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PMY2107 Applied Clinical Pharmacology and Therapeutics > UTI > Flashcards

UTI Flashcards

1
Q

Why are females more prone to get a UTI compared to males?

A

Due to the size of their urethra. Females’ urethra is shorter at 4cm compared to 20cm for males. Hence, it is easier for bacteria to travel through the female urethra to reach the bladder or urinary tract.

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2
Q

Where do most urinary pathogens originate?

A

Originate in the rectal flora and enter the bladder via the urethra.

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3
Q

The lower urethra is usually contaminated with microorganisms, how are the microorganisms usually prevented from ascending?

A

By host defences.

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4
Q

How do infecting organisms over come the host defences?

A

Infecting organisms have virulence factors.

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5
Q

What determines the degree of virulence of an organism which causes UTI?

A

The ability to adhere to epithelial cells.

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6
Q

What are some virulence factors of E.Coli and what are they for?

A

Flagellae - for motility
Aerobactin - for Iron acquisition in Iron poor urinary tracts - Iron needed for growth
Haemolysin - form pores in target cells
Presence of adhesins on bacterial fimbriae (pili) and the cell surface - to adhere to cell surface

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7
Q

Name and describe the two types of E.Coli which cause UTIs.

A
  1. Those with Type 1 fimbriae = FimH adhesin - can cause cystitis
  2. Those with Type 2 fimbriae = PapG adhesin - can cause pyelonephritis
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8
Q

What are adhesins?

A

Structures required for attachment of bacteria to the mucous membranes.

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9
Q

List the 7 host defenses which fight against UTI causing organisms.

A 
Neutrophils
Urine osmolality and pH
Uroepithelium
Urine flow
Blood group antigens 
Complement
Commensal organisms
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10
Q

Describe how neutrophils act as host defense against UTI causing organisms.

A

Adhesins from E.Coli activate the receptors on the mucosal surface which results in IL-8 production and neutrophil activation.

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11
Q

Describe how complements act as host defense against UTI causing organisms?

A

Complement activation with IgA production by uroepithelium is a major defence mechanism - part of acquired immunity.

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12
Q

How does urine flow act as host defence?

A

Normal flow and micturition can wash out the bacteria.

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13
Q

How does uroepithelium play a role in host defence?

A

Mannosylated proteins are present in the mucus and the glycocalyx has anti-bacterial properties.

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14
Q

What are the characteristics of an uncomplicated infection?

A
  1. Confined to the lower urinary tract
  2. Typically affects women
  3. Responds to minimal therapy e.g. OTC, Ibuprofen
  4. Caused by urethral trauma usually sexual intercourse
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15
Q

What are the characteristics of a complicated infection?

A
  1. Caused by anatomical or functional abnormalities affecting urine flow
  2. Presence of foreign objects e.g. catheters
  3. Resistant pathogens
  4. Immunosuppression
  5. Prostatic hypertrophy = enlarged prostate affects urine flow
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16
Q

Describe recurrent UTI.

A

It is characterised by symptomatic episodes and symptoms free intervals.

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17
Q

What does relapse mean?

A

Second infection of the original infecting strain following its apparent eradication.

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18
Q

What does reinfection mean?

A

Isolation of a new pathogenic strain.

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19
Q

What are some host risk factors in healthy pre-menopausal women which can result in UTI?

A
  1. Sexual intercourse and use of spermicide
  2. Taking antimicrobial agents
  3. Use of intimate washes and vaginal cleansers
  4. History of UTIs in childhood/mother with a history of UTIs
  5. Increased expression of E.Coli receptors on vaginal epithelial cells
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20
Q

What are some host risk factors in healthy post-menopausal women which can result in UTI?

A
  1. All of the above
  2. Recurrent UTI
  3. Urinary incontinence - leak urine by accident
  4. Atrophic vaginitis - thinning, drying, inflammation of the vaginal walls
  5. Mechanical/physiological factors affecting bladder emptying
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21
Q

How does sexual intercourse increase the risk of developing UTIs?

A

Can cause damage to the epithelium and move pathogens into the urethra resulting in infection.

22
Q

How does the use of spermicides, antimicrobials and intimates washes cause UTIs?

A

These eliminate the protective effects of the vaginal lactobacilli (commensal organisms) and hence promote growth of the pathogens.

23
Q

How does childhood UTI or mother having UTIs cause an increase in risk of developing a UTI?

A

Genetic predisposition to urinary infections.

24
Q

Why are pregnant women at a higher risk of developing UTIs?

A

In pregnancy, the growth of the foetus puts pressure on the bladder and urethra. This cause vesicoureteric reflux and dilation of ureters (pressure on bladder pushing urine back up to the ureters). This will cause urinary retention and stasis.
Also progesterone in pregnancy tends to relax the smooth muscle which causes dilation of ureters and the effect of retention and stasis more likely.

25
Q

What is meant by stasis of urine?

A

Halting of urinary flow.

26
Q

What are the symptoms of uncomplicated lower urinary tract infection?

A
  • dysuria (burning and stinging on urination)
  • increased frequency in urination but low volume voiding
  • urgency
  • haematuria (blood in urine)
  • nocturia (frequently urinating and night)
27
Q

What are the symptoms of complicated upper tract/ acute pyelonephritis UTI?

A
  • systemic symptoms
  • fever, chills, loin pain, tenderness
  • nausea vomiting
  • blood in urine (haematuria)
    (can be difficult to assign to upper or lower on basis of symptoms)
28
Q

What are the symptoms of UTI in children?

A

Above the age of 2 - classical symptoms of frequency, haematuria, dysturia, sometimes acute abdominal pain and vomiting.

Under the age of 2 - fever, fretful, sick child who fails to thrive (atypical symptoms)

29
Q

For asymptomatic bacteriuria -

A

Treatment not given to non-pregnant women

30
Q

What are the two dipstick tests used to diagnose UTIs as said by SIGN 2020?

A
  1. Urinary pathogens catalyse the reduction of nitrate to nitrite - the presence of nitrite in the urine can be tested to confirm the diagnosis. The urine must be in the bladder for over 4 hours to allow nitrite build up.
  2. Test for leukocyte esterase (LE) - esterases are released by leukocytes when pyuria is present.
31
Q

When are the SIGN dipstick tests used?

A

Used to help decide when dealing with healthy women under the age of 65 presenting with >2 symptoms of UTI.

32
Q

Describe the diagnosis of UTI for women under 65.

A
  1. when 2 or more symptoms of UTI are present
  2. no vaginal discharge and irritation
  3. positive nitrile dipstick test

(SIGN - UTI diagnosis not made if patient only has one symptom - they must return if the single symptom worsens)

33
Q

When is diagnosis using culture done?

A
  1. when UTI diagnosis is likely
  2. when there is more than 2 signs of infection in patients over 65
  3. patient is pregnant
  4. pyelonephritis is present
  5. patient is male
  6. persistent symptoms
  7. failed treatment - need to investigate why
  8. patient is a child
34
Q

What is mid-stream specimen of urine (MSU)?

A

It is a sample of urine sent to the laboratory to be tested. It is rapidly processed or refrigerated after collection.

35
Q

Which microorganism causes most cases of UTIs?

A

E.Coli and other coliforms

Staphylococcus in younger women

36
Q

What condition can asymptomatic bacteriuria lead to in pregnant women?

A

Can lead to acute pyelonephritis.

It rarely leads to this in non-pregnant women.

37
Q

What happens if bacteriuria is not treated in pregnant women?

A

Failure to treat can lead to premature labour.

And if previous renal disease, it may escalate to pre-eclampsia, anaemia and small/premature babies.

38
Q

What is pre-eclampsia/pre-eclamptic toxaemia?

A

Condition which causes high bp during pregnancy or after labour.

39
Q

Most women have asymptomatic bacteriuria. How is this found out?

A

Women are screened at their first antenatal visit. If bacteria is detected, it is cultured and a second culture will also be done to confirm presence of bacteria.

40
Q

In pregnancy, it should be shown that the bacteria/infection has been eradicated. How is it shown?

A

Shown to be eradicated through culturing urine after taking the antibiotic.

41
Q

What is the treatment for lower UTIs as said by SIGN?

A

Take NSAID as first-line treatment in women aged under 65 with suspected uncomplicated UTI who describe their symptoms as mild
e.g. ibuprofen 400mg tid.

42
Q

What one thing to tell the patient who is taking NSAID for UTI treatment?

A

NSAID must only be taken for 3 days to minimise adverse effects and prescriber must be informed if UTI symptoms get worse or don’t resolve in 3 days.

43
Q

What advice do you give patients with antibiotic prescription?

A

Possible adverse effects of antibiotics are nausea and diarrhoea.
Seek medical help if symptoms worsen, they do not improve within 48 hours of taking antibiotic or person becomes very unwell.

44
Q

What is the first-line empirical therapy recommended by NICE and SIGN to treat acute uncomplicated UTIs?

A

Treat non-pregnant women with a 3 days course of nitrofurantoin 1000mg MR tabs bd
OR
Trimethoprim 200mg tabs bd for 3 days

45
Q

What are some alternative antibiotics used to treat acute uncomplicated UTIs?

A
  • ampicillin/amoxicillin or cephalosporins
  • fosfomycin - second line (NICE)
  • co-amoxiclav - reserved for treatment failures
  • pivmecillinam - second line (BNF and NICE)
46
Q

What is the antibiotics given in pregnancy for symptomatic or asymptomatic UTI?

A

Nitrofurantoin or cephalosporins/ penicillin

47
Q

How is UTI in older patients above 65 treated?

A

UTI is often asymptomatic hence no antibiotics necessary.
Do not use dipsticks to diagnose.
If symptomatic treat with standard antibiotic course such as nitrofurantoin or trimethoprim.

48
Q

How is upper UTI/acute pyelonephritis treated in non-pregnant women?

A

Ciprofloxacin - 7 day course

Co-amoxiclav - 14 day course

49
Q

How is relapse of UTI treated?

A

Search for the cause such as kidney stone and treat if found.
Treat with aminoglycoside (IV/IM) for 7 days or oral antibiotics for 4-6 weeks - if failed long-term antibiotics required.

50
Q

How is reinfection of UTI treated?

A

Reinfection indicated that patient has a predisposition to colonisation or poor defence mechanisms.
Review contraceptive practice - discourage use of diaphragm and spermicides.
Identify atrophic vaginitis in women over 65.
Treat for 6-12 months with low dose prophylaxis - trimethoprim 100mg or nitrofurantoin 50-100mg at night

51
Q

Give the patients some points on self-care and prophylaxis.

A
  • take 2.5L of fluid daily
  • void at 2-3 hour intervals (2x if reflux)
  • void at bedtime and after sexual intercourse
  • avoid spermicidal jelly, bubble baths and other chemicals
  • drink cranberry juice
  • take paracetamol or ibuprofen for pain relief
52
Q

How does cranberry juice help in treating UTI?

A

Cranberry juice contains proanthocyanins which prevent bacteria from adhering to the surface of the bladder.

PMY2107 Applied Clinical Pharmacology and Therapeutics (21 decks)

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