uti Flashcards
what is cystitis
pyelonephritis
cystitis- inflammation of bladder
what is pyelonephritis - infection of kidney
begins in urethra or bladder and travels to one or both kidneys
0-6 months prevalent in males or females
males
- more functional and structural abnormalities in males
1- adult prevalent in males or females
females , bc urethra shorter
- easier access to bladder
males have additional protection by antibacterial substance from prostate
in elderly describe the prevalence
equal in both genders
- more comorbidities
- obstruction or retention of urine
explain how benign prostatic hypertrophy can lead to uti
prostate bigger
= urinary retention
= more urine and bowel incontinence due to muscular dysfunction or stroke
explain ascending route of infection and who is at greater risk
colonic / fecal flora colonise periurethra area/ urethra
-> ascend to bladder and kidney
females greater risk of bc shorter urethra , use of spermicides, and diaphragm contraceptives
organisms causing ascending route of infection
ecoli
klebsiella
proteus
usually gram neg
explain hematogenosu ( descending route of infection)
organism @ distant primary site like heart value, bone
-> goes to blood stream -> urinary tract then uti
organisms causing descending/hematogenous route of infection
staph aureus
mycobacterium tubercolosis
( staph not common unless from somewhere else )
describe the 4 host defence mechanisms
- bacteria in bladder stimulates micturition w inc diuresis
= emptying of bladder which gets rid of bacteria thru the urine - urine and prostatic secretion have antibacterial properties
- bladder has anti-adherence mechanisms , prevent bact attaching to bladder
- polymorphonuclear leukocytes ( PMNs) have inflammatory response
= phagocytosis
= prevents and controls spread
which bact is resistant to washout or removal by bladder mechanisms
pili bact
eg ecoli
what are some risk factors
gender sexual intercourse abnormalities of urinary tract neurological dysfunction stroke, diabetes, spinal cord injuries => malfunction of UT - anti cholinergic drugs - catheterisation - pregnancy - diaphragms & spermicides - genes - prev UTI -vesicoureteral reflux
non pharmaco advice
lots of fluid to flush out bact , 6-8 glasses ( if allowed)
urinate frequently
urinate shortly after sex
wipe from front to back
cotton, loose fitting clothes, keep area dry
- modify birth control methods if using diaphragm or spermicide as they inc bacterial growth
uncomplicated uti normally in which grp of patients
premenopausal and non pregnant women with no history of abnormal UT
complicated uti in which grps of patients
anything besides premenopausal women without history of abnormal urinary tract
subjective symptoms of lower UTI ( cystitis)
dysuria- pain on urinartion urgency frequency - bladder not emptied - nocturia - suprapubic heaviness or pain gross hematura ( blood in urine )
subjective symptoms of upper UTI ( pyelonephritis)
fever rigors HA nausea, vomitting malaise flank pain ( pain on each lower back side ) costovertebral tenderness ( renal punch !!!!) abdominal pain
what are some signs and symptoms for elderly bc their symptoms usually arent specific
altered mental status, less alert, changes in eating habits etc
what are the objective vital signs indicating infection
fever > 38 deg
( would be reduced when taking with antipyretics )
inc in total white count
normal 4-10x10^9/L
inc neutrophil count normal 45-75%
CRP protein inc > 40 infection < 10 normal
ESR - indicative of bone/joint infection
procalcitonin levels
is cystitis or pyelonephritis more likely to show signs of general infection
pyelonephritis > cystitis
3 methods of urine collection
midstream clean catch
catheterisation
subrapubic bladder aspiration ( needle to bladder to collect)
UFEME criteria and what its for
UFEME- urine formed elements and microscopic examination
- WBC
>10WBCs/mm3 = pyuria ( pus in urine )
- signifies inflammation but may or may not be due to infection
if patient symptomatic , pyuria correlates with significant bacteuria - RBC
microscopic>5 / HPF or gross = hematuria
shows blood in urine , common but not specific - identification of bacteria or yeast using gram-stain
- WBC cast cells
- indicates upper UTI
/ kidneys involved
( masses of cells and proteins formed in renal tubes and kidneys )
note for WBC and RBC if > 225 no longer counted
describe chemical urinalysis ( dipstick ) - objective diagnosis tool
nitrite
- positive test shows gram neg bacteria present
- requires 10^5 bacteria/mL
- only gram neg reduces nitrate to nitrite
Leukocyte esterase ( LE)
- positive test shows esterase activity of leukocytes in urine which is wbc activity
- correlates with significant pyura or wbc >10 wbc/mm3
what could cause nitrate test false negative results
gram pos p.aeruginosa low urinary pH frequent voiding and dilute urine
when to obtain urine culture
complicated uti -preg , recurrent if 2 weeks or frequent - pyelonephritis - catheter associated uti - uti in men
likely pathogen for uncomplicated or comm-acquired UTI
- ecoli >85% ( more common in females and not so much in males )
- staphyloccus saprophyticus ( 5-15% ) - common coloniser of uti
others - enterococcus faecalis
klebsiella penumoniae
proteus spp
likely pathogen for complicated or healthcare-associated UTI
- ecoli abt 50%
- enterococci ( gram pos )
- proteus spp, klebsiella spp, enterobacter spp,
p. aeruginosa
other likely pathogens for UTI which would require other considerations
s.aureus
commonly due to bacteremia , so consider other sites of infection - come thru bloodstream and isolated in urine
yeast or candida
- could be a possible contaminant
so consider other sites of infection, but normallly dont need to treat
when to treat UTI
positive urine culture
- if symptomatic
dont need to treat if patients not symptomatic UNLESS - pregnant
- children
- patient undergoing invasive urologic procedures w mucosal trauma eg
TURP , cystoscopy with biopsy
why must treat pregnant women
dec risk of developing pyelonephritis ,
risk of preterm labour and
low birth weight infant
why must treat patients going for invasive urologic procedures with mucosal trauma
whats turp and cytosocopy with biopsy
and how
- prophylaxis
to prevent postoperative bacteremia and sepsis
Turp - trans urethral resection of prostate
cytoscopy - scope of bladder with tissue sample
- culture @ start
then start ab based on culture and sensitivity 12-24 hrs before procedure
empiric 1st line ab for uncomplicated cystitis in women
+ dosing
cotrimoxazole 800/160mg bid 3d
nitrofurantoin 50mg qid 5d
fosfomycin 3g single dose
ALL PO
empiric alternatives for uncomplicated cystitis in women
blactams 3-7 days
cefuroxime 250mg bid
cephalexin 500mg bid
augmentin 625mg bid
fluroquinolones x 3 days ciprofloxacine 250mg bid levofloxacin 250mg daily ( but risk of collateral damage ) ALL PO ALSO
for complicated cystitis in women, or uncomplicated cystitis in men with no concern for prostatitis whats the dosing adjustment
treat for a longer duration from 7-14 days
for fosfomycin
eg every other day x 3 doses
why is fosfomycin not recommended even tho 1st line and when to use it
tendon joint muscle pain , cns side effects also reported
use if no other alternative
empiric ab for comm-acquired pyelonephritis in women
cipro 500mg bid x 7 days levo 750mg od x 5 days co-trimoxazole 800/160mg bid x 14 days po cephalexin 500mg bid 10-14 days po augmentin 625mg tds 10-14 days
IV options - for hospitalised or severely ill unable to take oral eg nausea, vomitting
cipro 400mg bid
cefazolin 1g q8h
augmentin 1.2g q8h and or iv/IM gentamicin 5mg/kg ( added for esbl producing ecoli and klebsiella)
not needed in community acquired
switch to oral when can
streamline when urine culture avail
what to note about the duration of treatment for ab
total duration so if total is 14 days empiric for 3 days then remaining 11 days even if negative urine test
empiric ab for comm acquired uti in men with concern for prostatitis OR
pyelonephritis in men
ciprofloxacin 500mg bid
co-trimoxazole 800/160mg bid
treat po for 10-14 days
will need longer duration if prostatitis is confirmed ( 6 weeks )
s&s of prostatitis ( 2 )
localised pain or
pain upon ejaculation
nosocomial meaning
and most common cause of nosocomial uti
onset of uti 48hr post admission
CA uti- most common cause
healthcare associated meaning
patients hospitalised or
underwent invasive urological procedures in last 6 months ,
indwelling catheter etc
for nosocomical, Healthcare acquired pyelonephritis whats the possible organism
what kind of ab spectrum coverage to use
possibility of p.aureug
and other ESBL ecoli and klebsiella
- use broad spectrum b lactam
empiric ab for nosocomial/healthcare associated pyelonephritis
for less sick - po
ciproflocaxin 500mg bid
levofloxacin 750mg bid
iv cefepime 2g q12h w/wo amikacin 15mg/kg for better coverage
iv imipenem 500mg q6h
iv meropenem 1g q8h
duration for 7-14days
definition of catheter associated uti
s&s compatible w UTI but no other identifiable source of infection
+ 10^3 cfu/mL of at least 1 or more bacterial species in single catheter urine specimen in patients with indwelling urethral, indwelling suprapubic or intermittent catheterisation or in a midstream voided urine specimen from patient whose catheter removed in prev 48 hrs
risk factors for CA uti
duration of catheterisation , every day catheter used 3-5% inc in risk of having ca uti
- colonisation of drainage bag, cathether or periurethral segment
- dm
- female
- impaired renal func
- poor catheter care and insertion
organisms causing uti in short terms catheterisation <7 days
single organisms 85%
those prevailing in environment
eg ecoli and klebsiella
organisms causing CA UTI in long term catheterisation >28 days
95% is polymicrobial including 2-3 organisms
eg ecoli, klebsiella and pseudomonas
when to treat ca uti
- treat w ab only is symptomatic Or prior traumatic urological procedure
- <10% febrile causes
- usually low risk
- always consider removal of the catheter , if >2 weeks and theres still an indication for CA-UTI then replace the catheter
what symptoms of CA uti then start ab
new onset fever worsening fever rigors alt mental status malaise lethargy w no other cause flank pain costovertebral angle tenderness , acute hematuria pelvic discomfort
if stable and low grade fever consider observing first
should urine and blood culture be taken before ab given for CA uti
yes mUST
why high threshold for treatment of ca uti
usualy always have positive urine culture
so if low threshold and treat right away can develop resistance
empiric ab for ca uti
IV imipenem 500mg q6h
iv meropenem 1g q8h
iv cefepime 2g q12h +/- amikacin 15mg/kg ( 1 dose )
po/iv levofloxacin 750mg x 5d ( for muld ca-uti )
po co-trimoxazole 960mg bid x 3d
( for women 65 or less with cauti without upper uti symptoms after indwelling catheter removed )
duration - 7 days for prompt resolution of symptoms / afebrile in 72 hrs
10-14 days if delayed response
chronic suppressive therapy & prophylactic why is it not recommended for ca uti
bc ca uti q common
so only given chronic suppressive if frequent life threatening infection then risk to benefit ratio is better
- must be given long term
ca uti prevention
- dont use if not needed
- minimise duation
- change before blockage
- closed system
- antiseptic techniques
- topical ab not reco
- prophylactic ab not reco
abs to avoid for uti in pregnancy
avoid cipro
- fetal cartilage damage
- arthropathies in animals
avoid co-trimoxazole in 1st trimester & close to term
- folate antagonism of TMP can cause neutral tube defects
- avoid close to termbc risk of kernicterus due to comp binding between bilirubin and sulfonamides to plasma albumin
- concern for fetus being g6pd deficient
nitrofurantoin at term
- g6pd deficiency concern
amingolycosides
- toxicity
which ab for pregnnacy is okay
and treat for how long
blactams
7 for asymptomatic bacteriuria or cystitis
14 days for pyelonephritis
additional adjunctive therapy for uti
for pain and fever give antipyretics eg paracetemol and nsaids
for vomitting - rehydration
phenazopyridine ( urogesic )
- topical analgesic effect on ut, symptomatic relief
urine alkalisation
- relief discomfort for mild uti of
phenazopyridine ( urogesic ) dose duration caution adr
100-200mg tds limited for duration of symptoms avoid in g6pd deficiency adr : - nausea - vomitting - orange red discolouration of urine and stool
non pharmaco for avoiding uti
cranberry juice
- inhibits adherence of ecoli to UT epithelial cells
intravaginal estrogen cream
- dec incidence of uti in postmenopausal women
- restores vaginal flora preventing ecoli colonisation
lactobacillus probiotics
- restore normal vaginal flora , prevent ecoli colonisation
- recent small controlled trial showed reduction in uncomplicated cystitis
monitoring
resolution of symptoms by 24-72 hrs after initiating effective ab
if failure after 48-72 hrs, investigate is resistance, obstruction, abscess or other disease
- absence of adr and allergies
- bacteriological clearance but repeat culture not needed for patients who respond
need to do culture to document clearance of infection for who
pregnant women
