- urine got bacteria + urinary symptoms - cystitis -> pyelonephritis -> UTI w bacteraemia/sepsis/death

1) females > males 2) sexual intercourse 3) abnormalities of UT - prostatic hypertrophy, kidney stone, urethral strictures, vesicoureteral reflux 4) neurologic dysfunction - stroke, DM, spinal cord injuries 5) anti-cholinergic drugs - 1st gen antihistamine, atropine - cause urinary retention 6) catheterisation & other mechanical instrumentation 7) DM 8) pregnancy 9) use of diaphragm & spermicide 10) genetic association - +ve family history, 1st degree female relative 11) previous UTI

1) WBC - pyuria: > 10 WBC/mm^3 - presence of inflammation but may/may not be cuz of infection - symptomatic pt: correlate w significant bacteriuria - absence of pyuria = unlikely UTI 2) RBC - presence = haematuria (microscopic > 5/HPF or gross) - frequent in UTI but non specific 3) microorganism: gram stain 4) WBC cast - mass of cell & protein that form in renal tubule - indicate upper tract infection/disease (kidneys X involved)

UTI Flashcards by Justin Tan

definition of asymptomatic bacteriuria (ASB)

urine got bacteria (bacteriuria) but X stymptoms

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UTI

urine got bacteria + urinary symptoms
cystitis -> pyelonephritis -> UTI w bacteraemia/sepsis/death

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what population is ASB especially common in?

old, women, long term indwelling urinary catheter

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indication of screening/treatment of ASB

1) pregnant women

prevent pyelonephritis, preterm labour, infant low birthweight
screen at one of the visits (12-16 wk gestation period)
bacteriaemia -> treat w Abx according to AST for 4-7 days

2) pt undergoing urologic procedure where mucosal trauma/bleeding expected

prevent bacteriaemia & urosepsis
screen prior to procedure
bacteriuria -> active Abx as SAP
X include placement of urinary catheter

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epidemiology of UTI

increases prevalence w age
1) 0 - 6 months: males > females
2) 1 - adult: females > males
3) > 65 yo: equal

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pathogenesis of UTI - ascending

colonic/fecal flora colonise periurethra area/urethra -> ascend to bladder & kidney
factors that increase risk
1) females (shorter urethra)
2) use of spermicide & diaphragms as contraceptives
types of organisms: E.coli, Klebsiella, proteus

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pathogenesis of UTI - descending

more rare
organism at distant primary site -> bloodstream (bacteriaemia) -> urinary tract -> UTI
types of organism: staph aureus, myco tb

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what are the 3 factors determining development of UTI

1) competency of natural host defense mechanism
2) size of inoculum
3) virulence/pathogenicity of microorganism

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factors determining development of UTI - competency of natural host defense mechanism

bacteria in bladder stimulate micturition w increased diuresis -> increase urge to empty bladder -> pee out urine
urine & prostatic secretion antibacterial properties
bladder anti-adherence mechanism: prevent bacterial attachment to bladder
inflammatory response w polymorphonuclear leukocyte (PMNs) -> phagocytosis -> prevent/control spread

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factors determining development of UTI - virulence & pathogenicity of microorganism

bacteria w pili resistant to
1) washout (E.coli)
2) removal by anti-adherence mechanism of bladder

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risk factors for UTI

1) females > males
2) sexual intercourse
3) abnormalities of UT

prostatic hypertrophy, kidney stone, urethral strictures, vesicoureteral reflux

4) neurologic dysfunction

stroke, DM, spinal cord injuries

5) anti-cholinergic drugs

1st gen antihistamine, atropine
cause urinary retention

6) catheterisation & other mechanical instrumentation
7) DM
8) pregnancy
9) use of diaphragm & spermicide
10) genetic association

+ve family history, 1st degree female relative

11) previous UTI

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lifestyle modification to prevent UTI

1) hydration to flush out bacteria
2) urinate frequently & go when first feel urge
3) urinate shortly after sex
4) women: wipe from front to back after bowel movement
5) cotton underwear & loose fitting clothes to keep area dry
6) if using diaphragm/spermicide: consider changing birth control method, unlubricated condoms/spermicidal condom increase irritation -> help bacteria grow

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classification of UTI based on sypmtoms

1) complicated

associated w conditions that increase potential for serious outcomes/risk for therapy failure
** UTI in men, children, pregnant women
** presence of complicating factors: functional & structural abnormalities of urinary tract, genitourinary instrumentation, DM, immunocompromised host

2) uncomplicated

none of the above
healthy premenopausal, non-pregnant women w no history suggestive of abnormal urinary tract

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subjective evidence for lower UTI

1) dysuria, urgency, frequency
2) nocturia
3) suprapubic (hypogastric) heaviness/pain
4) gross haematuria: pee blood

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subjective evidence for upper UTI

more serious
fever, headache, N/V, malaise, flank pain, costovertebral tenderness (renal punch), abdominal pain

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additional subjective symptoms elderly face for UTI

altered mental status (more drowsy, less alert), small GI symptoms, change eating habits

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urine collection method

1) midstream clean-catch
2) catheterisation
3) suprapubic bladder aspiration

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when to get urine culture

1) pregnant women
2) recurrent UTI (relapse within 2 wks/frequent)
3) pyelonephritis
4) catheter-associated UTI
5) all men w UTI

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what is done during urinalysis

UFME, chemical analysis

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UFME components

1) WBC

pyuria: > 10 WBC/mm^3
presence of inflammation but may/may not be cuz of infection
symptomatic pt: correlate w significant bacteriuria
absence of pyuria = unlikely UTI

2) RBC

presence = haematuria (microscopic > 5/HPF or gross)
frequent in UTI but non specific

3) microorganism: gram stain

4) WBC cast

mass of cell & protein that form in renal tubule
indicate upper tract infection/disease (kidneys X involved)

chemical urinalysis through dipstick components

1) nitrite

+ve test = gram -ve bacteria present cuz only gram -ve reduce nitrate to nitrite
at least 10^5 bacteria/mL
possible false positives
** gram pos, Pseudomonas
** low urinary pH
** frequent voiding
** dilute urine

2) leukocyte esterase (LE)

+ve test = esterase activity of leukocyte in urine
correlate w significant pyuria

likely pathogen for uncomplicated/community acquired UTIs

E.coli, staph sacrophyticus, enterococcus faecalis, klebsiella pneumoniae, proteus spp

likely pathogen for complicated/hospital acquired UTIs

E.coli, enterococci, proteus spp, klebsiella spp, enterobacter spp, pseudomonas, drug resistant strain (ESBL producing E.coli)

when to consider other site of infection for UTI

staph aureus, yeast/candida possible contaminant

determining need to treat for UTI

X treat if X symptoms of UTI (ASB) unless pregnant women & urologic procedure in which mucosal trauma/bleeding expected

types of UTI

1) cystitis in women 2) community acquired pyelonephritis in women 3) community acquired UTI men 4) nosocomial/healthcare associated UTI 5) catheter-associated UTI 6) UTI in pregnancy

cystitis in women - 1st line

1) PO cotrimoxazole 2) PO nitrofurantoin

cystitis in women - alternatives if allergic

1) PO beta lactam for 5-7 days - cefuroxime, augmentin 2) PO fluoroquinolone 3 days - ciprofloxacin, levofloxacin - X use if possible because associated w disabling effect

complicated cystitis in women

- longer treatment (7-14 days) - consider fosfomycin ** X 1st line cuz high rate of resistance ** used for cystitis caused by ESBL producing E.coli

community acquired pyelonephritis in women - normal

1) PO fluoroquinolone (ciprofloxacin, levofloxacin) 2) PO cotrimoxazole 3) PO beta-lactam (cefuroxime, augmentin)

community acquired pyelonephritis - initial IV therapy

- severely il pt who require hospitalisation - pt X tolerate oral - types 1) IV ciprofloxacin 2) IV cefazolin 3) IV augmentin 4) +/- IV/IM gentamicin (work for gram -ve ESBL, X work for bacteriaemia) - switch to oral after improve/can tolerate oral

community acquired UTI for men - cystitis wo prostatitis concern

- same as complicated cystitis in women

community acquired UTI for men - cystitis w prostatitis/pyelonephritis concern

1) PO ciprofloxacin 2) PO cotrimoxazole - 10-14 days - 6 wks if prostatitis confirmed

what is nosocomial UTI

onset of UTI > 48h after hospitalisation

possible causes of nosocomial/healthcare-associated UTI

pseudomonas, other resistant bacteria

empiric therapy for nosocomial/healthcare-associated UTI

broad spectrum beta lactam 1) IV cefepime +/- IV amikacin 2) IV imipenem or IV meropenem 3) PO levofloxacin, PO ciprofloxacin - duration 7-14 days - consider oral for less sick pt

definition for catheter-associated UTI (CAUTI)

UTI S&s + X identified source of infection + 10^3 cfu/mL of ≥ 1 bacterial species

catheter-associated UTI (CAUTI) Risk factors

1) duration of catherisation 2) colonisation of drainage bag, catheter, periurethral segment 3) DM 4) female 5) impaired renal function 6) poor quality of catheter care (insertion)

causative organism for catheter-associated UTI

short term (< 7 days): single organism long term (> 28 days): polymicrobial

symptoms for CAUTI

new/worsen fever, rigor, altered mental status, malaise, lethargy w no identified cause, flank pain, costovertebral angle tenderness, acute haematuria, flank pain, change lab values

general treatment for CAUTI

- X treat asymptomatic - consider remove catheter - if CAUTI occur when IDC > 2 wks & still indicated then replace catheter - Abx only for symptomatic

empiric treatment for CAUTI

1) IV imipenem or IV meropenem 2) IV cefepime +/- IV amikacin 3) PO/IV levofloxacin 4) PO cotrimoxazole (women ≤ 65 w CAUTI wo upper urinary tract symptoms after indwelling catheter removed) - 7 days, 10-14 if delayed response

CAUTI prevention

1) avoid unnecessary catheter 2) use for minimal duration 3) change long-term indwelling before blockage likely to occur 4) use of closed system (X a lot of fiddling, X introduce microorganism) 5) ensure aseptic insertion technique 6) x recommend topical/prophylactic antiseptic/Abx & chronic suppressive Abx

what to avoid for pregnant UTI

1) ciprofloxacin - potential fetal cartilage damage & arthropathies in animal studies 2) cotrimoxazole - 1st trimester: folate antagonism of TMP -> neural tube defect - 3rd trimester: kernicterus in newborn - foetus maybe G6PD deficiency 3) nitrofurantoin - X at term (38-42 wks) - concern about G6PD deficiency

what to use w caution for pregnant UTI

1) aminoglycosides (neural tox)

what is safest to use for pregnant UTI

- beta lactams - 4-7 days asymptomatic bacteriuria/cystitis - 14 days pyelonephritis

monitor response

- resolution by 24-72 hrs - if X respond within 2-3 days/persistently positive culture -> reinvestigate to exclude bacterial resistance, possible obstruction, renal abscess, other disease process

adjunctive therapy for UTI

1) fever & pain - paracetamol & NSAID 2) vomiting - rehydration 3) urinary symptoms - phenazopyridine ** topical analgesic on urinary tract mucosa -> symptomatic relief ** treatment limited to duration of symptoms ** X G6PD ** N/V, orange-red discolouration

nonpharmaco for UTI

1) cranberry juice 2) intravaginal estrogen cream 3) lactobacillus probiotics