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3124 ca2 > uti > Flashcards

uti Flashcards

1
Q

what is cystitis

pyelonephritis

A

cystitis- inflammation of bladder
what is pyelonephritis - infection of kidney
begins in urethra or bladder and travels to one or both kidneys

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2
Q

0-6 months prevalent in males or females

A

males

- more functional and structural abnormalities in males

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3
Q

1- adult prevalent in males or females

A

females , bc urethra shorter
- easier access to bladder
males have additional protection by antibacterial substance from prostate

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4
Q

in elderly describe the prevalence

A

equal in both genders

  • more comorbidities
  • obstruction or retention of urine
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5
Q

explain how benign prostatic hypertrophy can lead to uti

A

prostate bigger
= urinary retention
= more urine and bowel incontinence due to muscular dysfunction or stroke

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6
Q

explain ascending route of infection and who is at greater risk

A

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

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7
Q

organisms causing ascending route of infection

A

ecoli
klebsiella
proteus
usually gram neg

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8
Q

explain hematogenosu ( descending route of infection)

A

organism @ distant primary site like heart value, bone

-> goes to blood stream -> urinary tract then uti

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9
Q

organisms causing descending/hematogenous route of infection

A

staph aureus
mycobacterium tubercolosis
( staph not common unless from somewhere else )

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10
Q

describe the 4 host defence mechanisms

A
  1. bacteria in bladder stimulates micturition w inc diuresis
    = emptying of bladder which gets rid of bacteria thru the urine
  2. urine and prostatic secretion have antibacterial properties
  3. bladder has anti-adherence mechanisms , prevent bact attaching to bladder
  4. polymorphonuclear leukocytes ( PMNs) have inflammatory response
    = phagocytosis
    = prevents and controls spread
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11
Q

which bact is resistant to washout or removal by bladder mechanisms

A

pili bact

eg ecoli

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12
Q

what are some risk factors

A 
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
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13
Q

non pharmaco advice

A

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

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14
Q

uncomplicated uti normally in which grp of patients

A

premenopausal and non pregnant women with no history of abnormal UT

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15
Q

complicated uti in which grps of patients

A

anything besides premenopausal women without history of abnormal urinary tract

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16
Q

subjective symptoms of lower UTI ( cystitis)

A 
dysuria- pain on urinartion 
urgency 
frequency - bladder not emptied 
- nocturia 
- suprapubic heaviness or pain 
gross hematura ( blood in urine )
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17
Q

subjective symptoms of upper UTI ( pyelonephritis)

A 
fever 
rigors 
HA 
nausea, vomitting 
malaise 
flank pain ( pain on each lower back side ) 
costovertebral tenderness ( renal punch !!!!) 
abdominal pain
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18
Q

what are some signs and symptoms for elderly bc their symptoms usually arent specific

A

altered mental status, less alert, changes in eating habits etc

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19
Q

what are the objective vital signs indicating infection

A

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

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20
Q

is cystitis or pyelonephritis more likely to show signs of general infection

A

pyelonephritis > cystitis

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21
Q

3 methods of urine collection

A

midstream clean catch
catheterisation
subrapubic bladder aspiration ( needle to bladder to collect)

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22
Q

UFEME criteria and what its for

UFEME- urine formed elements and microscopic examination

A
  1. 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
  2. RBC
    microscopic>5 / HPF or gross = hematuria
    shows blood in urine , common but not specific
  3. identification of bacteria or yeast using gram-stain
  4. 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

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23
Q

describe chemical urinalysis ( dipstick ) - objective diagnosis tool

A

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
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24
Q

what could cause nitrate test false negative results

A 
gram pos 
p.aeruginosa 
low urinary pH 
frequent voiding and
dilute urine
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25
Q

when to obtain urine culture

A 
complicated uti 
-preg
, recurrent if 2 weeks or frequent 
- pyelonephritis 
- catheter associated uti 
- uti in men
26
Q

likely pathogen for uncomplicated or comm-acquired UTI

A
  • 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
27
Q

likely pathogen for complicated or healthcare-associated UTI

A
  • ecoli abt 50%
  • enterococci ( gram pos )
  • proteus spp, klebsiella spp, enterobacter spp,
    p. aeruginosa
28
Q

other likely pathogens for UTI which would require other considerations

A

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

29
Q

when to treat UTI

positive urine culture

A
  • 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
30
Q

why must treat pregnant women

A

dec risk of developing pyelonephritis ,
risk of preterm labour and
low birth weight infant

31
Q

why must treat patients going for invasive urologic procedures with mucosal trauma

whats turp and cytosocopy with biopsy

and how

A
  • 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
32
Q

empiric 1st line ab for uncomplicated cystitis in women

+ dosing

A

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

33
Q

empiric alternatives for uncomplicated cystitis in women

A

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
34
Q

for complicated cystitis in women, or uncomplicated cystitis in men with no concern for prostatitis whats the dosing adjustment

A

treat for a longer duration from 7-14 days

for fosfomycin
eg every other day x 3 doses

35
Q

why is fosfomycin not recommended even tho 1st line and when to use it

A

tendon joint muscle pain , cns side effects also reported

use if no other alternative

36
Q

empiric ab for comm-acquired pyelonephritis in women

A 
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

37
Q

what to note about the duration of treatment for ab

A

total duration so if total is 14 days empiric for 3 days then remaining 11 days even if negative urine test

38
Q

empiric ab for comm acquired uti in men with concern for prostatitis OR
pyelonephritis in men

A

ciprofloxacin 500mg bid
co-trimoxazole 800/160mg bid

treat po for 10-14 days

will need longer duration if prostatitis is confirmed ( 6 weeks )

39
Q

s&s of prostatitis ( 2 )

A

localised pain or

pain upon ejaculation

40
Q

nosocomial meaning

and most common cause of nosocomial uti

A

onset of uti 48hr post admission

CA uti- most common cause

41
Q

healthcare associated meaning

A

patients hospitalised or
underwent invasive urological procedures in last 6 months ,
indwelling catheter etc

42
Q

for nosocomical, Healthcare acquired pyelonephritis whats the possible organism

what kind of ab spectrum coverage to use

A

possibility of p.aureug
and other ESBL ecoli and klebsiella

  • use broad spectrum b lactam
43
Q

empiric ab for nosocomial/healthcare associated pyelonephritis

A

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

44
Q

definition of catheter associated uti

A

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

45
Q

risk factors for CA uti

A

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
46
Q

organisms causing uti in short terms catheterisation <7 days

A

single organisms 85%
those prevailing in environment
eg ecoli and klebsiella

47
Q

organisms causing CA UTI in long term catheterisation >28 days

A

95% is polymicrobial including 2-3 organisms

eg ecoli, klebsiella and pseudomonas

48
Q

when to treat ca uti

A
  • 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
49
Q

what symptoms of CA uti then start ab

A 
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

50
Q

should urine and blood culture be taken before ab given for CA uti

A

yes mUST

51
Q

why high threshold for treatment of ca uti

A

usualy always have positive urine culture

so if low threshold and treat right away can develop resistance

52
Q

empiric ab for ca uti

A

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

53
Q

chronic suppressive therapy & prophylactic why is it not recommended for ca uti

A

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

54
Q

ca uti prevention

A
  • dont use if not needed
  • minimise duation
  • change before blockage
  • closed system
  • antiseptic techniques
  • topical ab not reco
  • prophylactic ab not reco
55
Q

abs to avoid for uti in pregnancy

A

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

56
Q

which ab for pregnnacy is okay

and treat for how long

A

blactams
7 for asymptomatic bacteriuria or cystitis
14 days for pyelonephritis

57
Q

additional adjunctive therapy for uti

A

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

58
Q 
phenazopyridine ( urogesic ) 
dose 
duration 
caution 
adr
A 
100-200mg tds 
limited for duration of symptoms 
avoid in g6pd deficiency 
adr : 
- nausea
- vomitting 
- orange red discolouration of urine and stool
59
Q

non pharmaco for avoiding uti

A

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
60
Q

monitoring

A

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
61
Q

need to do culture to document clearance of infection for who

A

pregnant women

3124 ca2 (5 decks)

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