Urinary Tract Infections

Question 1

uncomplicated vs complicated UTIs?

Answer 1

• Determined by: infecting organism, functioning of urinary tract, general health of patient

uncomplicated

• healthy (non-pregnant) person, nml GU tract, easily treated with limited testing, premenopausal

Complicated

• compromised immune system
• structurally abn GB tract
• highly virulent/ abx resistant pathogen
• men
• comorbidities: DM

Question 2

UTI pathogens

Answer 2

Uncomplicated

• E.coli 75-90% of uncomplicated UTIs
• staphylococcus saprophyticus (more likely to have upper UTIs and recurrent UTI)

Complicated

• uropathogenic E.coli is a virulent G- bacteria with fimbriae for adherence
• postmenopausal- e.coli, klebsiella, proteus
• diabetes- klebsiella
• indwelling catheters- Pseduomonas.

Question 3

UTI risk factors

Answer 3

• Previous UTI and frequent or recent sexual intercourse
• 60x higher risk of acute cystitis w/i 48h of sex
• spermicides & diaphragms 2-3x higher incident
• delayed micturiation
• anatomy
• genetics

Question 4

symptoms of UTI?

Answer 4

• Classic symptoms: dysuria with urinary frequency and urgency
• also possible: bladder/suprapubic fullness/discomfort, hematuria, mild referred flank pain and malaise
• fever, chills, flank pain & CVAT
• vaginal discharge
• diagnosis can often be made with a good focused hx

Question 5

diagnosing UTIs

Answer 5

midstream, clean-catch urinalysis

• leukocytes esterase indicated pyruia
• nitrite (urease-splitting bacteria)
• hematuria 40-60% of UTIs
• bacteruria
• cultures not needed in uncomplicated UTIs
• urine culture is needed if pt fails tx

Question 6

Treatment of UTIs

Answer 6

• tx is dependent on complicated bs uncomplicated, age and sex of patients
• Nitrofurantoin- higher treatment failure rates in white
• TMP-SMX: increasing E.coli resistance
• ciprofloxacin- superior eradication rates

dont use bactrim if used in preceding six months

Question 7

drugs to avoid with UTIs during pregnancy

Answer 7

Bactrim
nitrofurantoin

Question 8

Treatment of UTI symptoms

Answer 8

urinary analgesics

• Phenazopyridine (pyridium) 200mg PTO TID prn
• methenamine (urised) 2 tabs PO QID PRN
• limit use (2 days)
• symptoms improved, but ADRs
• routine follow up not needed for uncomplicated UTIs

Question 9

Difference between Macrobid vs Macrodantin

Answer 9

Both are nitrofurantoin but the dosing is different

Macrobid

• 100mg BID x 5-7 days
• remember macrobid
• macrocystal formulation less GI ADR

Macrodantin

• macrodantin (nictrofurantoin)
• 50-100mg PO QID x 5-7 days
• QID dosing increased GI ADRs
• prophylaxis (post-coital or continual)

FOR BOTH: avoid in renal dysfunction, negligible tissue penetration

Question 10

why is nitrofurantoin inappropriate for the elderly?

Answer 10

• inadequate drug concentration in the urine when creatinine clearance falls below 60mL/min
• patients may be at increased risk for adverse events secondary to drug accumulation

Question 11

• diabetic, pregnant, immunosuppresed, previous pyelonephritis, urinary tract structural abnormalities, nosocomial factors, voiding dysfunction, elderly
• clinical feature, causative organism and testing same as in uncomplicated UTI
• antibiotics typically the same, but longer courses of t
• test for cure in 3 weeks to confirm clearance

Answer 11

Complicated UTI

Question 12

• relapse for vs reinfection
• risk factors: intercourse w/in 1 month, maternal hx of UTIs, new sex partner in the past year, spermicide use in past year, age of 1st UTI < 5
• clinical feature, causative organism and testing same as in uncomplicated UTI
• antibiotics choices the same, but longer courses of treatment (1-2 weeks) do not use same abx as last used
• continuous or post-coital prophylaxis

Answer 12

Recurrent UTI

Question 13

• upper urinary tract infection
• uncomplicated if typical pathogen in immunocomprimised host
• 5x more common in females, but higher mortality in males
• misdiagnosis- urosepsis, chronic pyelonephritis, renal abscess, renal failure & HTN
• e.coli, s.saprophyticus, proteus, klebsiella

Answer 13

Acute pylonephritis

Question 14

presentation and admission criteria for acute pyelonephritis?

Answer 14

Presentation

• mild to severely ill
• evidence of UTI, fever, chills, flank pain, n/v, CVAT
• elderly and immunocompromised have atypical sxs (GI or pulmonary sxs)

Admission criteria

• persistent vomiting
• suspected sepis
• uncertain diagnosis
• urinary tract obstruction
• age > 60, immunocompromised, f/u, poor social support, pregnancy

Question 15

diagnosis of acute pyelonephritis?

Answer 15

• urinalysis and confirmatory culture of midstream CC
• pyruia + leukocyte esterase & +/- nitrate
• white blood cell casts- their presence indicates inflammation of the kidney
• gram stain can help in choosing antibiotic therapy
• +/- blood cultures

Question 16

Treatment of acute pyelonephritis?

Answer 16

• outpatient oral therapy successful in 90% of selected who tolerate oral intake, have social support & will f/u
• urine C&S will guide therapy, always perform
• ciprofloxacin 500mg PO BID x 7 days (+/- initial iv dose of cipro 400mg or 1 gm ceftriaxone)
• cipro 1000mg ER PO q DAY 7 days
• levofloxacin 750mg PO q day x

Question 17

Causes of dysuria in men?

Answer 17

• urethritis - N.gonorrheae, C. trachomatic
• prostatitis, cystitis, pylonephritis, epididymo-orchitits- coliform bacteria
• BPH- age
• uretheral stricture- prior surgery
• renal cell carcinoma
• bladder cancer- smoking
• ureterolithiasis- stone disease

Question 18

UTIs in men

Answer 18

Treatment of UTI- Men (age-related)

• bactrim DS 1, PO BID x 7-10 days
• fluroquinolone as discussed above x7-10days
• ceftriaxone 250mg IM x1, plus azithromycin 1g PO x 2

Question 19

what should you know about dysuria?

Answer 19

• men with dysuria need a thorough histroy and physical exam with UA and C&S
• younger pts- C. trachomatis #1 (also. e.coli if anal sex or uncircumcised)
• > 35y/o- coliform bacteria (E.coli, enterobacter, klebsiella, serratia.. due to urinary stasis (BPH)
• treatment typically longer than women

Question 20

• irritative voiding symptoms with a negative urine culutre
• typically 30-70 years of age
• doctor shopped an average of 5 by diagnosis
• disrupts work, social relationships and sexual activity
• urgency & frequency of urination, suprapubic pain, dysparunia and chronic pelvic pain
• possibly autoimmune vs. allergic. vs infectious

Answer 20

interstitial cystitis

Question 21

symptoms of interstitial cystitis?

Answer 21

• Chronic pain, frequency, urgency, sleep deprivation, depression, dyspareunia, suicidal ideation (IBS, Fibromyalia, migraine pts)
• pain/urgency relieved by voiding small amounts
• sxs worsen the week prior to menses (differential-endometrosis)
• dietary association (coffee, alcohol, citrus, tomatoes)
• urinary frequency is 16 to 40x a day

Question 22

diagnosis of intersitital cystitis?

Answer 22

Diagnosis:

Confirmed cystoscopy findings

• glomeerulations- pinpoint hemorrhages seen with hydrodistention (hydrodistention can cause period of symptomatic relief)
• hunner’s ulcers- results in bladder wall scarring and decreased bladder capacity

Question 23

• presence of urgency or frequency or pelvic pain
• presence of glomerulation or ulcers on cystoscopy
• negative urine culture
• absence of GU infection or prostatitis
• absence of neoplasstic disease or tumor
• absence of hx or radiation, TB or chemical cystitis
• bladder capacity of < 350ml

Answer 23

Interstitial cystitis

Question 24

• greater than 100,000 CFU per mL in an asymptomatic pt
• present in 40% of elderly men and women
• who benefits from treatment (pregnant women, renal transplant pts, pts that undergo GU tract procedures)
• these three have the highest levels of complications from this condition
• treat the patient not the urinalysis

Answer 24

Asymptomatic bacteriuria