
Q

Empiric antibiotics for Nosocomial/Healthcare-associated Pyelonephritis

A

Nosocomial: Onset >48h post-admission
Healthcare-associated: Hospitalized/ Underwent invasive urological procedure in the last 6mths

  • To consider possibility of Pseudomonas aeruginosa & resistant bacteria*
  • IV Cefepime 2g Q12h +/- IV Amikacin 15mg/kg/d
  • IV Imipenem 500mg Q6h
  • IV Meropenem 1g Q8h

For less sick:

  • PO Levofloxacin 750mg
  • PO Ciprofloxacin 500mg BD

Duration: 7-14days

26
Q

What is the most common cause for nosocomial UTI?

A

Catheter-associated UTI
- Presence of symptoms/signs compatible with UTI with no other identified sources of infection frm pt whose catheter has been removed within previous 48h

27
Q

Risk for Catheter-associated UTI?

A
  • Duration (3-5% chance/day)
  • -> Short-term (<7days): 85% Single organism
  • -> Long-term(>28days): 95% Polymicrobial
  • DM
  • Female
  • Renal function impairment
  • Poor quality of catheter care, including insertion
  • Colonisation of drainage bag, catheter & periurethral segment
28
Q

Treatment of asymptomatic Catheter-associated UTI?

A

NOT RECOMMENDED except prior to traumatic urological procedures

  • ALWAYS consider removing catheter
  • If catheter has been placed for >2weeks at onset of CA-UTI & is still consider, should replace catheter to hasten resolution of symptoms & reduce risk of subsequent CA-bacteriuria
29
Q

Treatment of symptomatic Catheter-associated UTI?

A
  • Consider observation b/f immediate therapy if patient stable & fever low grade
  • Urine culture MUST be taken
  • Start empiric therapy, adjust after culture & sensitivity testings
30
Q

Antibiotic treatment of symptomatic Catheter-associated UTI

A
  • IV Imipenem 500mg Q6h
  • IV Meropenem 1g Q8H
  • IV Cefepime 2g Q12h +/- IV Amikacin 15mg/kg (1 dose)

Mild cases:
- PO/IV Levofloxacin 750mg X 5d

Women <65 with CA-UTI w/o upper ut symptoms after indwelling catheter removed:
- PO Cotrimoxazole 800/160mg BDS X 3d

Duration: 7 days
(10-14 days if delayed response)

31
Q

Prevention of Catheter-associated UTI

A
  • Avoid unnecessary catheter use
  • Minimal duration
  • Long-term indwelling catheter changed before blockage
  • Use closed system
  • Aseptic insertion technique

AVOID:

  • Topical antiseptic/antiobiotics
  • Prophylatic antiobiotics
  • Chronic supressive antibiotics
32
Q

Antibiotics to avoid in pregnancy

A

1) Ciprofloxacin
- Reports of fetal cartilage damage & arthropathies in animal studies

2) Cotrimoxazole in 1st & 3rd trimester
- Folate deficiency
- G6PD-Deficiency
- Kernicterus (Hyperbilirubinemia)

3) Nitrofurantoin at term
- G6PD Deficiency

4) Aminoglycosides used with caution

33
Q

Antibiotics for UTI in pregnancy

A
  • Beta-lactams
    –> Cephalexin 500mg BD/
    Augmentin 625mg TDS

Duration: 7days (Asymptomatic bacteruria/cystitis); 14 days (Pyelonephritis)

Choice based on culture

34
Q

Adjunctive therapy for UTI

A

Pain & Fever: Paracetamol/NSAIDs
Vomiting: Rehydration
Urinary symptoms: Phenazopyridine 100-200mg TDS for duration of symptoms

35
Q

Monitoring therapeutic response of UTI

A
  • Should respond clinically within 2-3days; If persistently + blood/urine culture, further investigation needed:
  • To exclude bacterial resistance/ possible obstruction/ Renal abscess/ Other disease process
  • Repeat culture ONLY for pregnant women
  • Absence of adverse drug reactions/allergies

PR3124 (16 decks)

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