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1st Repro > Urinary tract infections > Flashcards

Urinary tract infections Flashcards

1
Q

Commensals are primarily comprise bacterial species, and are often referred to as an individuals “normal flora”, what is their mechanism

A

compete for resources with more virulent organisms

produce their own AMPs

keep innate immune cells in a“attentive” state

lower vaginal pH

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2
Q

species are of particular significance to protection of female urinary tract.

A

Lactobacillus

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3
Q

Role of lactobacillus in the vagina

A

decrease the vaginal pH through lactic acid production, generating H2O2

• occupy the chemical resources that would otherwise be available for exploitation by pathogenic organisms

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4
Q

Although the urinary and genital tracts are in close proximity to one another, it is important to differentiate between the two as the defenses along the______are more limited in scope.

A

urinary tract

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5
Q

Defenses present in the urinary tract

A

o Physical force of urine flow

o Exfoliation
o Antimicrobial Proteins

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6
Q

What two and antimicrobials are present in the urinary tract

A

Antimicrobial peptides

Tamm-Horsfall protein

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7
Q

With the exception of the____, innate and adaptive leukocytes are absent from the lower urinary tract during times of health.

A

urethra

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8
Q

The flow of urine physically prevents the ascension of pathogens up the urinary tract but there are many sources of flow obstruction:

A

Congenital abnormality

Urethral stricture

Uretheral stone

Neurogenic dysfunction

Obstruction of any part of the

urinary tract by cancer

Benign prostatic hyperplasia

or cancer of the prostate

Cystocele

Pregnancy

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9
Q

The points where the ureters attach to the bladder __________ act as one-way valves to prevent urine from backing up toward the kidneys

A

(ureterovesical junction, UVJ)

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10
Q

The physical force of urine flow, and the pressures that accompany it, require the lower urinary tract epithelia to be elastic.The epithelium of the bladder and urethra is_______; folds and sliding cells allow stretching.

A

TRANSITIONAL

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11
Q

How does exfoliation help protect the vagina

A

o Exfoliated bladder cells are epithelial cells sloughed from the surface of the urinary tract.

o This serves as a defense against pathogens, “ejecting” them into the urine for removal.

o The appearance of exfoliated cells in the urine is a sign of urinary tract infection

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12
Q

the infectious agent (e.g. E coli) moves up to kidneys from the urethra. Most common form of UTI.

A

Ascending:

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13
Q

: associated with a structural or functional abnormality of the GU tract, or the presence of a comorbidity, which increases the risks of acquiring an infection or of failing therapy.

A

uncomplicated UTI

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14
Q

What is the most common uropathogenic agent in adults

A

E.Coli

UPEC (use type 1 pili to adhere to bladder epithelium)

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15
Q

Most common UTI causing species in children

A

enterobacter

klebsiella

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16
Q

most common non socomial UTI agent

A

pseudomonas aeruginosa

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17
Q

How does the bladder respond to UTI

A

The body responds to UTI by both exfoliation and neutrophil recruitment

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18
Q

Bladder inflammation is the consequence of ________ into the bladder

o painful urination

o lower abdomen discomfort, low- grade fever, pelvic pressure, and frequent urination

o diagnosed by presence of leukocytes in urine

A

leukocyte infiltration

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19
Q

The activation of neutrophils results in degranulation and release __________, which is used as a diagnostic for UTI

A

leukocyte esterase

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20
Q

UTIs are most commonly diagnosed using a ______that measures several aspects of urine chemistry (see Reference slide)

______are the most common treatment for UTI, the selection and efficacy of which depends on:

the causative species

the ability to concentrate in the urine well

A

“dipstick”

Antibiotics

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21
Q

– for individuals who frequently develop UTI following coitus, these may be taken prophylactically

A

Coital prophylaxis

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22
Q

The ability to UPEC to reside in___ is a cause of recurrent UTI

A

calculi

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23
Q

Lower tract UTI (bladder, prostate, urethra) - Mainly bladder =_____

Upper tract UTI (kidney, ureter)
- Mainly kidney =________

A

cystitis

pyelonephritis

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24
Q
  • Female >> Male
  • ___% of women will develop a UTI in their lifetime
  • ___% of nosocomial (hospital-acquired) infections are UTIs
  • ___% of gram –ve bacteremias/year in the hospital setting start as UTIs.
A

60

40

40

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25
Q
  • ______ = painful urination–> Burning, stabbing, “peeing shards of glass”
  • _______ = needing to urinate often–> It hurts to hold urine
A

Dysuria

Urinary frequency

26
Q

_______= blood in urine
– Gross(visible)–more concerning.Can’t necessarily attribute it to UTI

(needs further investigation) – Microscopic

A

Hematuria

27
Q

Symptoms of bladder infection

A

• Dysuria

– Burning, stabbing, “peeing shards of glass”
• Urinary frequency

Urinary urgency

Suprapubic pain/discomfort/pressure

Cloudy/smelly urine

Hematuria

28
Q

Differential Diagnosis of Dysuria

A

UTI

Diet related irritants

Urethritis

Vulvitis/vaginitis

Stones/foreignbody

Atrophy

Recent intercourse

Interstitial cystitis and other inflammatory conditions

29
Q
  • Flank/back pain
  • High fever, chills
  • Headache
  • Nausea/vomiting
  • Maybe septic shock
  • +/- cystitis symptoms
A

Pyelonephritis (kidney infection) Symptoms

30
Q

: UTI in healthy patient with normal urinary tract

– Young to middle age female with “run of the mill” UTI (often triggered by sex)

A

Uncomplicated UTI

31
Q

: UTI associated with factors that predispose to bacterial infection and decrease efficacy of therapy

– These infections are more prone to become disseminated resulting in sepsis and even death

A

Complicated UTI

32
Q

What are some causes of Abnormal GU tract

A

– Urinary obstruction (BPH, scar tissue, stone)

– Urinary stasis (incomplete bladder emptying, diverticulum)

– Vesicoureteral reflux (backwashing of urine from bladder to

ureters/kidneys – mainly a pediatric issue)

– Foreignbody(catheter,stone)

– Neurogenicbladderwithhighpressures(e.g.spinalcordinjury)

33
Q

Immunocompromised/unhealthy host

– Diabetes, transplant patients, chronic steroids

• Multi-drug resistant bacteria

These are both examples of:

A

causes of complicated UTI

34
Q

Chemical strip analysis (urine dipstick) can screen for:

A

– Good screening test for urinary blood, pus (leukocytes), bacteria, pH, specific gravity (ie concentration), protein, glucose

35
Q

– Definitive test for blood (RBC) and pus (leukocytes)

– Can have false positive dipsticks so they should be confirmed with

A

microscopic analysis

36
Q

Detects pyuria (pus or WBC in urine)

UTIs usually have pyuria

A

UA Dipstick: Leukocyte Esterase (LE)

37
Q

DDx of pyuria seen with leukoctye esterase test

A

• Pregnancy

  • Vaginalinfection
  • Inflammation from bladder or kidneys or adjacent organs • Tumors
  • Stones
  • Non-bacterial cystitis
38
Q

Sensitivity and specificity of leukocyte esterase test

A

Sensitivity is HIGH

Specificity is LOW

39
Q

Produced by action of bacteria on dietary nitrates through nitrate reductase (converts nitrates to nitrites)

Specificity: HIGH (66%-99%)
– Low false positive rate for UTI

Sensitivity: LOW (29%-92%)

– False negative rates

A

UA Dipstick: Nitrites

40
Q

Nitrites have low sensitivty for testing. Why and what are important testing tips?

A

– False negative rates
• Not all bacteria have the enzyme nitrate reductase • Nitrate to nitrite conversion takes 4-6 hours

– First AM void is best

****+ve nitrite test likely rules in UTI but a –ve nitrite test doesn’t rule out UTI

41
Q

Dipstick test detects the peroxidase activity of erythrocytes

A

UA Dipstick: Blood (microscopic hematuria)

42
Q

What are some concerns for using Blood analysis with UA dipstick : microscopic hematuria

A

Potential false +ves:
– Myoglobin and Hemoglobin can catalyze this reaction

Need microscopy for confirmation

Microhematuria noted in 50% of women with acute UTI

43
Q

Can persist up to one week after successful treatment of UTI but if persistent beyond this:

– 5-22% will have serious urologic disease

• 0.5-5% will have a GU malignancy

A

microscopic hematuria

44
Q

Reason to obtain urine culture and sensitivity

A

To determine growth of bacteria from urine sample

– Identification and quantification of bacterial species

– Determining sensitivities to various antibiotics (to guide therapy)

45
Q

Three specimen collection methods for urine

A

Clean catch voided specimen

  • Easiest but most prone to contamination – Catheterized specimen
  • Less risk of contamination but more invasive

– Suprapubic aspirate
• Less risk of contamination but more invasive

46
Q

Organism responds to antibiotic and will likely respond to treatment with a standard antibiotic dosage

A

Sensitive

47
Q

At standard antibiotic doses organism may or may not respond

– Organism may be eradicated if:

high Abx concentrations at the site (in urine) of infection

higher than normal dosage is used

A

Intermediate (I)

48
Q

Organism won’t respond to antibiotic

– Physiologic concentrations required to overcome resistance would cause toxicity in humans

A

Resistant (R)

49
Q

Antibiotics are mainstay for UTI tx, what do we need to keep in mind when prescribing antibiotics?

A

May start Abx based on a “best guess” (empiric treatment) of which will be sensitive using hospital/clinic data on most commonly cultured organisms and antibiotic sensitivities

– Must factor in prior use of antibiotics (a recently used antibiotic may not be effective because of development of bacterial resistance)

• Want high Abx concentrations in urine (see handout)

50
Q

Duration of treatment determined by degree of illness, complicated vs uncomplicated UTI

– For uncomplicated UTI in healthy female:

– For complicated UTI:

A

typically 3-5d course of Abx (sometimes up to 7d)

Must correct any structural or functional urinary tract abnormality (eg relieve obstruction) and treat with Abx for at least 7d and often longer (10-14d)

51
Q

• Basic UTI evaluation = H&P, UA & C&S ± Blood testing:

–____ – to see if elevated WBC (may be sign of more serious infection)

– Basic chemistry
• Creatinine – estimate of____ function (Abx dosing)

• Electrolytes

A

CBC

renal

52
Q

when do we need to get imaging?

A
  • Complicated UTIs :But not always – Predisposing factors :GU anomalies or Hx of stones
  • Lack of response to appropriate therapy

• Recurrent pyelonephritis

Use kidney/bladder ultrasound or CT scan (CT is better at identifying stones)

53
Q

_____from bacteria outside the urinary tract (ie a new infection)

•_____ of bacteria in a focus within the urinary tract (ie same infection as before; didn’t resolve)

A

Reinfection

Persistence

54
Q

Causes of Bacterial persistence

A

Inadequate/inappropriate/incomplete antibiotic therapy

Stones/foreign bodies

Chronic bacterial prostatitis (infection harbored in prostate)

Urethral diverticula

Fistula (abnormal connection between epithelialized structures (eg. colon to bladder – colovesical fistula)

Urinary stasis

– Poor bladder emptying (e.g. BPH, weak detrusor) – Vesicoureteralreflux

55
Q

Management of Recurrent UTI

A

Use Abx (typically at lower than therapeutic dosing e.g. half strength) taken on a daily or every other day basis to prevent symptomatic recurrence

Prophylaxis: prevention of UTI from outside re-infection

Suppression: prevention of UTI from bacterial persistence (eg have a known focus of infection but it can’t be removed)

56
Q

Recommended antibiotics for long term prophylaxsis

A

– NTF 50 mg QHS

– Bactrim SS 1 tab QHS

– Trimethoprim 100 mg QHS

– Cipro 100 mg or 250 mg QHS
• Would reserve for more complicated UTIs or failure with above

regimens

57
Q

– Converted to formaldehyde and ammonia in acidic urine (need pH<6)

– Found in combination with other acids

A

Methenamine salts

58
Q

three non antibiotic prophylaxis options for UTIs

A

methenamine salts, cranberry juice, ascrobic acid or Vit C

59
Q

What pts are at risk for asymptomatic bacteriuria:
+ve urine culture but no symptoms = bacterial colonization

A

Elderly women (especially in care homes)

Pregnancy

Diabetes

Use of catheters (intermittent, indwelling)

Spinal cord injury (often due to use of catheter)

60
Q

We generally don’t tx asymptomatic bacteriuria,why? and when would we want to?

A

1) treatment doesn’t reduce incidence of symptomatic UTI
2) it recurs soon after treatment stopped
3) overuse of Abx risks bacterial resistance

Exception; pregnancy; treat to prevent preterm labor

61
Q

25 y.o. healthy female complains of “burning when I urinate for past 3 days. Tried drinking lots of cranberry juice which helped a little but still having the burning and having to urinate often”

No history of UTIs, no hematuria

Sexually active on “the pill”
• Unremarkable physical exam

What do you do?

A

Check urinalysis!

62
Q

You note your pt has an acute bacterial UTI

options to tx:

Nitrofurantoin for 14 days

Bactrim for 3 days

Cipro for 7 days

Amoxicillin for 7 days

A

bactrim for 3 days (only need 3-5 days)

1st Repro (16 decks)

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