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3151 finals > UTI > Flashcards

UTI Flashcards

1
Q

Asymptomatic bacteriuria

A

Isolation of sig colony counts of bacteria in urine (bacteriuria)

From person without symptoms of UTI (asymptomatic)

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2
Q

Pt pop to screen for ASB

A

1) Preg women
a. Prevent pyelo, preterm labour, infant of low birth weight
b. screen on one of first visits 12-16wks gestation
i. Treat with AB (AST) 4-7days

2) Pt going for urologic procedure
a. Mucosal, trauma bleeding is expected
b. Prevent bacteremia, urosepsis (blood stream)
c. Screen before procedure (2-3 days)
i. Use active AB as surgical AB prophylaxis (SAP)
ii. Not include placement of urinary catheter

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3
Q

ASB is common (esp in certain pops)

A

Do not screen in
* Elderly persons (in LT care facility F>M)
* Persons with spinal cord injury (catheter use)
* Kidney transplant
*Indwelling catheter use (ST, LT)

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4
Q

Mental status changes for ASB

A

Bacteriuria & delirium independently COMMON in elderly
○ Delirium, falls, confusions =/= sx of UTI
§ May dehydrated
No diff in insomnia, malaise, fatigue, weakness, anorexia (in presence/ absence of ASB)

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5
Q

Urinary tract infection

A

Isolation of sig colony counts of bacteria in urine

From person with urinary symptoms

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6
Q

severity of UTI

A

cystitis

pyelonephritis

UTI w/ bacteremia/ sepsis/ death

-dysregulated host response to infection cause life-threatening organ dysfunction

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7
Q

Epidemiology of UTI by age
0-6mnths

A

M>F

-structural/ functional abnormality of urinary tract

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8
Q

1- adult

A

F>M

  • shorter urethra, more bacteria access to urinary tract
  • M: protection as prostate secretes antimicrobials
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9
Q

elderly . 65yo

A

EQUAL

Comorbidities, urinary retention, muscular atrophy, stroke
Incr catheter use

M: benign prostatic hypertrophy

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10
Q

Ascending pathophysiology of UTI

A

a. Colonic/ fecal flora colonise periurethra area
b. Ascend to bladder & kidney
c. ** F: shorter urethra, use spermicides, diaphragms contraceptives
- E.coli, klebsiella, proteus

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11
Q

descending pathophysiology of UTI

A

a. Organism at distant primary site (heart valve, bone)
b. Bloodstream (bacteremia)
c. Urinary tract
d. UTI
i. Staphylococcus aureus, mycobacterium tuberculosis
ii. Non-gut bact found in urine + bacteremia lab values

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12
Q

3 factors for development of UTI in host

A

1) competency of natural host defence

2) size of inoculumn
- urinary obstruction= growth

3) virulence of microog
- pili , anti-adherence of bladder

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13
Q

natural host defence

A
  • Bacteria in bladder stimulates micturition
    ○ incr diuresis (empty bladder)
    • Urine, prostatic secretion: Antibacterial properties
    • Bladder anti-adherence mechanism: prevent bact attachment
      *Inflammatory resp with polymorphonuclear leukocytes (PMNs): phagocytosis (prevent spread + control)
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14
Q

risk factors for UTI

A
  • F>M
    • Short urethra, risk ASCENDING
  • Sexual intercourse
    • colonise bact at periurethra area
  • Abnormalities of urinary tract
    • Prostatic hypertrophy
    • Kidney stones
    • Urethral strictures (narrow, retention)
    • Vesicoureteral reflux (urine flows back to bladder)
      ○ Lack valves, risk pyelonephritis
  • Neurologic dysfunction (stroke, DM, spinal cord injury)
    • Malfunction of urinary reflex
  • Anti-cholinergic drugs
    • 1st gen antihistamines/ atropine
  • Catheterisation and other mechanical instrumentation
    • Biofilms, harvest growth. Proliferate in devices
    • Incr access of bact into urethra
  • DM
    • Nephropathy.
    • Incr glucose in urine, more bact growth
  • Preg
  • Diaphragms, spermicides
  • Genetic association (fam hist)
  • Previous UTI
    *Risk factors continue to persist, root cause not removed
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15
Q

prevention of UTI

A
  • Drink fluids (6-8 glasses)
    • Fluid restricted? CKD, HF
  • Urinate frequently when first feel urge
    • Not let bact grow in urine, within bladder
  • Urinate shortly after sex
    • Flush away bact that might have entered urethra
  • Wipe from front to back (after bowel movement)
  • Cotton underwear, loose fitting clothes. Air can keep area DRY
    • Moisture trapped, help bact to grow
  • Alter contraceptives in women, diaphragm/ spermicides
    • Lead to UTI, incr bact growth
      • Incr irritation helps bact grow
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16
Q

complicated UTI

A

a. Associated with conditions that incr potential for serious outcomes, risk for therapy failure
i. UTI in men, children, preg women
ii. Presence of complicating factors:
□ Funct/ struc abnormalities of UT
□ Genitourinary instrumentation
□ DM
□ immunocompromised host

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17
Q

pop for complicated UTI

A

Men, women, children with funct, metabolic, anat conditions
Incr risk of treatment failure
Serious outcomes

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18
Q

uncomplicated UTI pop

A

Healthy, ambulatory women
No history suggestive of ABNORMAL urinary tract

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19
Q

culture for complicated UTI?

A

urinalysis, urine culture indicated

-MDR common, less predictable (FQ)

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20
Q

culture for uncomplicated UTI?

A

culture recc for pyelonephritis

Infection suspected on basis of typical symptoms
-urinalysis and urine culture not routinely needed for susp cystitis

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21
Q

subjective sx for uti

A

i. Localised vs systemic pain
May be diff in elderly
- alr don’t exp much urinary symptoms
1) Altered mental status
2) Drowsy, less alert
3) Change in eating habits
4) General GI symptoms

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22
Q

cystitis sx

A

dysuria, urgency, freq, nocturia
suprapubic pain, heaviness, flank pain
gross hematuria

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23
Q

pyelonephritis sx

A

SYSTEMIC (fever, rigors, headache, maliase)
NV
flank pain, costovertebral tenderness (renal punch)
ab pain

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24
Q

objective sx based on

A

1) UFEME (urine formed elements and microscopic examination)
- WBC, RBC, MICROOG, WBC CAST

2) chemical analysis
- nitrite
- leukocyte esterase

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25
Q

UFEME

A

-WBC
◊ >10 WBCs/mm3 = PYURIA
-Presence of inflammation
- May or may not be due to infection
* Symptomatic pt (pyuria ~~ sig bacteriuria)
* Absence of pyuria = UNLIKELY UTI
- RBC
◊ Presence microscopic >5/ HPF or gross = HEMATURIA
◊ Freq occur in UTI, but non-specific
- Mensus? Transmem in catheterisation, kidney stones, malignancy

  • MICROORG
    ◊ Identify bact, yeast using gram stain
  • WBC CASTS
    ◊ Mass of cells and proteins that form in renal tubules (kidney)
    ◊ Indicate UPPER UTI/ disease
26
Q

chemical analysis

A

-NITRITE
◊ +ve: presence of GRAM NEG bact (> 10*5 bacteria/mL)
*Can reduce nitrate –> nitrite
◊ False -ve: presence of GRAM POS, p. aeruginosa, low urinary pH, freq void/ dilute urine)

-LEUK ESTERASE (LE)
◊ +ve test: esterase activity of leukocytes in urine
◊Sig pyuria (>10 WBCs/mm3)

27
Q

URINE Culture (AST) for who and not for who

A

□ Not for uncomplicated cystitis
- Just treat with empiric

□ FOR: need find out what bact causing infection <– complicated UTI
1) Preg
2) Recurrent UTI (relapse within 2wks/ freq)
3) Pyelonephritis
4) Catheter-associated Uti
5) MEN with UTI

28
Q

Urine collection via 3 methods

A

Midstream clean catch (no contaminants)
Catheterization
Suprapubic bladder aspiration (NEEDLE)

29
Q

uncomplicated bact

A

Gut enterobact// common coloniser of urinary tract
1) E coli
2) Staphylococcus saprophyticus
3) Enterococcus faecalis, klebsiella pneumoniae, proteus spp

30
Q

Complicated UTI or HAI UTI pathogen

A

1) E coli (50%)
2) Enterococci
3) klebsiella pneumoniae, proteus spp, enterobacter spp
- P. Aeruginosa

31
Q

HAI risk factors when pt recent/ freq exposure to healthcare settings:

A

Hosp in last 90 days
current hosp >2 days
residence in nursing home
recent AB use

32
Q

other possible pathogens for UTI

A
  • s.aureus
    (bacteremia, maybe other primary site infections)
  • yeast, candida (contaminant, consider other sites of infection)
33
Q

CA UTI Abx choice

A

empiric treatment
based on susceptibilities

Aim 70% sensitivity for comm (pt well enough, no need high cover = higher selection P.)

34
Q

HAI UTI abx choice

A

a. Dependent on hosp (empiric —> streamline to culture directed)
E.coli, Enterobacteriaceae

35
Q

Cystitis in women 1st line Abx

A

PO - empiric
1) Co-trimoxazole 800/160 BD (3days)
2) Nitrofurantoin 50mg QDS, 5days
a. Only for cystitis, no pyelo
3) Fosfomycin 3g single dose
a. Only for cystitis. MOA: inhibit cell wall
b. (no pyelo: unable to get to kidney tissue, weak bioavail)

36
Q

Complicated cystitis tx

A

PO - empiric but longer duration (7-14d)
1) Co-trimoxazole 800/160 BD
2) Nitrofurantoin 50mg QDS,
3) Fosfomycin: PO 3g every other day (EOD) x 3 doses

37
Q

cystitis alternative drugs

A
  • Beta-lactams (5-7 days)
    • Cefuroxime 250mg BD
    • Amox-clav 625 mg BD
    • Cephalexin 250-500mg QID
  • Fluoroquinolones (3 days)
    • Ciprofloxacin 250mg BD
    • Levofloxacin 250mg daily
      **ADR!
38
Q

CA pyelonephritis PO

A

1) FQ – good can give shorter duration = good conc, but resistance
a. Ciprofloxacin 500mg BD x 7days
b. Levofloxacin 750mg daily 5days

2) Cotrimoxazole 160/800mg BD x 10-14 days

39
Q

CA-pyelonephritis severe ill (IV)

need culture before start IV for step down

A

1) Ciprofloxacin 400mg BD
2) Cefazolin 1g q8hr
3) Amox-clac 1.2g q8h

(add on) Gentamicin 5mg/kg
a. To cover ESBL, Kleb (found in CA)
a. Esp if risk bacteremia

40
Q

beta allergy for CA-pyelo

A
  • Beta lactam x 10-14 days (PO)
    • Cefuroxime 250mg BD
    • Amox-clauv 625 mg TDS
    • Cephalexin 500mg QDS

Need high dose

41
Q

CA-UTI in MEN = NO concern for prostatitis

culture needed

A

complicated UTI in women

PO - empiric but longer duration (7-14d)
1) Co-trimoxazole 800/160 BD
2) Nitrofurantoin 50mg QDS,
3) Fosfomycin: PO 3g every other day (EOD) x 3 doses

42
Q

Abx for those with Concern for prostatitis// pyelonephritis in men

culture needed

A
  • PO ciprofloxacin 500mg BD
  • Po co-trimoxazole 160/800mg BD

10-14 days if at risk
6wks (longer duration) if CONFIRMED

43
Q

HAI- pyelonephritis IV

A
  • Cefepime 2g q12h
    ○ +/- amikacin 15mg/kg/d (cover psuedo/ other ESBL resistant)
  • Imipenem 500mg q6h
  • Meropenem 1g 8h
44
Q

HAI - pyelo risk factors

Broad spectrum empiric —> (change to culture directed)
Pseudo, other resistant (ESBL)

A
  • UTI > 48h post admission
  • pt hosp in last 6mnths
  • pt underwent urological procedure in last 6mnths
  • pt has Indwelling catheter
45
Q

Catheter-associated UTI – iv

A

IV
* Imipenem 500mg q6H
* Meropenem 1g q8h
* Cefepime 2g q12h
+/- amikacin 15mg/kg (1 dose)

Duration for 7days

46
Q

catheter-associated UTI – PO

A

PO/ IV
* Levofloxacin 750mg x 5d (MILD CA-UTI)

  • Co-trimoxazole 960mg BD 3days
    ○ Women <65yrs with CA-UTI
    ○ Without upper urinary tract symptoms after indwell catheter removed
47
Q

catheter-associated UTI duration

A

Duration for 7days (deferverse - no fever in 72hrs, resolve symptoms)

Duration 10-14 days (delayed resp)

48
Q

Catheter-Associated UTI diagnosis

A
  • Presence of symptoms or signs compatible with UTI
  • With NO OTHER identified source of infection
  • 10^3 cfu/mL of >1 bacterial species in single catheter urine specimen in pt with
    ○ indwelling urethral
    ○ Indwelling suprapubic
    ○ Intermittent catheterisation
    ○ Midstream voided urine specimen from pt catheter removed within previous 48h
    - NOT FROM urine bag, from old catheter (biofilm)
49
Q

risk factor of catheter-associated UTI

A
  • Risk factors:
    ○ Duration of catherisation
    § 1 day = 5%
    § 2 day = 10%
    ○ Colonisation of drainage bag, catheter, periurethral segment
    ○ DM
    ○ Female
    ○ Renal function impairment
    ○ Poor quality of catheter care, including insertion
50
Q

Causative org of catheter-associated UTI
depending on duration of use of catheter

A
  • ST <7days: 85% MONOORG (prevailing from environ)
    ○ E.coli, pseudo, kleb
  • LT >28days: 95% POLY (2-3 org)
51
Q

when tx for catheter-associated UTI

A
  • Not recommended to treat ASB
    a. (except prior to traumatic urological procedures)
  • Remove catheter
    a. If indwelling > 2wks at onset of CA-UTI
    b. Replace to hasten resolution, reduce risk of CA-bacteriuria// CA-UTI
  • AB only for symptomatic infection
    a. Symptoms:
    b. OBSERVE > immediate AB (Pt stable, low grade fever)
    c. Need culture (urine + blood) before given AB
    i. Start empiric Abx first —> culture based
52
Q

sx to treat catheter-associated UTI

A

i. new onset/ worsen fever
ii. Rigors
iii. Altered mental status, malaise, lethargy (but elderly sooo)
iv. Flank pain
v. Costovertebral angle tenderness
vi. Acute hematuria
vii. Pelvic discomfort

53
Q

prevention of catheter-associated UTI

A
  • Avoid catheter use
  • Use for minimal duration (trial off)
    ○ Reinsert only if retention
  • LT indwell catheter change before blockage occur
  • Close system insertion (reduce contamination)
  • Ensure aseptic insertion technique
54
Q

Not recc TOP, PROPHYLAXIS, CHRONIC SUPPRESSIVE

A

Chronic suppressive therapy not needed

Not recc TOP, PROPHYLAXIS, CHRONIC SUPPRESSIVE
* Prophylaxis
* ONLY IF Pt high risk sepsis, constant UTI

55
Q

Preg UTI duration for ASB/ cys/ pyelo

A

4-7 days for asymptomatic bacteriuria or cystitis

14days for pyelonephritis

56
Q

preg UTI chocie of therapy

A
  • Beta-lactams
    • 1st line for preg
  • clindamycin safe
  • ery, azi (macrolide) used in preg
  • Choice of drug based on cultures
    • Can be Fosfomycin
      ○ 3 day dose given, not 1 day
      ○ PO 3g every other day (EOD) x 3 doses
57
Q

what to avoid in preg

A
  • Ciprofloxacin
    ○ Fetal cartilage damage
    ○ Arthropathies in animal
    ○ child< 18yrs old
  • Co-trimoxazole
    ○ 1st & 3rd trimester (0-13 wks/ 29-40th wk)
    ○ Folate antagonist TMP cause neural tube defect
    ○ Kernicterus (comp bind bilirubin and sulfonamides to plasma albumin)
    ○ Foetus G6PD def
  • Nitrofurantoin
    ○ 38-42 wks
    ○ Fetus G6PD def
  • Aminoglycosides (caution)
    ○ 8th cranial nerve toxicity in fetus (ana, streptomycin)
    New AG safe

*tetracycline (stain grey), glycycline, linezolid

58
Q

adjunct therapy for UTI

A
  • NSAID
    ○ Pain, fever
  • Rehydration
    ○ Vomit
  • Urinary symptoms
    ○ Phenazopyridine 100-200mg TDS
    § Analgesic effect for urinary tract, symptomatic relief
    § CI: G6PD def
    § ADR: NV, orange-red discolour urine/ stool
    ○ Urine alkalinsation
    § Relief discomfort in mild UTI
59
Q

Non-antimicrobial options (UTI prevention)

A
  • Cranberry
    ○ Inhibit adherence E.coli to urinary tract epithelial cells
    ○ Decr incidence of UTI (clinical studies but have limitations)
  • Intravag estrogen cream
    ○ Remain controversial
    ○ Decr incidence of UTI in post-menopausal women
    ○ Restore vag flora, prevent colonisation of E.coli
  • Lactobacillus probiotics
    ○ Restore normal vag flora
    § BUT !! Protective effect against E.coli colonisation
    Intravag lactobacillus reduced recurrence uncomplicated cystitis
60
Q

monitor UTI

A

1) Resolution of signs and sx
1. Improve in 24-72hrs after effective AB
a. Fail to respond 2-3 days
b. Persistent +ve blood/ urine culture
i. Maybe (bacterial resistance, obstruction, renal abscess, other disease?)

2) Bacteriological clearance
1. Repeat culture not required for pt who responded
2. Culture to document Clearance: preg women

3) Absence of ADR & allergies

61
Q

why moxifloxacin not used for UTI

A

Moxifloxacin not recommended due to it’s poor concentration in the kidneys

drug excreted unchanged in the urine (~20%)

3151 finals (9 decks)

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