UTI Flashcards
What is considered an upper UTI?
Kidney and Ureters
What is considered a lower UTI
Prostate
Bladder
Urethra
What is another name for a lower UTI and what are the symptoms?
Simple
Urinary frequency Urinary urgency Dysuria Suprapubic tenderness Gross Haematuria
What is another name for upper UTI and what are the symptoms?
Complicated
Often cystitis Sx (not always) with addition of:
Systemic symptoms
Fever, rigors, lethargy
Loin pain/ paravertebral tenderness
What are the common uropathogens causing UTIs
Enterobacteriaceae Escherichia coli (75-95% cystitis) P-fimbriated Klebsiella spp. Proteus spp. Staphylococci saprophyticus- young women
Recent antimicrobials, hospitalisation and urinary catheters
Pseudomonas spp, Enterococcus spp, and Staphylococci spp.
What tests are required for UTI diagnosis?
Urinalysis
urine culture
How does urinalysis work?
Detect
Leukocyte esterase released by leukocytes indicating pyuria
Nitrites- produced by some Enterobacteriaceae by breaking down nitrates
Can modestly improve diagnosis but cannot adequately rule out infection.
When do you not use urinalysis?
Asymptomatic, elderly or catheterised patients
Function of urine culture?
Confirm the presence of bacteriuria and to provide antibiotic susceptibility.
Mid stream urine routine
Out-with pregnant women only perform culture of urine on symptomatic patients.
≥ 100 000 cfu/ml of a single strain of bacteria confirms bacteriuria, however recent studies have suggested ≥1000 cfu/ml of E. coli can represent infection in symptomatic patients1.
Mixed cultures usually indicate contamination.
Why are woman at more risk for cystitis than men?
Anatomy- shorter distance from anus to urethra compared to men
Risk factors for cystitis in adult woman
Sexual activity Recent UTI Diabetes mellitus Urinary tract abnormalities Post-menopause
Clinical symptoms in acute cystitis in women?
Dysuria Urinary frequency Urinary urgency Suprapubic pain Haematuria (sometimes)
When should you look for an alternative diagnosis for acute cystitis in women?
Explore alternative diagnosis if vaginal discharge/itch present
What investigations for AC in women under 65 years?
In women with 3 or more symptoms of cystitis
Treat empirically. No further investigations required.
Urinalysis:
use to guide treatment decisions mild or 2 symptoms or less or atypical symptoms.
Be wary of using urinalysis in elderly patients
MSU:
Risk of multidrug resistant pathogens, to guide treatment in patients who do not respond to first line antibiotics.
Epidemiology of AC in men?
Much less common in men between 16-50 years due to anatomical differences.
Elderly males: risk increases = elderly women, in part due to outflow obstruction
AC in men?
Urinary frequency, dysuria, urgency, suprapubic pain, haematuria
What should you always evaluate for in AC in men?
Systemic upset/costovertebral tenderness upper urinary tract infection.
Prostatitis- pelvic/perineal pain, obstructive symptoms (dribbling and hesitancy).
Chronic prostatitis-recurrent infections.
STIs and urethritis in all sexually active men.
Diagnosis of AC in men?
Diagnosis of UTI: There is no evidence to suggest the best method for diagnosing UTI in men.
All men with suspected UTI should be regarded as complicated.
Send urine for culture in all suspected cases.
All men with recurrent UTIs should be referred for Urological investigation.
Antibiotics treatment of acute cystitis?
Empirical treatment: Nitrofurantoin or Trimethoprim
Women: 3 days
Men: 7 days
Nitrofurantoin: Avoid in renal failure (eGFR <45 ml/min) due to concerns regarding toxicity.
Second line therapy: in treatment failure use antibiotic susceptibility from urine cultures to guide therapy.
How to confirm asymptomatic bacteriuria?
Laboratory confirmed bacteriuria:
2 x specimens with at least 100 000 cfu/ml of a pure culture for women, only 1 required for men.
Common especially in elderly patients-
DO NOT TREAT
there is no benefit in terms of morbidity/mortality from treating UNLESS Pregnant or in Renal Transplant.
Define recurrent UTI
3 or more laboratory confirmed UTIs within a year
What should you assess for with recurrent UTI
Constipation Uterine prolapse Atrophic vaginitis Diabetes Prostatitis Relating to sexual intercourse Sexually transmitted diseases
Investigations for recurrent UTI in women?
Investigations: Check renal function, urinary tract USS
How to treat recurrent UTI in women?
Non-antibiotic approaches:
Consider cranberry supplements in women- evidence is lacking but some may benefit from this.
Antibiotic approaches:
Post-intercourse antibiotic e.g. trimethoprim single dose
Standby antibiotics- 3 day course dependant on known susceptibilities
Prophylactic antibiotics- 3- 6 months course, stop and assess. Specialist input only. Trimethoprim preferred.
Promotes resistance. Evidence for benefit is not strong.
Define acute pyelonephritis
Infection causing inflammation of the kidneys
Most common cause of upper UTI
E. coli
Clinical presentation of acute pyelonephritis
Cystitis symptoms of dysuria, urinary frequency, suprapubic pain and haematuria PLUS
Systemic illness – fever, rigors, marked fatigue.
Loin pain/costovertebral tenderness- often unilateral
Fever and flank pain think pyelonephritis.
Sepsis and no localizing symptoms think pyelonephritis in differential
Pelvic/perineal pain in men- ? prostatitis
Discharge/itch- ?pelvic inflammatory disease
Clinical presentation of acute pyelonephritis
Cystitis symptoms of dysuria, urinary frequency, suprapubic pain and haematuria PLUS
Systemic illness – fever, rigors, marked fatigue.
Loin pain/costovertebral tenderness- often unilateral
Fever and flank pain think pyelonephritis.
Sepsis and no localizing symptoms think pyelonephritis in differential
Pelvic/perineal pain in men- ? prostatitis
Discharge/itch- ?pelvic inflammatory disease
Examination of acute pyelonephritis
Fever
SIRS and SEPSIS 6
Costovertebral tenderness.
Suprapubic tenderness.
Caution if significant abdominal tenderness/guarding consider reasons for acute surgical abdomen.
Investigations for pyelonephritis
All patients: Urine culture.
Urinalysis- absence of pyuria may indicate alternative diagnosis if atypical presentation.
Inpatients:
Blood cultures, FBC, UECs, LFTs, CRP, (lactate if sepsis).
Indications of sever pyelonephritis
Severely unwell,
Persisting clinical symptoms (48-72 hours)
Urinary tract obstruction or Acute Kidney Injury
Recurrence of symptoms.
Renal tract ultrasound or
Computed tomography
Who is at risk of a complicated urinary tract infection and how should they be managed?
Patients with urinary stones, history of urological surgery e.g. ureteric stents are at increased risk of both upper urinary tract infections and complications.
Perform imaging
Seek prompt urological input for obstructive related upper urinary tract infections.
Surgical management aimed at relieving the obstruction
When should pyelonephritic patients be admited?
If septic, at higher risk of complications (e.g. diabetic), unable to take oral medication or concerns re urinary tract obstruction.
Antibiotics therapy for pyelonephritis
IV amoxicillin 1g TDS and IV gentamicin (NHS Lothian calculator)
Oral options include:
cotrimoxazole, co-amoxiclav and ciprofloxacin.
Do not use nitrofurantoin.
Review with culture results
7 to 14 days in acute pyelonephritis.
Do not continue gentamicin >72 hours without specialist input.
All male patients with upper urinary tract infections should be referred for urological investigation.
Signs and symptoms of catheterised UTIs
New fever, rigors, delirium. Flank pain Pelvic discomfort Acute haematuria In patients whom catheter has been removed- dysuria, urgency, suprapubic pain
Investigations for UTI catheterized patients
Do not perform urine dipstick on catheterised patients.
Send urine for culture.
Send bloods and blood cultures.
Do not treat asymptomatic bacteriuria.
Catheters become colonised very rapidly after insertion, 80% of urinary catheters are colonized at 1 month.
UTI antibiotic management in catheterised patients
IV gentamicin dose as per NHS Lothian calculator.
Change urinary catheter, consider the need for ongoing catheterisation.
Monitor daily decision for ongoing antibiotic therapy
7 day course of antibiotic therapy for males and females with symptomatic catheter associated UTI with prompt resolution of symptoms.
Do not continue gentamicin for longer than 72 hours without specialist input
Review with urine culture results and refine antibiotic choice.
Why is diagnosing UTIs in elderly patients more difficult
Non-specific symptoms- delirium, abdominal pain, loss of diabetic control.
High rates of bacteriuria
How to assess UTI for elderly patients
Urinary tract infection based upon full clinical assessment.
Urine dipstick is not routinely recommended in this age group due to difficulties with interpretation.
Extra care with antibiotic prescribing due to increased risk of adverse effects and Clostridiodes difficile infection.
