Urinary Tract Infections and Pyelonephritis

Question 1

What is cystitis and what are it’s signs and symptoms?

Answer 1

• Infection of the bladder
• Features include:
  
  • Dysuria
  • Suprapubic pain or discomfort
  • Frequency
  • Urgency
  • Incontinence
  • Confusion (in more frail patients)
  • Haematuria

Question 2

What is pyelonephritis and what are it’s signs and symptoms?

Answer 2

• Infection of the kidney
• Features include:
  
  • Symptoms of cystitis
  • Fever/chills/rigors
  • Loss of appetite
  • Haematuria
  • Flank, loin or back pain
  • Costo-vertebral angle tenderness
  • Nausea and vomiting

Question 3

What are the risk factors for pyelonephritis?

Answer 3

• Infancy (<1 year of age)
• Abnormal urinary tract
• Females (anatomy, sexual intercourse, pregnancy)
• Bladder dysfunction (constipation, neurogenic bladder, prostate enlargement)
• Foreign body (catheters, stones)
• Diabetes mellitus
• Renal transplant
• Immunosuppression

Question 4

How is pyelonephritis diagnosed?

Answer 4

• Multistix (leukocyte esterase from WBC walls as proxy marker for pus cells, bacteria can convert nitrates to nitrate to indicates bacteria in urine)
• Microscopy/flow cytometry (negative for pus cells and bacteria)
• Urine culture (E.coli, Klebsiella, Proteus, Pseudomonas, Streptococcus, Enterococcus, Enterobacter)

Question 5

How is pyelonephritis managed?

Answer 5

• Antibiotics (oral; trimethoprim, cephalosporin, co-amoxiclav, nitrofurantoin, or IV; cefotaxime, ceftrixone, gentamicin)
• Nitrofurantoin, trimethoprum or co-amoxiclav can be used as prophylaxis

Question 6

What imaging can be used?

Answer 6

• US – good for dilated drainage tracts and cysts
• MCUG – gold standard for VUR & PUV
• DMSA (static) – gold standard for scars
• MAG3 indirect cystogram – used for VUR study with no catheter needed
• MAG3 diuresis renogram – gold standard for obstruction

Question 7

What is vesico-ureteric reflux (VUR)?

Answer 7

• Retrograde passage of urine from the bladder into the upper urinary tract
• Management involves antibiotic prophylaxis until toilet trained

Question 8

What kinds of congenital obstructions of urinary drainage tracts are there?

Answer 8

• Pelvi-ureteric junction obstruction (PUJO) is the commonest cause of hydronephrosis in children and presents with mass. pain, haematuria and UTI
• Vesico-ureteric junction obstruction (VUJO) is an anatomical narrowing and presents with antenatal dilation UTI, abdominal mass, pain and haematuria

Question 9

How are UTI’s diagnosed?

Answer 9

• Urine dipstick
  
  • Nitrates
  • Leukocytes
• MSSU
  
  • Culture and sensitivities

Question 10

Causes of UTI

Answer 10

• E. coli (most common)
• Klebsiella pneumoniae
• Enterococcus
• Pseudomonas aeruginosa
• Staphylococcus saprophyticus
• Candida albicans

Question 11

Management of UTI

Answer 11

• 3 days of antibiotics for simple UTI in women
• 5-10 days for women who are immunosuppressed, have abnormal anatomy or impaired kidney function
• 7 days for men, pregnant women and catheter related UTIs
• Antibiotic choice:
  
  • Trumethoprim (first line - avoided in 1st trimester of pregnancy or if on other medication that affects folic acid)
  • Nitrofurantoin (first line in pregnancy - avoided in 3rd trimester as linked with haemolytic anaemia)
  • Amoxicillin
  • Cefalexin (second line in pregnancy)