Urinary-tract Infections Flashcards
What is the most common cause of UTIs?
Bacteria from the GI tract entering the urinary tract, esp E.coli
Which organism should be suspected in a hospitalized patients with a UTI who is immunocompromised or has an indwelling catheter?
Candida, otherwise a rare cause of UTI
What is considered a lower UTI?
Infection of the bladder or urethra (cystitis or urethritis)
What is considered an upper UTI?
Infection of the ureters +/- the kidneys (pyelitis, pyelonephritis)
What are the main complications of upper UTIs? (4)
- Renal scarring
- Abscess formation
- Renal failure
- Sepsis
Which symptoms are considered lower urinary tract symptoms?
Dysuria, increased urinary frequency and urgency, urine that is strong smelling, cloudy, or contains blood, and persistent lower abdominal pain
Which symptoms are associated with upper UTI? (2)
Loin pain and fever
Is asymptomatic bacteriuria in pregnant women regularly treated?
Yes, it is a risk factor for pyelonephritis and premature labor
UTIs in pregnancy have also been associated with developmental delay and cerebral palsy in infants, as well as fetal death
At what point are UTIs considered recurrent?
At least 2 episodes within 6 months OR
3 episodes within 12 months
What is an important complication of UTIs in men?
Acute prostatitis, usually caused by a UTI
What are the symptoms of prostatitis?
Sudden onset fever, acute urinary retention or irritative voiding symptoms
What are the possible complications of prostatitis? (4)
- Prostatic abscess
- Bacteremia
- Epididymitis
- Pyelonephritis
How is chronic prostatitis defined?
A complication of acute prostatitis wherein urogenital pain and LUTS last at least 3 months
What are the aims of treatment of UTIs? (4)
- Relieve symptoms
- Treat underlying infection
- Prevent systemic infection
- Reduce the risk of complications
What is the non-drug treatment advised for patients with UTIs? (3)
- Drink plenty of fluids to avoid dehydration
- Use self-care strategies to reduce risk of infections
- wipe from front to back after defecation
- do not delay urination
- do not wear occlusive underwear - Some non-pregnant women with recurrent UTIs may wish to try cranberry products or D-mannose to prevent future infection (not a treatment)
Is asymptomatic bacteriuria routinely treated with antibacterials?
No, except in pregnant women
When should patients being treated for UTIs be reassessed? (2)
- If symptoms worsen at any time
2. If symptoms do not start to improve within 48 hours of starting treatment
Should pain management be offered to patients with UTIs?
Paracetamol or ibuprofen can be used for pain relief in most patients
Where appropriate, codeine may be used in patients with acute pyelonephritis or prostatitis
What is the treatment of choice for non-pregnant women with lower UTIs?
FIRST LINE:
- oral nitrofurantoin
- oral trimethoprim (if low risk of resistance)
SECOND LINE: if no improvement after at least 48 hours or if first line not suitable
- oral nitrofurantoin (if not used first line)
- oral fosfomycin
- oral pivmecillinam hydrochloride
- oral amoxicillin (high rate of resistance, so only if culture susceptible)
Can a back-up prescription be prescribed for non-pregnant women with uncomplicated lower UTIs?
Yes, delaying antibacterial treatment with a back-up prescription to see if symptoms will resolve, may be an option. Consider a back-up antibacterial prescription for use if symptoms worsen or do not improve within 48 hours OR an immediate antibacterial prescription depending on the case
Can a back-up prescription be prescribed for men with uncomplicated lower UTIs?
No, UTIs in men are inherently complicated and should therefore be treated with immediate antibacterial prescription AND midstream urine sample (before treatment) to be sent for culture and susceptibility testing
What is the treatment of choice for men with lower UTIs?
FIRST LINE:
- oral nitrofurantoin
- oral trimethoprim
SECOND LINE: if no improvement in 48 hours or if first line not suitable
- consider pyelonephritis or prostatitis
Can a back-up prescription be prescribed for pregnant women with uncomplicated lower UTIs?
No, lower UTIs in pregnant women are inherently complicated, therefore an immediate antibacterial prescription should be given PLUS midstream urine sample obtained before treatment for culture and susceptibility
What is the treatment of choice for pregnant women with lower UTIs?
FIRST LINE:
- oral nitrofurantoin
SECOND LINE: (if no improvement after at least 48 hours OR if first line not suitable)
- oral amoxicillin (only if culture susceptible)
- oral cefalexin
What is the treatment of choice for pregnant women with asymptomatic bacteriuria?
Amoxicillin, cefalexin, or nitrofurantoin
Is trimethoprim safe to use in pregnancy?
No, it is a folate antagonist
What is the management of acute prostatitis?
- An immediate abx should be given
- A midstream urine sample should be obtained before starting treatment to be sent for C/S
- Refer patient to hospital if symptoms are not improving after 48 hours of treatment or if they have any signs or symptoms suggestive of a more serious condition eg sepsis, acute urinary retention, or prostatic abscess
What is the treatment of choice for acute prostatitis?
FIRST LINE:
- oral ciprofloxacin
- oral ofloxacin
- oral trimethoprim (if unable to take quinolones)
SECOND LINE: (on specialist advice)
- oral Levofloxacin
- oral co-trimoxazole
What is the treatment of choice for patients with acute prostatitis who are severely unwell or unable to take oral treatment?
Intravenous administration of the following
- Amikacin
- ceftriaxone
- cefuroxime
- ciprofloxacin
- gentamicin
- Levofloxacin
*abx may be combined if concerned about sepsis
What is the immediate management of acute pyelonephritis? (3)
- Immediate antibacterial prescription
- MSU obtained before treatment
- Consider referring or seeking specialist advice for patients who are significantly dehydrated or unable to take oral fluids and medicines, are pregnant, or have a higher risk of developing complications
What is the treatment of choice for acute pyelonephritis in non-pregnant women and men who are NOT severely unwell?
FIRST LINE:
- oral cefalexin or ciprofloxacin
- IF SENSITIVITY KNOWN, oral co-amoxicillin or TMP
What is the treatment of choice for acute pyelonephritis in non-pregnant women and men who ARE severely unwell or unable to take oral treatment?
FIRST LINE: ALL IV
- Amikacin
- ceftriaxone
- cefuroxime
- ciprofloxacin
- gentamicin
- co-amoxiclav IF given in combination or sensitivity known
*antibacterials may be combined if concerned about susceptibility or sepsis
What is the treatment of choice for pregnant women with acute pyelonephritis who are NOT severely unwell?
FIRST LINE:
- oral cefalexin
What is the treatment of choice for pregnant women with acute pyelonephritis who ARE severely unwell or unable to take oral treatment?
FIRST LINE:
- IV cefuroxime
Which patients should be referred to specialist care for recurrent UTIs? (5)
- Men
- Pregnant women
- Patients with suspected cancer
- Patients with recurrent upper UTIs
- Patients with recurrent lower UTIs with an unknown cause
What management should be offered for post menopausal women experiencing recurrent UTIs?
Vaginal estrogen (unlicensed) at the lowest effective dose IF behavioral and personal hygiene measures alone are not effective or appropriate
Treatment should be reviewed within 12 months
oral HRT should not be given specifically to reduce the risk of UTIs
What measures should be offered to non-pregnant women with recurrent UTIs? (3)
- Behavioral and personal hygiene measures
- Vaginal estrogens (in post menopausal women)
- Antibacterial prophylaxis (single dose OR daily)
- Advise patients about the risk of resistance with long-term antibacterial use, seeking medical help if symptoms of an acute UTI develop, and to return for review within 6 months
For patients receiving prophylactic antibiotics for recurrent UTI prevention, how often should treatment be reviewed?
Review the success and ongoing need for antibacterial prophylaxis at least every 6 months. If antibacterial prophylaxis is stopped, ensure the patient has rapid access to treatment if they develop an acute UTI
What is the antibiotic of choice for UTI prevention?
FIRST LINE:
- oral TMP or oral nitrofurantoin
SECOND LINE:
- amoxicillin (unlicensed) or cefalexin
What is the immediate management of patients with catheter-associated UTIs? (3)
- Consider removing or changing the catheter as soon as possible if it has been in place for longer than 7 days
- An immediate antibacterial prescription should be given
- Urine sample obtained before treatment is taken
*Consider referring or seeking specialist advice for patients who are significantly dehydrated or unable to take oral fluids and medicines, if pregnant, have higher risk of developing complications, have recurrent catheter associated UTIs, or have bacteria resistant to oral antibacterials
What is the treatment of choice for non-pregnant women and men with catheter-associated UTI WITHOUT signs of upper UTI?
FIRST LINE:
- oral amoxicillin (ONLY if culture susceptible)
- oral nitrofurantoin
- oral TMP (if low risk of resistance)
SECOND LINE:
- oral pivmecillinam hydrochloride
What is the treatment of choice for non-pregnant women and men with catheter-associated UTI WITH signs of upper UTI who are NOT severely unwell?
FIRST LINE:
- oral cefalexin, ciprofloxacin, co-amoxicillin (if culture susceptible), or TMP (if culture susceptible)
What is the treatment of choice for non-pregnant women and men with catheter-associated UTI WITH signs of upper UTI who ARE severely unwell or unable to take oral treatment?
FIRST LINE: ALL IV
- Amikacin
- ceftriaxone
- cefuroxime
- ciprofloxacin
- gentamicin
- co-amoxiclav (only in combination, unless culture results confirm susceptibility)
*antibacterials may be combined if concerned about susceptibility or sepsis
What is the treatment of choice for catheter-associated UTI in pregnant women who are NOT severely unwell?
FIRST LINE:
- oral cefalexin
What is the treatment of choice for catheter-associated UTI in pregnant women who ARE severely unwell?
FIRST LINE:
- IV cefuroxime
Which organisms are associated with catheter-associated UTIs? (7)
- E.coli
- Klebsiella
- Proteus
- Enterococcus
- Pseudomonas
- Enterobacter
- Serratia
Which gram(-)s are covered by first generation cephalosporins? (3)
- Proteus
- E.coli
- Klebsiella
(In addition to gram positives, first gen cephalosporins cover “PEcK” gram negative organisms)
Which gram(-)s are covered by second generation cephalosporins? (6)
- Proteus
- E.coli
- Klebsiella
- H.influenza
- Neisseria
- Serratia
(In addition to gram positives and PEcK organisms covered by first gen cephalosporins, second gen cephalosporins cover “HeNS PEcK” gram negative organisms)
