UTI Flashcards
Host defense mechanism against UTI?
- Bacteria in bladder stimulates micturition with increased diuresis → emptying of bladder
- Antibacterial properties of urine & prostatic secretion
- Anti-adherence mechanisms of bladder (prevent bacterial attachment to bladder)
- Inflammatory response with polymorphonuclear leukocytes (PMNs) → phagocytosis → prevent/ control spread
Risk factors for UTI?
Females > males
Sexual intercourse
Abnormalities of urinary tract
Neurologic dysfunctions
Anti-cholinergic drugs (e.g. atropine, 1st gen antihistamine)
Catheterization and other mechanical instrumentation
Diabetes
Pregnancy
Use of diaphragms & spermicides
Genetic association (positive family history)
Previous UTI
Complicated UTI?
UTI associated with conditions that increase the potential for serious outcomes, risk for therapy failure
UTIs in men, children & pregnant women, functional and structural
abnormalities of urinary tract, genitourinary instrumentation, diabetes mellitus, immunocompromised host
uncomplicated UTI?
Usually in healthy premenopausal, non-pregnant women with no history suggestive of an abnormal urinary tract
Subjective evidence (symptoms) for cystitis?
dysuria, urgency, frequency, nocturia, suprapubic heaviness or pain; gross hematuria
Subjective evidence (symptoms) for pyelonephritis?
fever, rigors, headache, nausea, vomiting, and malaise, flank pain, costovertebral tenderness (renal punch), or abdominal pain
When to culture?
✔ Pregnant women, recurrent UTI, pyelonephritis, catheter-associated UTI, all men with UTI
❌Uncomplicated cystitis
UFEME
- White blood cells (WBC)
o > 10 WBCs/mm3 = pyuria (w/ smx = UTI) - Red blood cells (RBC)
o Presence (microscopic >5/ HPF or gross) = hematuria –> frequently occurs in UTI but non-specific - WBC casts
o Indicate upper tract infection / disease
Chemical urinalysis (dipstick)
- Nitrite
Positive test detects presence of Gram-negative bacteria; requires at least 10^5 bacteria/mL - Leukocyte esterase (LE)
Positive test detects esterase activity of leukocytes in urine. Correlates with significant pyuria (>10 WBCs/mm3)
Pathogen for uncomplicated/ community-acquired UTI
- Escherichia coli (>85%)
- Staphylococcus saprophyticus (5-15%)
- Others: Enterococcus faecalis, Klebsiella pneumoniae, Proteus spp
Pathogen for complicated/ healthcare-associated UTI
- E. coli (≈50%)
- Enterococci
- Proteus spp, Klebsiella spp, Enterobacter spp, P.aeruginosa
Miscellaneous pathogen
S. aureus – commonly due to bacteremia; consider other primary site of infections
Yeast or Candida – possible contaminant; consider other
sites of infection
Need to treat?
Yes if smx No except: 1. Pregnant woman 2. Pt going for invasive urologic procedures 3. Children
Community-acquired women’s uncomplicated cystitis
First line • PO co-trimoxazole 800/160 mg bid x 3d • PO nitrofurantoin 50 mg qid x 5d • PO fosfomycin 3 g single dose Alternative [PO beta-lactams x 3-7 days] preggo • PO cefuroxime 250 mg bid • PO cephalexin 500 mg bid • PO amoxicillin-clavulanate 625 mg bid [PO fluroquinolones x 3 days] • PO ciprofloxacin 250 mg bid • PO levofloxacin 250 mg daily
Community-acquired women’s complicated cystitis
Same as uncomplicated cystitis but
Treat for longer duration e.g. 7-14days
Fosfomycin: PO 3g EOD x 3 doses
Community-acquired women’s pyelonephritis
Oral: [PO fluoroquinolones] • PO ciprofloxacin 500 mg twice daily x 7 days or • PO levofloxacin 750 mg daily x 5 days [PO co-trimoxazole 160/800mg twice daily x 14 days] [PO beta-lactam x 10-14 days] • PO cephalexin 500 mg bid • PO amoxicillin-clavulanate 625 mg tds IV: • IV ciprofloxacin 400mg bid • IV cefazolin 1g q8h • IV amoxicillin-clavulanate 1.2g q8h and/or • IV/IM gentamicin 5mg/kg
Community-acquired men’s cystitis
Same as uncomplicated cystitis in women but
Treat for longer duration e.g. 7-14days
Fosfomycin: PO 3g EOD x 3 doses
Community-acquired men’s pyelonephritis/ cystitis + prostatitis
▪ PO ciprofloxacin 500 mg twice daily x 10-14 days
▪ PO co-trimoxazole 800/160 mg twice-daily x 10-14days
Nosocomial/ healthcare associated pyelonephritis
Possibility of pseudomonas aeruginosa, ESBL E.coli/klebsiella should be considered
• IV cefepime 2g q12h +/- IV amikacin 15mg/kg/d x 7-14 days
• IV imipenem 500mg q6h or IV meropenem 1g q8h x 7-14 days
• PO levofloxacin 750mg (for less sick patients) x 7-14 days
• PO ciprofloxacin 500mg bid (for less sick patients) x 7-14 days
CA-UTI tx?
• IV imipenem 500mg q6H or IV meropenem 1g q8h
• IV cefepime 2g q12H +/- IV amikacin 15mg/kg (1 dose)
• PO/ IV levofloxacin 750mg x 5d (for mild CA-UTI)
• PO Co-trimoxazole 960mg bid x 3d (for women ≤65 years with CA-UTI without upper urinary tract symptoms after an indwelling catheter has been removed)
- Duration of treatment: usually 7 days in those with prompt resolution of symptoms and 10–14 days of treatment for those with a delayed response
CA-UTI occurs in?
Presence of symptoms or signs compatible with UTI +
10^3 cfu/mL of ≥1 bacterial species in a single catheter urine specimen in patients with indwelling urethral/ related shit/ in urine of pt who removed it last 48h
Risk factors of CA-UTI?
- Duration of catheterization <7days only 1 organism, >28days likely polymicrobial
- Colonisation of drainage bag, catheter and periurethral segment
- DM
- Female
- Renal function impairment
- Poor quality of catheter care, including insertion
To treat?
Yes if smx; take culture before antibx given
- consider if pt is stable & fever is low grade
No except:
prior to traumatic urological procedure
Smx of CA-UTI?
: new onset or worsening of fever, rigors, altered mental status, malaise, or lethargy with no other identified cause; flank pain; costovertebral angle tenderness; acute hematuria; pelvic discomfort
Prevention of CA-UTI?
- Avoid unnecessary catheter use
- Use for minimal duration
- Long-term indwelling catheters changed before blockage is likely to occur
- Use of closed system
- Ensure aseptic insertion technique
- Topical antiseptic or antibiotics not recommended
- Prophylactic antibiotics and antiseptic not recommended
- Chronic suppressive antibiotics is not recommended
UTI drug to avoided in pregnancy
Ciprofloxacin
Cotrimoxazole (Folate, kernitctus, G6PD)
Nitrofurantoin (G6PD)
AG
What to use in UTI pregnancy?
beta lactams
- Treat for 7 days for asymptomatic bacteriuria or cystitis
- Treat for 14 days for pyelonephritis
Adjunctive therapy for UTI?
Pain & fever Paracetamol/ NSAIDs
Vomiting Rehydration
Urinary symptoms Phenazopyridine
an azo dye and exerts a topical analgesic effect on the urinary tract mucosa to provide symptomatic relief
treatment should be limited for the duration of symptoms
C/I: G6PD deficiency
ADR: nausea, vomiting, orange-red discolouration of urine and stool
Urine alkalization
relief discomfort in mild UTI, unproven benefit
Non-antimicrobial options for UTI prevention?
Cranberry juice
Intravaginal estrogen cream
Lactobacillus probiotics
