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PR3124 CA2 > UTI > Flashcards

UTI Flashcards

1
Q

Upper UTI:

A

pyelonephritis

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2
Q

Lower UTI:

A

cystitis, urethritis, prostatitis, epididymitis

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3
Q

Prevalence at:

  • 0 - 6mths
  • 1 - adult
  • elderly (age >65)
A
  • 0 - 6mths: male > female
  • 1 - adult: female > male
  • elderly (age >65): equal
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4
Q

Common organisms for

  1. Ascending
  2. Descending
A
  1. Ascending: E. coli, Klebsiella pneumoniae, Proteus spp, Staphylococcus saprophyticus
  2. Descending: Staphylococcus aureus, Mycobacterium tuberculosis
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5
Q

Host Defense Mechanisms against development of UTI

A

Bacteria stimulates micturition with increased diuresis -> emptying of bladder
Antibacterial properties of urine & prostatic secretion
Anti adherence mechanisms of bladder (bacterial attachment)
Inflammatory response with polymorphonuclear leukocytes (PMNs) -> phagocytosis -> prevent/control spread

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6
Q

Factors in determining development of UTI besides host defense mechanisms

A

Size of the inoculum: increased with urinary retention/obstruction
Virulence/pathogenicity: bacteria with pili e.g. E. coli resistant to washout or anti-adherence

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7
Q

Risk Factors for UTI

A
  1. Females > males: Pregnancy, Use of diaphragms & spermicides
  2. Sexual intercourse
  3. Abnormalities of the urinary tract eg prostatic hypertrophy, kidney stones, urethral strictures, vesicoureteral reflux
  4. Neurologic dysfunctions eg stroke, diabetes, spinal cord injuries
  5. Anti cholinergic drugs
  6. Catheterization and other mechanical instrumentation
  7. Diabetes
  8. Genetic association (positive family history)
  9. Previous UTI
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8
Q

Prevention of UTI

A
  1. drink lots of fluid
  2. urinate frequently and when you feel the urge
  3. urinate shortly after sex
  4. wear cotton underwear and loose-fitting clothes
  5. modify birth control (diaphragm, spermicide, unlubricated or spermicidal condoms)
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9
Q

What counts as uncomplicated UTI?

A

healthy, premenopausal, non-present women without Hx of abnormalities of urinary tract

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10
Q

Symptoms of cystitis

A

dysuria, urgency, frequency, nocturia, suprapubic heaviness or pain, gross hematuria

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11
Q

Symptoms of pyelonephritis

A

Systemic: fever >38C, rigors, headache, nausea, vomiting, malaise
Pain: flank, renal punch (costovertebral tenderness), abdominal

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12
Q

Symptoms of UTI in elderly (less urinary symptoms)

A
  1. altered mental status (drowsy, less alert)

2. less appetite

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13
Q

Methods of urine collection

A
  1. Midstream clean catch
  2. Catheterization
  3. Suprapubic bladder aspiration
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14
Q

Objective markers from microscopic examination

A

Pyuria: WBC >10cells/mm3 (most indicative)
Hematuria: >5/HPF or gross (non-specific)
Gram-stain
WBC casts: masses of cells/proteins in renal tubules -> upper UTI

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15
Q

Common contaminants in UFEME

A

Yeast (not pathogen)

Squamous epithelial cells (if >5)

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16
Q

What do the dipstick indicators mean? (nitrite and leukocyte esterase)

A
  1. Nitrite: gram-neg bacteria (>10^5 bacteria/mL)
    - False negative: gram-pos or P. aeruginosa, low urinary pH, frequent voiding/dilute urine
  2. Leukocyte esterase: correlate w/ pyuria
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17
Q

What are healthcare-associated risk factors for healthcare associated or complicated UTI?

A
  1. Hospitalization in the last 90 days
  2. Current hospitalization >2 days
  3. Residence in nursing home
  4. Abx use in the last 90 days
  5. Home infusion therapy
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18
Q

What is characteristic of complicated or healthcare-associated UTI?

A

More drug resistant organisms e.g. ESBLs are likely

19
Q

When should you treat asymptotic UTI?

A
  1. Pregnant: reduce pyelonephritis, risk of preterm labour and low birth weight
  2. Invasive procedures w/ mucosal trauma: culture then start abx on culture and sensitivity 12-24h before procedure
20
Q

1st line Empiric antibiotics for uncomplicated cystitis

A

PO cotrimoxazole 800/160 mg bid x 3d or
PO nitrofurantoin 50 mg qid x 5d
PO fosfomycin 3 g single dose

21
Q

alternative empiric antibiotics for uncomplicated cystitis

A
  1. PO beta lactams x 3-7d
    - PO cefuroxime 250mg bd
    - PO cephalexin 500mg bd
    - PO augmentin 625mg bd
  2. PO fluoroquinolones x 3d
    - PO ciprofloxacin 250mg bd
    - PO levofloxacin 250mg od
22
Q

Abx duration for complicated cystitis in women

A

Longer duration of 7-14d

- PO Fosfomycin 3g EOD x3 doses

23
Q

Empiric abx for CA-pyelonephritis

A
  1. PO fluoroquinolones
    - ciprofloxacin 500 mg bd x 7d
    - levofloxacin 750 mg od x 5d
  2. PO cotrimoxazole 160/800 mg bd x 14d
  3. PO Beta-lactams x 10-14d
    - cephalexin 500 mg bid
    - amoxicillin/clavulanate 625 mg tds
24
Q

Initial IV therapy for severely ill patients who require hospitalisation or cannot take oral drug (CA-pyelonephritis)

A 
IV ciprofloxacin 400mg bid 
IV cefazolin 1g q8h
IV augmentin 1.2g q8h and/or 
IV/IM gentamicin 5mg/kg 
***Switch to oral when patient improved or able to take orally
25
Q

Empiric abx for UTI in men without concern for prostatitis

A

Same as regimen for complicated cystitis in women but longer duration

26
Q

Empiric abx for UTI in men with cystitis (concern for prostatitis) or with prostatitis

A

PO ciprofloxacin 500 mg twice daily x10-14d

PO co trimoxazole 800/160 mg twice daily x7d ok

27
Q

How long is the abx duration for UTI in men with confirmed prostatitis?

28
Q

Empiric abx for nosocomial/healthcare-associated pyelonephritis

A

Duration: 7-14 days
IV cefepime 2g q12h +/ IV amikacin 15mg/kg/d or
IV imipenem 500mg q6h or IV meropenem 1g q8h
For less sick patients:
- PO levofloxacin 750mg od
- PO ciprofloxacin 500mg bid

29
Q

When is the onset of nosocomial UTI?

A

> 48h post admission

30
Q

What is the rationale of choosing broad spectrum B-lactams for nosocomial/healthcare-associated pyelonephritis?

A

Possibility of P. aeruginosa and other resistant bacteria (e.g. ESBL producing E. coli and Klebsiella)

31
Q

Risk factors for development of catheter-associated UTI

A
  1. Duration of catheterisation: +3-5% risk per day
  2. Colonisation of drainage bag, catheter and periurethral segment
  3. DM
  4. Female
  5. Renal function impairment
  6. Poor quality of catheter care, including insertion
32
Q

Definition of Catheter-associated UTI

A
  1. UTI symptoms/signs w/ no other identified source of infection
  2. 10^3 cfu/mL of ≥1 bacterial species in:
    - 1 catheter urine specimen in patients with indwelling urethral/suprapubic, or intermittent catheterization
    OR
    - midstream voided urine specimen when catheter has been removed within the previous 48 h
33
Q

After 28 days, catheter-associated UTI is likely to be ___. Before 7 days, catheter-associated UTI is likely to be ___ reflecting that prevailing the environment.

A

After 28 days, catheter-associated UTI is likely to be polymicrobial. Before 7 days, catheter-associated UTI is likely to be single organisms reflecting that prevailing the environment.

34
Q

What is the first thing to consider for catheter-associated UTI?

A

Consider removal of catheter
Removal not possible: Indwelling catheter has been in place for >2 wks at the onset of CA UTI and is still indicated -> replace the catheter
- Rationale: to hasten resolution of symptoms and to reduce the risk of subsequent CA bacteriuria and CA UTI

35
Q

Are cultures required for catheter-associated UTI?

A

Yes, urine culture must be taken before initiation of antibiotics.

36
Q

What counts as symptomatic CA-UTI for initiation of abx?

A
  1. new onset or worsening of fever, rigors
  2. altered mental status, malaise, or lethargy with no other identified cause
  3. flank pain; costovertebral angle tenderness; acute hematuria; pelvic discomfort
37
Q

Empiric abx and abx duration for CA-UTI

A

Duration: 7d for prompt resolution, otherwise 10-14 days

  • IV imipenem 500mg q6H or IV meropenem 1g q8h
  • IV cefepime 2g q12H +/ IV amikacin 15mg/kg (1 dose)
  • Mild CA UTI: PO/ IV levofloxacin 750mg x 5d
  • PO Co trimoxazole 960mg bid x 3d (for women ≤65yo w/ CA UTI w/o upper UTI symptoms after an indwelling catheter has been removed)
38
Q

Why is ertapenem not used for CA-UTI?

A

not effective against Pseudomonas aeruginosa

39
Q

What are the abx to avoid in pregnant women with UTI?

A
  1. Cotrimoxazole (1st & 3rd trimester)
  2. Nitrofurantoin (at term)
  3. Ciprofloxacin
  4. Aminoglycosides
40
Q

For UTI in pregnant women, what is the duration of abx?

A

7 days: asymptomatic bacteriuria or cystitis

14 days: pyelonephritis

41
Q

Are cultures needed for UTI in pregnant women?

A

Yes, cultures are required for clearance of infection

42
Q

What should we look at if a patient is not responding after 2-3 days or has persistently positive cultures?

A
  • Bacterial resistance
  • obstruction
  • renal abscess: big load/inoculum, requires drainage
43
Q

What are adjunctive therapy options for urinary symptoms?

A
  1. Phenazopyridine 100-200mg tds
    - avoid in G6PD deficiency
    - ADR: nausea, vomiting, orange-red discolouration
  2. Urine alkalinization w/ Na or K citrate

PR3124 CA2 (4 decks)

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