Urinary Tract Infections Flashcards
1
Q
Urine Characteristics
A
- Low pH
- Extremes in osmolality
- High urea and organic acid concentration
2
Q
Flushing Mechanisms
A
Introduction of bacteria stimulates increased diuresis
3
Q
Anti-Adherence Mechanisms
A
Coated epithelial cells of the bladder
4
Q
Other Potential Factors
A
- Presence of lactobacillus in vaginal flora
- Estrogen levels
5
Q
Classification
Uncomplicated
A
Nonpregnant female
Childbearing age (15-45 yo)
Otherwise healthy
No structural or functional abnormalities
6
Q
Classification
Complicated
A
Pregnant females Males Children Diabetics Anatomical or structural abnormalities
7
Q
Pylonephritis
A
Is a type of urinary tract infection (UTI) that generally begins in your urethra or bladder and travels to one or both of your kidneys. A kidney infection requires prompt medical attentio.
Infection of renal parenchyma
8
Q
Signs and Symptoms
Uncomplicated Cystitis in Adults
A
Dysuria Polyuria Urgency Nocturia Suprapubic discomfort Gross hematuria
9
Q
Signs and Symptoms
Pyelonephritis in Adults
A
Fever Nausea and vomiting Leukocytosis Dysuria, polyuria, urgency Flank pain Costovertebral angle (CVA) tenderness
10
Q
Signs and Symptoms: Special Populations
Elderly
A
Altered mental status
Change in eating habits
GI symptoms
11
Q
Lower UTI
A
Local symptoms: dysuria, frequency, urgency, suprapubic tenderness, hematuria (+/-)
Systemic symptoms: rarely present
12
Q
Upper UTI
A
Local symptoms: lower UTI symptoms often NOT present
Systemic symptoms: fever, flank pain, abdominal pain, malaise, vomiting, chills, leukocytosis
13
Q
Elderly
A
Altered mental status, change in eating habits, gastrointestinal symptoms
14
Q
diagnosis of UTI
A
***Symptomatic Patients **
±
Positive Urine Culture
15
Q
Urinalysis: Macroscopic
A
Color, appearance, and odor
Dipstick
16
Q
Urinalysis: Macroscopic
Dipstick
A
Urine pH
Presence of glucose, blood, bilirubin, or protein
Leukocyte esterase
Detect presence of WBC
Nitrite test
Formed by bacteria that reduce nitrate to nitrite
Only members of the Enterobacteriaceae family
17
Q
Urinalysis: Microscopic
Bacteriuria
A
≥ 10^5 CFU/mL –> indicative of UTI
≥ 10^2 CFU/mL –> diagnostic in presence of symptoms
18
Q
Urinalysis: Microscopic
Pyuria
A
> 10 WBC/mm3
Nonspecific to UTI
Signifies presence of inflammation
19
Q
Microscopic hematuria
A
Nonspecific to UTI
20
Q
Urine Cultures
A
Gold standard for diagnosis Obtain prior to initiating antibiotics Identification and quantification Sensitivities Alter antibiotic treatment as needed
21
Q
Gram-Negative
A
Escherichia coli Proteus species Klebsiella pneumoniae Enterobacter species Pseudomonas aeruginosa
22
Q
Gram-Positive
A
Staphylococci species
Enterococcus species
23
Q
Uncomplicated
Escherichia coli
A
•Most common: 80-90%
24
Q
Uncomplicated
Staphylococcus saprophyticus
A
- Usually seen in young sexually active females
* Less common: 5-15%
25
Uncomplicated
| Klebsiella pneumoniae, Proteus spp., Enterococcus spp., Citrobacter spp.
•Less common: 5-10%
26
Complicated
| Escherichia coli
•Most common: <50%
27
Complicated
| Enterococcus spp.
•Second most frequently isolated organism in hospitalized patients
28
Complicated
Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella pneumoniae, Proteus spp., Citrobacter spp., Acinetobacter spp. and Morganella spp.
•Less common
29
Causartive agents - Pearls
| E. coli
Most common – responsible for 80-90% of cases
30
Causartive agents - Pearls
| Proteus species
Produce urease – increases pH of urine
31
Causartive agents - Pearls
| E. coli and K. pneumoniae
Common ESBL organisms
32
Causartive agents - Pearls
| Pseudomonas aeruginosa
Does not reduce nitrate to nitrite
33
Treatment Goals
Eradicate infection and prevent recurrence
Prevent or treat systemic consequences
Provide supportive care
Minimize cost, adverse effects, and collateral damage of antimicrobial therapy
34
UTI Treatment Principles
Treat ALL symptomatic UTIs
| Treatment of asymptomatic bacteriuria is patient specific
35
Treatment Principles
| Before initiating treatment, always consider:
Age, gender, symptoms, site of infection, possible recurrent infection
Medication allergies
Previous cultures for that patient (if available)
Susceptibility patterns within the region
Drug characteristics
Tolerability and adherence
Pregnancy status
36
Empiric Antimicrobial Selection
| Dr. Plasma
D Drug-drug interactions
R. Renal & hepatic function
```
P Primary source(s) of infection
L Location of acquisition
A Antimicrobial history
S Severity of illness
M Microbiological history
A Allergy history
```
37
Urinary tract infections: females
| Asymptomatic Bacteriuria
Significant bacteriuria (≥10^5) in the absence of symptoms
38
Urinary tract infections: females
| Symptomatic Abacteriuria
Symptomatic in the absence of significant bacteriuria (<10^5)
39
Urinary tract infections: females
| Cystitis
Infection of the bladder
40
Urinary tract infections: females
| Pyelonephritis
Infection of the kidney
41
Which of the following patients listed below would be classified as having an uncomplicated cystitis infection?
A.) 27 year-old healthy male
B.) 29 year-old non-pregnant healthy female
C.) 40 year-old diabetic male
D.) 90 year-old female with urethral obstruction
B.) 29 year-old non-pregnant healthy female
42
Asymptomatic Bacteriuria
Microbiologic criterion generally ≥ 10^5 CFU/mL
Asymptomatic Bacteriuria Treatment in Pregnancy
Acceptable Options
Nitrofurantoin
Cephalexin
Amoxicillin-clavulanate
43
Asymptomatic Bacteriuria
Microbiologic criterion generally ≥ 10^5 CFU/mL
Asymptomatic Bacteriuria Treatment in Pregnancy
Use with Caution
Trimethoprim/Sulfamethoxazole (TMP/SMX): avoid in 1st and 3rd trimester
44
Asymptomatic Bacteriuria
Microbiologic criterion generally ≥ 10^5 CFU/mL
Asymptomatic Bacteriuria Treatment in Pregnancy
****AVOID****
Tetracyclines
| Fluoroquinolones
45
Acute Uncomplicated Cystitis
| Nitrofurantoin monohydrate 100 mg PO BID
5 days
•Minimal resistance and low risk for collateral damage
•Caution in renal impairment
46
Acute Uncomplicated Cystitis
| TMP/SMX 160/800 mg PO BID
3 days
•Avoid if local resistance exceeds 20%
•Watch for sulfa allergy
47
Acute Uncomplicated Cystitis
| Fosfomycin 3 g PO once
1 dose
•Minimal resistance and low risk for collateral damage
•High cost and inferior efficacy
48
Acute Uncomplicated Cystitis
Ciprofloxacin 250 mg PO BID
Levofloxacin 250 mg PO daily
3 days
•FDA does not recommend
•Concern for collateral damage
49
AL is 28 yo non-pregnant female presenting to the clinic with painful and frequent urination. She denies fever, nausea, and vomiting. Her UA is leukocyte esterase and nitrite positive. Local resistance to TMP/SMX is > 20%.
What is the most appropriate treatment regimen for AL?
A.) Nitrofurantoin PO for 5 days
B.) Ciprofloxacin PO for 3 days
C.) Amoxicillin/Clavulanate PO for 7 days
D.) TMP/SMX DS PO BID for 3 days
A.) Nitrofurantoin PO for 5 days
50
Pyelonephritis
Treatment varies based on severity
Setting: Outpatient vs. Inpatient
Patient considerations
Obtain urine cultures prior to initiating antibiotics
Consider blood cultures if concern for systemic infection
51
Pyelonephritis
| Patient considerations
```
Hydration
Ability to take oral medications
High fever
Definitive diagnosis
Pregnancy status
```
52
Pyelonephritis: Mild to Moderate
Fluoroquinolones: Ciprofloxacin, Levofloxacin
-First-line option
If resistance to fluoroquinolones > 10%, use ceftriaxone 1g or aminoglycoside
Dose & Duration:
Ciprofloxacin 500 mg PO BID x 7 days
Levofloxacin 750 mg PO daily x 5 days
53
Pyelonephritis: Mild to Moderate
| Susceptible to Bactrim
Trimethoprim/Sulfamethoxazole (TMP/SMX) DS
Preferably used only if known susceptibility
If susceptibility unknown, use ceftriaxone 1 g or aminoglycoside
Dose & Duration:
TMP- SMX DS PO BID x 14 days
54
Pyelonephritis: Severe
```
Initially requires IV antibiotics
Duration: 10-14 days
May repeat cultures
Transition from IV to PO
Afebrile for 24-48 hours
Clinical improvement
Decreased WBC count
Functioning GI tract
```
55
Pyelonephritis: Severe
| Extended spectrum cephalosporin
Ceftriaxone, cefepime, ceftazidime
56
Pyelonephritis: Severe
| Extended spectrum penicillin
Piperacillin/tazobactam
| Ampicillin/sulbactam – resistance has been reported
57
Pyelonephritis: Severe
| Fluoroquinolone
Ciprofloxacin, Levofloxacin
| Consider resistance if using empirically
58
Pyelonephritis: Severe
| Aminoglycoside +/- ampicillin
Generally avoided due to side effects
59
Pyelonephritis: Severe
| Carbapenem
Reserve for people with confirmed multi-drug resistant (MDR) pathogen or those at risk
60
Ciprofloxacin as a surrogate marker for levofloxacin susceptibility
Levofloxacin susceptibility can be assumed based off of ciprofloxacin susceptibility for Enterobacteriaceae
-BUT NOT for Pseudomonas aeruginosa!
Also, does not work the other way around
Levofloxacin susceptibility cannot predict ciprofloxacin susceptibility
61
LK is a 44 yo non-pregnant female presenting to the urgent care clinic with a fever and nausea over the last 2 days. She also complains of dysuria, urinary frequency, and right sided CVA tenderness on exam. Her UA is positive for leukocyte esterases and nitrites. Local resistance patterns to E. coli are as follow: FQ 9%, TMP/SMX 25%.
What is the most appropriate empiric therapy for LK?
A.) Moxifloxacin IV for 7 days
B.) Levofloxacin PO for 5 days
C.) TMP/SMX DS PO for 14 days
D.) Ceftriaxone IV for 9 days
B.) Levofloxacin PO for 5 days
62
Recurrent Infections: Reinfection
Recurrence of infection by a different organism from preceding infection
Reinfection can be divided into two groups:
Less than three episodes per year
More frequent episodes
Three or more infections per year
Start long-term prophylaxis
Check urine cultures every 1 to 2 months
63
Recurrent Infections: Prophylaxis Treatment
| Continuous Low Dose Therapy
TMP/SMX SS 0.5 to 1 tablet PO daily
| Nitrofurantoin 50-100 mg PO daily
64
Recurrent Infections: Prophylaxis Treatment
| Self-Administered Therapy
Patient initiates treatment after first signs or symptoms of UTI
65
Recurrent Infections: Prophylaxis Treatment
| Post-Coital Therapy
TMP/SMX SS 1 tablet PO following sexual activity
66
Risk Factors for Men
****Very rare to see UTI in a younger male because of the prostatic fluid being secreted into the urine; allows for a protective mechanism.****
```
Lack of circumcision
- Colonization of bacteria
Urologic catheterization
- In-dwelling catheter
Obstruction
- Prostatic hypertrophy, renal calculi, kidney stones, etc.
Intercourse
- Sex with infected partner or anal intercourse
Age
- Incidence increases with age
Drugs
- Anticholinergics
```
67
Complicated
Treatment Options: Oral
sulfamethoxazole-trimethoprim (Bactrim)
Highly effective against most aerobic enteric bacteria
NO Pseudomonas aeruginosa coverage
High urinary tract tissue and urine concentrations
68
Complicated
Treatment Options: Oral
nitrofurantoin (Macrobid)
NOT used in males or pyelonephritis
| Contraindicated: CrCl <30mL/min
69
Complicated
Treatment Options: Oral
ciprofloxacin (Cipro)
levofloxacin (Levaquin)
Great spectrum of activity with Pseudomonas coverage
Effective for pyelonephritis and prostatitis
Moxifloxacin does not achieve adequate urinary concentrations
70
Complicated
Treatment Options: Oral
1.) amoxicillin/clavulanate (Augmentin)
cefdinir (Omnicef)
cefpodoxime (Vantin)
2.)fosfomycin (Monurol)
1. ) NO Enterococcus coverage
| 2. )Off-label
71
CAUTI Definition
Signs and symptoms consistent with UTI with no other identified source of infection
PLUS
≥10^3 cfu/mL of ≥ 1 bacterial species in a:
Single catheter urine specimen
Midstream voided urine specimen from a patient whose urethral, suprapubic, or condom catheter has been removed within the previous 48 hours
72
CAUTI: Duration of Therapy
| Women aged < 65 who develop CAUTI without upper UTI symptoms after catheter removal
3 Days
73
CAUTI: Duration of Therapy
| Quick resolution of symptoms
7 days
| If on levofloxacin – 5 days
74
CAUTI: Duration of Therapy
| Persistent symptoms or bacteremia
10-14 days
75
Prostatitis: Acute
Presentation:
fever, chills, malaise, myalgia, localized pain, frequency, urgency, dysuria, nocturia, retention
76
Prostatitis: Acute
Diagnosis:
clinical presentation and presence of significant bacteria isolated from midstream specimen
77
Prostatitis: Chronic
Presentation:
voiding difficulties, lower back pain, perineal suprapubic discomfort
78
Prostatitis: Chronic
Diagnosis:
Quantitative localization cultures which compare bacterial growth in sequential urine and prostatic fluid culture obtained during micturition
79
Prostatitis: Treatment
Sulfamethoxazole-trimethoprim
Ciprofloxacin
Levofloxacin
