Urinary tract infections

Question 1

Differentiate between urinary tract infection and bacteriuria

Answer 1

Bacteriuria: presence of bacteria in the urine

UTI: characteristic symptoms and significant bacteriuria

Question 2

Define uncomplicated UTI

Answer 2

• Infection of the urinary tract
• Usual pathogen
• Normal urinary tract
• Normal kidney function

Question 3

Define complicated UTI

Answer 3

• Infection of urinary tract
• Abnormal structural urinary tract, or
• Abnormal functional urinary tract
• Atypical pathogen
• Abnormal kidney function
• Male or child

Question 4

Name 3 causative organisms in UTIs

Answer 4

• Escherichia coli
• Staphylococcus saprophyticus
  
  • sexually active young women
• Proteus
• Klebsiella
• Enterobacter
• Pseudomonas

Question 5

State 5 risk factors for UTI

Answer 5

• Recent instrumentation of the renal tract
• Abnormality of the renal tract
• Incomplete bladder emptying
• Antibiotic use: changes vaginal flora
• Sexual activity
• New sexual partner
• Use of spermicide
• Diabetes
• Catheter in situ
• Pregnancy
• Immunocompromised

Question 6

Describe the presentation of UTIs

Answer 6

• Urinary frequency
• Painful frequent passing of only small amounts
• Dysuria
• Haematuria
• Foul-smelling +/- cloudy urine
• Urgency
• Urinary incontinence
• Suprapubic or loin pain
• Pyrexia and rigors
• Nausea and vomiting
• Delirium

Question 7

What is assessed on urinalysis for UTIs?

Answer 7

• Leuckocyte esterase
• Nitrates

Question 8

When should a urine culture be sent in UTI?

Answer 8

• Impaired renal function
• Abnormal urinary tract
• Immunosuppression

Question 9

Outline the initial management for suspected UTI

Answer 9

• Paracetamol +/- NSAIDs
• Uncomplicated: 3 day course
  
  • Nitofurantoin 50mg QDS
  • Trimethoprim 200mg BD
• Complicated: 5-10 day course
  
  • Nitofurantoin 50mg QDS
  • Trimethoprim 200mg BD

Antibacterial chosen should reflect current local bacterial sensitivity to antibacterials.

Question 10

What advise should be given regarding follow-up of a suspected UTI?

Answer 10

Advise all women to seek medical attention if any of:

• Fever
• Loin pain
• Do not respond to treatment

Question 11

Outline further management if UTI symptoms persist following inital treatment, without loin pain or fever

Answer 11

If persistent symptoms following treatment

• Send urine for culture and sensitivity
• Uncomplicated 3d or complicated 5-10d:
  
  • Trimethoprim if nitrofurantoin previously
  • Nitrofurantoin if trimethoprim previously

Question 12

Outline further management if UTI fails to respond to initial antibiotic, and loin pain or fever develops

Answer 12

• Arrange admission if indicated
• Midstream urine sample for culture and sensitivity
• Empirical antibiotics for 10-14 days, either:
  
  • Ciprofloxacin
  • Co-amoxiclav
• Paracetamol for pain and fever
• Full hydration: ensure frequent pale urine
• Change antibiotics if indicated by MCS result

Question 13

When should referral be considered following pyelonephritis?

Answer 13

Referal for investigation of renal tract abnormality

• Men: after first acute pyelonephritis
• Women: after second acute pyelonephritis
• All infected by Proteus species

Question 14

Which patients should be admitted for acute pyelonephritis?

Answer 14

• Significantly dehydrated or unable to take fluids
• Sepsis
• Pregnant and pyrexial
• Frail, elderly residents with recurrent UTI
• Fail to improve significantly within 24hrs of starting antibiotics

Question 15

Which patients are considered for admission for suspected acute pyelonephritis?

Answer 15

Able to take fluids, pyrexia and a risk factor for complication, including:

• Immunocompromised
• Foreign body in renal tract: stones, catheter
• Abnormalities in renal tract anatomy or function
• Diabetes mellitus
• Renal impairement
• Advanced age

Question 16

When can acute pyelonephritis be managed in primary care?

Answer 16

• Pyrexial, with no risk factors for complication
• Apyrexial, +/- risk factors for complication