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AKT - Lizzie Bain > Urology: infections > Flashcards

Urology: infections Flashcards

1
Q

What is the first line treatment for acute prostatitis?

A

ofloxacin or ciprofloxacin for 14 days

or trimethoprim 200mg Bd for 14 days if the above are unsuitable.

Send MSU, and alter as per culture results.

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2
Q

What severe adverse reactions have been reported with fluoroquinolones? (e.g. ciprofloxacin, levofloxacin, ofloxacin)

A
  • tendonitis (painful swelling/inflammation)
  • tendon rupture - esp Achilles tendon (can occur within 48hrs)
  • arthralgia
  • paraesthesia
  • gait disturbance
  • impaired hearing, vision, taste, smell
  • memory impairment

suicidal thoughts and behaviours
heart valve regurgitation
aortic aneurysm and dissection

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3
Q

Which patients are at higher risk of tendon damage with fluoroquinolones?

A
  • age >60
  • renal impairment
  • solid organ transplant
  • on corticosteroids
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4
Q

What is the definition of a recurrent UTI?

A

2 or more UTIs in 6 months or 3 or more episodes in a year

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5
Q

What is an uncomplicated UTI?

A

an infection caused by typical pathogens in people with a normal urinary tract and kidney function, and no predisposing co-morbidities

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6
Q

What is a complicated UTI?

A

one with increased likelihood of complications such as treatment failure, persistent infection or recurrent infection

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7
Q

What are the 3 key symptoms of UTI?

A
  • dysuria
  • new nocturia
  • cloudy urine
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8
Q

When should a urine dipstick be done in women?

A

Age <65

If patients have **2 or 3 of the key symptoms **there is 70% chance of UTI - consider empirical treatment. Urine dipstick not needed.

If only one key symptom, or they also have other urinary symptoms, do urine dipstick.

Other urinary symptoms are: urgency, visible haematuria, frequency, suprpubic tenderness.

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9
Q

What urine diptick results make a UTI likely?

A
  • positive nitrite OR leukocyte AND RBC positive

Only send MSU if risk of resistance.

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10
Q

What dipstick result makes a UTI equally likely to another diagnosis?

A
  • negative nitrite and positive leukocyte

Only half will have UTI. Send a mid-stream urine (MSU) to confirm the diagnosis. Morning sample most reliable. Sample containers with boric acid preservative should be filled to the marked line.

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11
Q

What dipstick result makes a UTI less likely?

A
  • **negative for ALL **nitrite, leukocyte, RBC

Do not send a urine sample for culture and susceptibility testing.

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12
Q

How to take an MSU - advice for patient:

A
  1. Label sterile screw-top container with name, date of birth and date
  2. Wash hands
  3. For women, guidelines also suggest holding the labia apart
  4. Start to pee and collect a sample of urine ‘midstream’ in the container
  5. Screw the lid of container shut
  6. Wash hands thoroughly

If the patient cannot hand in the MSU within an hour they should be advised to put the MSU in a sealed plastic bag in a fridge for up to 24 hours.

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13
Q

In a male patient <65 years when should MSU be sent?

A

Always.
Dipsticks are poor at ruling out infection.
Treat with ABX as per local guidelines.

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14
Q

In patients over age 65 should dipsticks be done?

A

No.
Older people can have asymptomatic bacteriuria (bacteria living in the urinary tract without causing infection).
This is not harmful and does not need ABX.

This is the case in 50% of older women
40% of older men
100% of those with a long-term catheter
Urinary dipsticks cannot determine if a UTI is present. Bacteria will cause a positive nitrite and leucocyte esterase (WCC).

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15
Q

In age >65 signs and symptoms of UTI should be searched for instead of using a dipstick. What are the signs and symptoms in older people?

A
  • New onset dysuria
  • Temperature 1.5oC above patients normal twice in the last 12 hours
  • New frequency or urgency
  • New incontinence
  • New or worsening delirium or debility
  • New suprapubic pain

New onset dysuria with 2 or more of those features in the list make a UTI likely.

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16
Q

In age >65 with signs and symptoms suggesting UTI, how should they be managed?

A
  • self-care advice, safety netting and send MSU before starting antibiotics.
  • If mild symptoms and low risk of complications consider back up antibiotics.
  • If a urinary catheter has been in-situ for more than 7 days consider changing or removing this.
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17
Q

What other causes of Delirium should be considered in the elderly? (PINCH ME)

A
  • Pain
  • other Infection (Resp, GI, skin)
  • poor Nutrition
  • Constipation
  • poor Hydration
  • Medication
  • Environment change
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18
Q

What are the lab rules for urine culture and bottles?

A
  • Urine should be cultured within 4 hours or refrigerated or have boric acid preservative.
  • Boric acid can cause false negative culture if urine is not filled to the correct mark on the specimen bottle.
  • Boric acid will also affect dipstick results. White top should be used for dipstick.
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19
Q

Which adult patients should have an MSU sent?

A
  • Over 65 years symptomatic and antibiotics prescribed
  • Pregnancy – routine and symptomatic women
  • Suspected sepsis or pyelonephritis
  • Suspected UTI in men
  • Failed antibiotic treatment or persistent symptoms
  • Recurrent UTI
  • If prescribing antibiotics to patient with a catheter

Risk factors for resistance:
* Abnormality of the genital tract
* Renal impairment
* Care home resident
* Hospitalisation for >7 days in the last 6 months
* Recent travel to a country with increased resistance
* Previous resistant UTI

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20
Q

What measurement of growth do labs use for a positive urine culture?

A

Most labs use growth 10x7-10x8 cfu/ml.

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21
Q

What are the signs and symptoms of UTI in a child <3 months?

A

Consider UTI in any sick child or those with unexplained fever.

  • Commonly: fever, vomiting, lethargy, irritability, poor feeding
  • Less commonly: abdominal pain, jaundice, haematuria, offensive urine
  • These patients should have a MSU and be referred urgently to paeds same day.
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22
Q

What are the signs and symptoms of UTI in a child >3 months?

A

consider a UTI in any sick child or those with an unexplained fever.

  • Common: fever, frequency, dysuria, abdominal pain, loin tenderness, vomiting, poor feeding, dysfunctional voiding, changes to continence
  • Less commonly: lethargy, irritability, haematuria, offensive urine, failure to thrive, malaise, cloudy urine.
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23
Q

In children should a urine dipstick be done? How can it be collected?

A
  • Yes in children >3 months. (if <3 months - MSU and send to hospital).
  • In infants and toddlers – clean catch urine, gentle suprapubic cutaneous stimulation using gauze soaked in cold fluid helps trigger voiding.
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24
Q

When should UTI be further investigated in children?

A
  • atypical infection: poor urine flow, abdo/bladder mass, raised creatinine, sepsis, not responding to ABX <48hrs, non-e.coli orgs.
  • recurrent UTI: Three or more episodes of lower UTI, 2 or more episodes upper UTI, one upper UTI + one or more lower UTI.
  • child <6 months old with UTI.

The above should have USS.

DMSA scan to detect renal parenchymal defects done within 4-6 months for all with recurrent UTI.

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25
Q

In sterile pyuria, which condition should be suspected?

A

consider Chlamydia trachomatis (especially 16-24 years)

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26
Q

What dipstick result in children >3 months suggests Treat for UTI and ABX should be started? (only need to send culture in certain cases)

A

Positive nitrite AND positive leukocyte

Only need to send culture if:
<3 years
* suspected upper UTI
* risk of serious illness
* previous UTI
* not been responding to current ABX and sample not yet sent.

27
Q

What dipstick result in a child >3 months suggests treat as UTI, start antibiotic, and send urine for culture then reassess with result?

A

positive nitrite and Negative leukocyte.

Only start the ABX if the sample was fresh. Repeat the sample if it was old (can give false positives).

28
Q

What urine dipstick result in child >3 months suggests send urine for culture, then reassess?

A

Negative nitrite, and positive leukocyte.
If under 3: start ABX then reassess with result

If over 3: only start ABX if good clinical evidence. Leukocytes can indicate infection outside urinary tract.

29
Q

What urine dipstick result in children >3 months suggests UTI unlikely?

A

Negative nitrite and negative leukocyte.

Do not start ABX
Exclude other causes

30
Q

What is the first line ABX treatment for lower UTI in women (not pregnant or catheterised)?

A

*Either of:
* Nitrofurantoin 100 mg modified-release twice a day for 3 days.
* Trimethoprim 200 mg twice a day for 3 days (if low risk of antimicrobial resistance).

31
Q

What is the second line ABX treatment for lower UTI in women (not pregnant or catheterised)?

A

Second-line, if there is no improvement in symptoms after at least 48 hours of first-line treatment, or first-line options are contraindicated or not tolerated, consider prescribing one of the following:
* Nitrofurantoin 100 mg modified-release twice a day for 3 days (if not used first-line).
* Pivmecillinam 400 mg initial dose, then 200 mg three times a day for a total of 3 days.
* Fosfomycin 3 g single dose sachet.

32
Q

What are the first line low-dose ABX prophylaxis for recurrent UTIs?

A
  • trimethoprim 100 mg at night (if low risk of antimicrobial resistance)
  • or nitrofurantoin 50–100 mg at night, depending on clinical judgement.

Can use single dose prophylaxis if clear trigger e.g. post-coital. prescribe trimethoprim 200 mg single dose, or nitrofurantoin 100 mg single dose.

Follow up within 6 months.
Consider topical vaginal oestrogen (off-label indication) if the woman is postmenopausal.

33
Q

When should a woman with recurrent UTIs be referred?

A
  • 60 years and over and has recurrent or persistent unexplained UTI — arrange a non-urgent urological referral.
  • Over 40 years of age, and no known underlying cause for recurrent UTI.
  • suspected underlying cause for recurrent UTI that needs specialist assessment or management: stone disease, interstitial cystitis, or urogynaecological cancer.
34
Q

What is first line ABX treatment for uncomplicated UTI in pregnant woman?

A

First-line, prescribe nitrofurantoin 100 mg modified-release twice a day for 7 days.

35
Q

What is second line ABX treatment for uncomplicated UTI in pregnant woman?

A

Second-line, if there is no improvement in symptoms after at least 48 hours of first-line treatment, or first-line treatment is contraindicated or not tolerated, consider prescribing:
* Amoxicillin 500 mg three times a day for 7 days (only if urine culture results show susceptibility).
* Cefalexin 500 mg twice a day for 7 days.

36
Q

What should be done if group B streptococcal bacteriuria is identified on pregnant woman’s urine culture?

A

ensure midwife and obstetric team are made aware - intrapartum IV antibiotic prophylaxis should be offered in labour.

37
Q

What are the first line ABX for catheter-associated UTI? (men and women)

A
  • Nitrofurantoin 100 mg modified-release twice a day for 7 days, or
  • Trimethoprim 200 mg twice a day for 7 days (if low risk of antimicrobial resistance), or
  • Amoxicillin 500 mg three times a day for 7 days (only if urine culture results show susceptibility).
38
Q

What are the first line ABX treatments for children with lower UTI (aged >3 months)?

A
  • first line options include trimethoprim (if there is low risk of resistance)
  • or nitrofurantoin (if eGFR ≥ 45ml/minute).
39
Q

What is first line ABX treatment for men with lower UTI?

A
  • Trimethoprim 200 mg twice daily for 7 days.
  • Nitrofurantoin 100 mg modified-release twice daily (or if unavailable 50 mg four times daily) for 7 days.

F/U in 48 hrs to ensure response, review culture results.

40
Q

Which antibiotic for UTIs is contraindicated in pregnancy?

A

Trimethoprim.

It is a folate antagonist - there is a teratogenic risk in the first trimester of pregnancy. It should not be used in women who are pregnant.

41
Q

When should trimethoprim be prescribed with caution?

A
  • impaired renal funciton - half the dose if eGFR <15.
  • Hyperkalaemia - or on meds which can cause hyperkalaemia (ACEI/ARB/diuretics). Monitor electrolytes.
  • folate deficiency
42
Q

what are the drug interactions with trimethoprim?

A
  • ACEI/ ARBs/ Diuretics / NSAIDs— increased risk of hyperkalaemia.
  • SSRIs , AMT, NSAIDs— increased risk of hyponatraemia.
  • MTX- bone marrow suppression
  • Aciclovir, NSAIDs - nephrotoxicity
43
Q

What are the contraindications to nitrofurantoin?

A
  • eGFR <45
  • G-6-PD deficiency (including infants with G6PD - affected through breastmilk)
  • pregnant at term - risk of neonatal haemolysis
  • Infants under 3 months of age - haemolysis
44
Q

What are the cautions for nitrofurantoin?

A
  • peripheral neuropathy incl folate deficiency - stop if develop paraesthesiae
  • hepatic impairment - hepatitis
  • renal impairment
  • Lung disease - if on long term Rx - monitor for resp symptoms, cough (pulmonary fibrosis)
  • DM
  • Anaemia (aplastic anaemia, thombocytopenia).
45
Q

When should pyelonephritis be suspected?

A

In people with signs or symptoms of a UTI as well as fever, nausea, vomiting, or flank pain. (triad)

46
Q

When should those with pyelonephritis be referred to hospital?

A
  • signs of sepsis
  • significantly dehydrated
  • Unable to take oral fluids/medications
  • pregnant
  • high risk for complications - structural abnormality of urinary tract, immunosuppressed, DM
  • recurrent UTIs

Non-urgent referral:
* men after a single episode without obvious cause,
* women with recurrent pyelonpehritis.

47
Q

What are the first line ABX for pyelonephritis in the community for all adults who are not pregnant (including with catheters)?

A
  • Cefalexin 500mg twice or three times a day (up to 1– 1.5g three or four times a day for severe infections) for 7-10 days.
  • Co-amoxiclav (only if appropriate in line with culture and sensitivity results) 500/125 mg three times a day for 7-10 days.
  • Trimethoprim (only if appropriate in line with culture and sensitivity results) 200mg twice a day for 14 days.
  • Ciprofloxacin 500 mg twice a day for 7 days.

Consider removing or changing the catheter as soon as possible if it has been in place for more than 7 days.

48
Q

What are the first line ABX for pyelonephritis in pregnant women not requiring hospital admission?

A

Cefalexin 500mg twice or three times a day (up to 1– 1.5g three or four times a day for severe infections) for 7-10 days.

49
Q

What are the first line ABX for pyelonephritis in children not requiring hospital admission?

A
  • Start oral antibiotic treatment with cefalexin, or co-amoxiclav (only if culture results are available and susceptible).
  • If culture results show that the causative organism is resistant to the initially prescribed antibiotic, switch to an alternative.
  • If already receiving prophylactic antibiotics, should be treated with an alternative antibiotic.
50
Q

When should a man with acute prostatitis be admitted?

A
  • cannot take PO ABX
  • severe symptoms
  • sepsis
  • acute retention
  • sign of prostatic abscess
  • consider if immunocompromised, DM, BPH, indwelling catheter
  • if not improved 48hrs after abx
51
Q

How should a man with acute prostatitis be followed up?

A
  • 48 hrs with culture results
  • At 14 days - review and either stop or continue Rx for another 14 days (bloods, urine, syx, examination)
  • once recovered refer for investigation to exclude structural abnormality of urinary tract.
52
Q

When should acute prostatitis be suspected?

A
  • symptoms of UTI
  • perineal, penile, rectal pain
  • acute urinary retention, obstructive voiding symptoms
  • Low back pain, pain on ejaculaton
  • tender, swollen, warm prostate
  • rigors, arthralgia, myalgia, fever, tachycardia.
53
Q

How should suspected acute prostatitis be examined & investigated?

A
  • dipstick & MSU
  • bloods: FBC, blood cultures
  • abdo exam, genital exam, DRE - in acute bacterial prostatitis, prostate will be tender, enlarged or boggy (gentle or can lead to sepsis)
  • screen for STIs if at risk.
54
Q

What is the first line antibiotic for epididymo-orchitis if enteric organism is likely cause?

A
  • Consider treating empirically with oral ofloxacin 200 mg twice daily for 14 days, or oral levofloxacin 500 mg once daily for 10 days.
  • If a quinolone antibiotic is contraindicated, treat with oral co-amoxiclav 500/125 mg three times a day for 10 days.
55
Q
A
55
Q

How should a man be treated if epididymo-orchitis is likely due to an STI? (men aged under 35, and if history suggests)

A

Refer urgently to local specialist sexual health clinic.
If not possible then start ABX in primary care, advise person to abstain until they and partners have completed treatment.

  • if could be due to any STI:
  • Treat empirically with ceftriaxone 1 g intramuscular (IM) injection as a single dose, plus oral doxycycline 100 mg twice daily for 10–14 days.

If a cephalosporin and/or tetracycline antibiotic is contraindicated, treat with oral ofloxacin 200 mg twice daily for 14 days.

56
Q

What is the positive predictive value for a UTI in a woman <65, with nitrite and either blood or leukocytes on dipstick?

A

92%

57
Q

What is the negative predictive
value when nitrite, leukocytes, and blood are all negative?

A

76%

58
Q

What is the positive predictive value for UTI for women <65 with all 3 key symptoms (dysuria, new nocturia, cloudy urine)?

A

82%

59
Q

What is the positive predictive value for UTI for women <65 with 2 key symptoms (dysuria, new nocturia, cloudy urine)?

A

74%

60
Q

What is the positive predictive value for UTI for women <65 with 1 key symptoms (dysuria, new nocturia, cloudy urine)?

A

68%

61
Q

What is the negative predictive value for having none of the 3 key symptoms of UTI (age <65) ?

A

67%

62
Q

In men with symptoms of UTI, what is the PPV of a positive nitrite on dipstick?

A

96%

63
Q

How does acute epididymo-orchitis usually present?

A
  • unilateral scrotal pain over a few days
  • fever and scrotal swelling (lasting <6/52)
  • tender swollen epididymis
  • may also have a hydrocele
  • testis in normal position

AKT - Lizzie Bain (55 decks)

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