UTI

Question 1

Symptoms and signs of lower/simple UTI

Answer 1

-Bladder ‘cystitis’
• Urinary frequency
• Urinary urgency
• Dysuria
• Suprapubic tenderness
• Gross Haematuria

Question 2

Symptoms and signs of complicated UTI

Answer 2

-Kidneys/ ureteric obstruction (stones)
• Often cystitis Sx (not always) with
addition of:
• Systemic symptoms
• Fever, rigors, lethargy
• Loin pain/ paravertebral tenderness

Question 3

Examples of uropathogens

Answer 3

-Enterobacteriaceae
• Escherichia coli (75-95% cystitis)
• P-fimbriated E.coli= virulent as adheres to epithelium
• Klebsiella Spp.
• Proteus Spp.
• Staphylococci saprophyticus- young women

-Recent antimicrobials, hospitalisation and urinary
catheters
• Pseudomonas Spp, Enterococcus Spp, and
Staphylococci Spp

Question 4

Describe urinalysis

Answer 4

-Detect
=Leukocyte esterase released by leukocytes indicating pyuria (white blood cells in urine)
=Nitrites- produced by some Enterobacteriaceae by breaking
down nitrates
* Can modestly improve diagnosis but cannot adequately rule out infection.
* Do not use urinalysis in asymptomatic/elderly/catheterised patients

Question 5

Describe urine culture

Answer 5

• 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.

Question 6

Types of lower urinary tract infections

Answer 6

-Cystitis in women and men
-Asymptomatic bacteriuria
-Recurrent UTI

Question 7

Why is cystitis more common in adult women?

Answer 7

-Anatomy
=Shorter distance from anus to urethra

Question 8

Risk factors for cystitis in adult women

Answer 8

• Sexual activity
• Recent UTI
• Diabetes mellitus
• Urinary tract abnormalities
• Post-menopause

Question 9

Clinical symptoms of acute cystitis in women

Answer 9

• Dysuria
• Urinary frequency
• Urinary urgency
• Suprapubic pain
• Haematuria (sometimes)

• Explore alternative diagnosis if vaginal discharge/itch present (STDs, thrush, urethritis)

Question 10

Investigations for acute cystitis in women <65 years

Answer 10

-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.

Question 11

How common is acute cystitis in men?

Answer 11

• 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 (prostate).
-Same symptoms

Question 12

Evaluation of cystitis in men

Answer 12

• 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.

Question 13

Describe diagnosis of cystitis in men

Answer 13

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.

Question 14

Antibiotics treatment of acute cystitis

Answer 14

-Empirical treatment: Nitrofurantoin (low level resistance in E. coli, high concentrations in urine) 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.

Question 15

Diagnosis and treatment of asymptomatic bacteriuria

Answer 15

-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.

Question 16

What is considered a recurrent UTI?

Answer 16

-3 or more laboratory confirmed urinary tract infections within year.
-Consider underlying causes and risk factors. History and examination

Question 17

What should be assessed for in recurrent UTI for causes?

Answer 17

-Constipation
-Uterine prolapse
-Atrophic vaginitis (post-menopausal)
-Diabetes
-Prostatitis
-Relating to sexual intercourse
-Sexually transmitted diseases

Question 18

Investigations for recurrent UTI

Answer 18

-Check renal function
-Urinary tract USS

Question 19

Treatment for recurrent UTI

Answer 19

-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.

Question 20

What is acute pyelonephritis?

Answer 20

Infection causing inflammation of the kidneys
=E Coli most common

-Risk factors
=Obstruction
=Immunosuppression
=DM
=Pregnancy

Question 21

Clinical presentation of acute pyelonephritis

Answer 21

-Cystitis symptoms
• Systemic illness – fever, rigors, marked fatigue.
• Loin pain/costovertebral tenderness- often unilateral
• Fever and flank pain pyelonephritis.
• Sepsis and no localizing symptoms pyelonephritis in differential
• Pelvic/perineal pain in men- ? prostatitis
• Discharge/itch- ?pelvic inflammatory disease, urethritis

Question 22

Examination findings of acute pyelonephritis

Answer 22

• Fever
• SIRS and SEPSIS 6
• Costovertebral tenderness.
• Suprapubic tenderness.
• Caution if significant abdominal tenderness/guarding consider reasons for acute surgical abdomen.

Question 23

Investigations for acute pyelonephritis

Answer 23

-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).

Question 24

Indications for renal tract ultrasound/ CT in acute pyelonephritis

Answer 24

• Severely unwell
• Persisting clinical symptoms (48-72 hours)
• Urinary tract obstruction or Acute Kidney Injury
• Recurrence of symptoms.

Question 25

Urinary stones in complicated urinary tract infection

Answer 25

• 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 related upper urinary tract infections.
• Surgical management aimed at relieving the obstruction

Question 26

Who should be admitted in acute pyelonephritis?

Answer 26

• If septic, at higher risk of complications (e.g. diabetic), unable to take oral medication or concerns re urinary tract obstruction.

Question 27

Empiric antibiotic therapy for pyelonephritis

Answer 27

• IV amoxicillin 1g TDS and IV gentamicin (NHS Lothian calculator)

• Oral options include:
=cotrimoxazole, co-amoxiclav and ciprofloxacin.
=Do not use nitrofurantoin (inability to achieve high levels in systemic circulation).

• 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.

Question 28

Risks and incidence of UTI in catheterised patients

Answer 28

• Patients with indwelling urinary catheters are at a significantly elevated risk for UTI.
• 75% of healthcare acquired UTIs are in patients with urinary catheter
• Do not rely on classical symptoms or signs for predicting the likelihood of symptomatic UTI.

Question 29

Signs and symptoms of UTI in catheterised patients

Answer 29

• New fever, rigors, delirium.
• Flank pain
• Pelvic discomfort
• Acute haematuria
• In patients whom catheter has been removed- dysuria, urgency, suprapubic pain

Question 30

Investigations for UTI in catheterised patients

Answer 30

-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.

Question 31

Antibiotic management for UTI in catheterised patients

Answer 31

• 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.

Question 32

Why is diagnosis of UTI more difficult in elderly patients?

Answer 32

• Non-specific symptoms- delirium, abdominal pain, loss of diabetic control.
• High rates of bacteriuria

Question 33

Management of UTI in elderly patients

Answer 33

• 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.