UTI Flashcards
Screening and Tx of asymptomatic bacteriuria (ASB) is only indicated for 2 adult populations. Which 2 adult populations are they?
- Pregnant women
- Patients going for urologic procedure in which mucosal trauma/ bleeding is expected
Do we associate mental state changes/ decreased feeling of well-being with ASB?
No.
But possible for pt to have symptomatic bacteriuria AND delirium → give empiric Abx therapy
Name the types of lower UTI (4) and upper UTI (1)
Lower UTI:
- Cystitis
- Urethritis
- Prostatitis
- Epididymis
Upper UTI:
- Pyelonephritis (kidneys)
List some examples of pathogens involved in the ascending and descending (hematogenous) route of infection for UTI
Ascending: E. coli, Proteus, Klebsiella
Descending: Staphylococcus aureus, Mycobacterium Tuberculosis
What are the risk factors for UTI? (11)
- Females > males (1 y/o - adult)
- Sexual intercourse
- Abnormalities of urinary tract (eg prostatic hypertrophy, kidney stones, urethral strictures, vesicoureteral reflux)
- Neurological dysfunctions (eg stroke, diabetes, spinal cord injuries)
- Anticholinergic drugs
- Catheterization and other mechanical instrumentation
- Diabetes
- Pregnancy
- Use of diaphragms and spermicides
- Genetic association (positive family history)
- Previous UTI
Non-pharmacological Tx to prevent UTIs?
- Drink lots of fluid to flush the bacteria (6-8 glasses/day), unless you have a condition that requires fluid restriction
- Urinate frequently
- Urinate shortly after sex
- For women: wipe from front to back after using the toilet
- Wear cotton underwear and loose-fitting clothes so that air can keep the area dry. Avoid tight-fitting jeans and nylon underwear which trap moisture
- Use of diaphragm and spermicide, unlubricated condoms or spermicidal condoms increase irritation and can increase bacterial growth
Define complicated UTI and list out several complicating factors. What type of people get complicated UTI?
Complicated UTI: UTI associated with conditions that ↑ potential for serious outcomes, risk for Tx failure
Eg UTIs in men, children and pregnant women
Complicating factors:
- Functional and structural abnormalities of urinary tract
- Genitourinary instrumentation (eg catheter)
- DM
- Immunocompromised
Define uncomplicated UTI. What type of people get complicated UTI?
Usually in healthy premenopausal, non-pregnant women with no history suggestive of abnormal urinary tract
What are the subjective s/sx for lower urinary tract infection (cystitis)? (6)
- Dysuria
- Urgency
- Frequency
- Nocturia
- Suprapubic heaviness or pain
- Gross hematuria
What are the subjective s/sx for upper urinary tract infection (pyelonephritis)?
- Fever
- Rigors
- Headache, n/v
- Malaise
- Flank pain, costovertebral tenderness (renal punch)
- Abdominal pain
What are some s/sx that especially elderly may experience if infected with UTI?
Elderly frequently do not experience specific urinary s/sx but can present with altered mental status, less alert, more drowsy, change in eating habits or GI s/sx
What are the 4 different lab results obtained from UFEME (urinalysis)?
What can you say about WBC?
WBC, RBC (non-specific), microorganisms, WBC casts
WBC > 10 x 10^9 cells/L
Signifies inflammation, but may or may not be due to infection, BUT absence of pyuria = unlikely UTI
In which type of pts do we take urine cultures?
- Pregnant women
- Recurrent UTI
- Pyelonephritis
- Catheter-associated UTI
- All men with UTI
Pathogens in uncomplicated cystitis in women
- E. coli (> 85%)
- Staphylococcus saprophyticus (5-15%)
- Enterococcus faecalis
- Klebsiella pneumoniae
- Proteus spp.
Pathogens in complicated/ healthcare-associated UTI?
- E. coli (~50%)
- Enterococci
- Proteus spp
- Klebsiella spp
- Enterobacter spp
- P. aeruginosa (consider covering if pt has health-care associated risk factors)
What are some healthcare-associated risk factors? (cover for P. aeruginosa if pt has these risk factors)
When pts have recent/ frequent exposure to healthcare settings.
- Recent hospitalisation
- Recent antimicrobial use
- Recent invasive urological procedures
- Use of long-term urinary catheters
Empiric abx Tx for cystitis in women? (first-line and alternatives?)
First-line:
- PO co-trimoxazole 800/160mg bid x 3d
- PO nitrofurantoin 50mg qid x 5d
- PO fosfomycin 3g single dose
Alternatives:
PO beta-lactams x 5-7d
- PO cefuroxime 250mg bid
- PO amoxicillin-clavulanate 625mg bid
PO fluoroquinolones x 3d
- PO ciprofloxacin 250mg bid
- PO levofloxacin 250mg daily
What is the empiric abx Tx for complicated cystitis in women? (first-line and alternatives?)
Duration of Tx?
(same as previous card)
First-line:
- PO co-trimoxazole 800/160mg bid x 3d
- PO nitrofurantoin 50mg qid x 5d
- PO fosfomycin 3g EOD x 3 doses
Alternatives:
PO beta-lactams x 5-7d
- PO cefuroxime 250mg bid
- PO amoxicillin-clavulanate 625mg bid
PO fluoroquinolones x 3d
- PO ciprofloxacin 250mg bid
- PO levofloxacin 250mg daily
Treat longer duration eg 7-14 days
What can you say about the use of FQs in complicated/ uncomplicated UTI?
Avoid giving FQs as it is the only PO option for P. aeruginosa + debilitating SEs
Pathogens involved in community-acquired pyelonephritis in women?
- E. coli (> 85%)
- Staphylococcus saprophyticus (5-15%)
- Enterococcus faecalis
- Klebsiella pneumoniae
- Proteus spp.
Tx for community-acquired pyelonephritis in women? (PO)
Should we do urine culture and AST?
Yes, while waiting for urine culture and susceptibility results…
If pts can take PO:
PO fluoroquinolones:
- PO ciprofloxacin 500mg bd x 7d
- PO levofloxacin 750mg od x 5d
- PO co-trimoxazole
160/800mg bd x 10-14d
PO beta-lactam x 10-14d:
- PO cefuroxime 250-500mg bid
- PO amoxicillin-clavulanate 625mg tds
Tx for community-acquired pyelonephritis in women? (pts severely ill requiring hospitalisation/ unable to take PO)
For severely ill pts requiring hospitalisation/ unable to take oral drug:
- IV ciprofloxacin 400mg bid
- IV cefazolin 1g q8h
- IV amoxicillin-clavulanate 1.2g q8h
AND/ OR
- IV/ IM gentamicin 5mg/kg
THEN
- Switch to PO when pt improves/ able to take oral
What is the Tx duration for UTI in pregnancy? (ASB/ cystitis and pyelonephritis)
Treat for 4-7 days for asymptomatic bacteriuria or cystitis.
Treat for 14 days for pyelonephritis
Tx for UTI pregnancy?
What must you take note about co-trimoxazole, nitrofurantoin and AGs?
PO beta-lactams x 5-7d:
- PO cefuroxime 250mg bid
- PO amoxicillin-clavulanate 625mg bid
- PO fosfomycin 3g single dose
- PO co-trimoxazole 800/160mg bid x 3d
- PO nitrofurantoin 50mg qid x 5d
Co-trimoxazole: avoid in first and third trimester
Nitrofurantoin: avoided at term; 38-42 weeks
AGs must be used with caution (cranial nerve toxicity in fetus reported with older AGs like kanamycin, streptomycin, but not for newer AGs)
What pathogens should we cover in community-acquired UTI in men?
Treat it as per complicated UTI;
- E. coli (~50%)
- Enterococci
- Proteus spp
- Klebsiella spp
- Enterobacter spp
- P. aeruginosa
Duration of Tx for community-acquired UTI in men?
Treat for 10-14 days, need longer duration if prostatitis is confirmed (6w)
Tx for community-acquired UTI in men? (cystitis with no concern for prostatitis)
Cystitis with no concern for prostatitis → regimen as per complicated cystitis in women:
First-line:
- PO co-trimoxazole 800/160mg bid
- PO nitrofurantoin 50mg qid
- PO fosfomycin 3g EOD x 3 doses
Alternatives:
PO beta-lactams
- PO cefuroxime 250mg bid
- PO amoxicillin-clavulanate 625mg bid
PO fluoroquinolones
- PO ciprofloxacin 250mg bid
- PO levofloxacin 250mg daily
Tx for community-acquired UTI in men? (cystitis with concern for prostatitis/ pyelonephritis)
- PO ciprofloxacin 500mg bd
- PO co-trimoxazole 160/800mg bd
Define nosocomial UTI.
Nosocomial: onset of UTI >48h post hospital admission
What pathogens must we cover for nosocomial/ healthcare associated UTI?
Must we do a culture?
- Pseudomonas aeruginosa
- Other resistant bacteria (ESBL-E. coli and ESBL-Klebsiella) should be considered and broad spectrum beta-lactam may be used
Yes, a culture is needed. Tx should be modified when result of culture and AST comes out
Tx duration for nosocomial/ healthcare associated UTI?
Treat for 7-14 days
Tx regimen for nosocomial/ healthcare associated UTI?
- IV cefepime 2g q12h +/- IV amikacin 15mg/kg/d
- IV imipenem 500mg q6h or IV meropenem 1g q8h
- PO levofloxacin 750mg (for less sick pts)
- PO ciprofloxacin 500mg bid (for less sick pts)
Define CA-UTI
Presence of UTI s/sx with no other identified source of infection along with 10^3 cfu/mL ≥ 1 bacterial species in pts with:
- Indwelling urethral
- Indwelling suprapubic
- Intermittent catheterisation
- Midstream voided urine specimen in pt whose catheter has been removed within past 48h
What are the pathogens to cover for CA-UTI?
(Same as nosocomial/ healthcare-associated UTI):
Pseudomonas aeruginosa
Other resistant bacteria (ESBL-E. coli and ESBL-Klebsiella)
Tx duration for CA-UTI?
Treat for 7 days if prompt resolution of s/sx (deferverse in 72h)
Treat for 10-14 days if delayed response
Tx regimen for CA-UTI? (what is the FIRST thing you need to consider doing?)
First, consider removing catheter
Abx:
- IV imipenem 500mg q6h or IV meropenem 1g q8h
- IV cefepime 2g q12h +/- IV amikacin 15mg/kg (1 dose or daily)
- PO/ IV levofloxacin 750mg x 5d (mild CA-UTI)
- PO co-trimoxazole 960mg bid x 3d (for women ≤ 65 y/o with CA-UTI without upper urinary tract s/sx after indwelling catheter has been removed
What are the steps to prevent CA-UTI?
Would you recommend topical antiseptic or abx for prophylactic tx?
- Avoid unnecessary catheter use
- Use for minimal duration
- Long-term indwelling catheters changed before blockage likely to occur
- Use closed system
- Ensure aseptic insertion technique
- Topical antiseptic or abx NOT recommended
- Prophylactic abx and antiseptic NOT recommended
- Chronic suppressive abx NOT recommended
List some adjunctive tx for UTI and what they treat
Paracetamol or NSAIDs: pain and fever
Rehydration: vomiting
Phenazopyridine: relieve urinary s/sx (do not use in G6PD deficiency)
Urine alkalization: relief discomfort in mild UTI but unproven benefit
What should we monitor for UTI?
Resolution of s/sx:
- Improvement or resolution by 24-72h after abx use
- If pt fails to respond clinically within 2-3 days/ has persistent positive blood/ urine cultures, further investigation needed (check for bacterial resistance, possible obstruction, renal abscess, other diseases)
Repeat culture NOT NEEDED to document clearance of infection, ONLY for pregnant women
Drug ADEs
