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PR3151 Infection: Optimising Prevention & Treatment > UTI > Flashcards

UTI Flashcards

1
Q

Difference between asymptomatic bacteruria and UTI?

A

Both: isolation of significant colony counts of bacteria in urine
ASB: without symptoms of UTI

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2
Q

When to screen & treat ASB? (2)

A

Pregnant women
Patients going for urologic procedure in which mucosal trauma or bleeding is expected

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3
Q

List 5 risk factors for UTI:

A
    1. Catheterization & other mechanical instrumentation
    1. Pregnancy
    1. Females > males
    1. Sexual intercourse
    1. Abnormalities of urinary tract e.g. kidney stones, vesicoureteral reflux
    1. Neurologic dysfunctions e.g. stroke, diabetes, spinal cord injuries
    1. Anti-cholinergics
    1. Diabetes
    1. Use of diaphragms & spermicides
    1. Genetic association (positive family hx)
    1. Previous UTI
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4
Q

What classifies as uncomplicated UTI?

A

Healthy premenopausal, non-pregnant with no history suggestive of an abnormal urinary tract

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5
Q

What classifies as complicated UTI?

A

UTI in men, pregnant women, children
Complicating factors: diabetes, functional and structural abnormalities of urinary tract, genitourinary instrumentation, immunocompromised host

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6
Q

Labs for UTI? (2):

A

Microscopic urinalysis - UFEME:
* WBC:
* * >10 WBC/mm3
* * Signifies presence of inflammation, may or may not be due to infection
* * Absence of pyuria= unlikely to be UTI
* RBCs:
* * Presence (microscopic >5/HPF or gross) = hematuria
* * Frequently occurs in UTI but non-specific
* Microorganisms
* * Identify bacteria or yeast using gram-stain
* WBCs casts
* * Masses of cells & proteins that form in renal tubules (in kidneys)
* * Indicate upper tract infection/ disease
Chemical urinalysis (dipstick)
* Nitrite
* * Positive test detects presence of gram-negative bacteria
* * Only gram-negative organisms reduces nitrate to nitrite
* Leukocyte esterase
* * Positive test detects esterase activity of leukocytes in urine
* * Correlates with significant pyuria (>10 WBCs/mm3)

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7
Q

When to obtain urine cultures (UTI)?:

A

May be necessary for:
* Pregnant women
* Recurrent UTI (relapse within 2 weeks or frequent)
* Pyelonephritis
* Catheter-associated UTI
* All men with UTI

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8
Q

What are the likely pathogens for uncomplicated/ community acquired UTIs?

A

E.coli (>85%), staphylococcus saprophyticus (5-15%)
Others:
* Enterococcus faecalis
* Klebsiella pneumoniae
* Proteus spp.

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9
Q

What are the likely pathogens for complicated or healthcare-associated UTIs?

A

E. coli (~50%)
Enterococci
Proteus spp., Klebsiella spp, Enterobacter spp, P. aeruginosa

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10
Q

What are the healthcare associated risk factors in UTI? (4)

A
  • Hospitalization in the last 90 days
  • Current hospitalization 2 or more days
  • Recent antimicrobial use
  • Residence in nursing home
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11
Q

Is there a need to treat positive urine cultures?

A

No if patient does not have symptoms of UTI except for:
* Pregnant
* Patients going for urologic procedure in which mucosal/bleeding is expected e.g. cystoscopy

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12
Q

Empiric antibiotics for uncomplicated cystitis in women

A

1st-line:
* Nitrofurantoin x5d
* Co-trimoxazole x3d
* Fosfomycin 3g single dose
Alternatives:
* PO beta-lactams x5-7d
* Augmentin 625mg BD
* Cephalexin 25-500mg QID
* Cefuroxime 250mg BD
PO fluoroquinolones x3d:
* PO ciprofloxacin 250mg BD
* PO levofloxacin 250mg daily

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13
Q

What is the treatment for complicated cystitis in women?

A

Same as uncomplicated cystitis in women except:
* Treat for longer duration e.g. 7-14 days
* Fosfomycin dose for complicated cystitis: PO 3g EOD x 3 doses

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14
Q

What are the empiric antibiotics for community acquired pyelonephritis in women?

A

PO fluoroquinolones:
* PO ciprofloxacin 500mg BD x 7 days
* PO levofloxacin 750mg daily x 5 days
PO Co-trimoxazole 800/160mg BD x 10-14 days
PO beta-lactam x10-14 days:
* Cefuroxime 250-500mg BD
* Augmentin 625mg TDS / 1g BD
* Cephalexin 500mg QID
IV options for severely ill patients who require hospitalisation OR unable take oral drug
* IV augmentin 1.2g Q8H and/or IV/IM gentamicin 5mg/kg
* IV ciprofloxacin 400mg BD
* IV cefazolin 1g q8h

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15
Q

What are the empiric antibiotics for community acquired UTI in men?

A

For cystitis:
* Same regimen as complicated cystitis in women (treat for longer duration)
For prostatitis or pyelonephritis in men:
* PO ciprofloxacin 500mg BD or
* PO Co-trimoxazole 800/160mg BD
Treat for 10-14 days, but will need longer duration if prostatitis is confirmed (6 weeks)

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16
Q

What does Nosocomial UTI means?

A

onset of UTI >48h post admission

17
Q

What are some examples of healthcare-associated pyelonephritis?

A

Patients who have been hospitalized or underwent invasive urologic procedures in the last 6 months, has an indwelling catheter etc.

18
Q

What additional microorgansisms should be considered when treating nosocomial/healthcare-associated Pyelonephritis?

A

Possibility of pseudomonas and other resistant bacteria (e.g. extended beta-lactamase producing E. coli and Klebsiella)

19
Q

What are some recommended antibiotic regimen for nosocomial/healthcare-associated pyelonephritis?

A
  • IV cefepime 2g Q12H +/- IV amikacin 15mg/kg/d
  • IV imipenem 500mg Q6H or IV meropenem 1g Q8H
  • PO levofloxacin 750mg (for less sick patients)
  • PO ciprofloxacin 500mg BD (for less sick patients)

Treat for 7-14 days, initial therapy should be modified when result of urine culture and susceptibility becomes available

20
Q

What is the definition of catheter associated UTI? (4)

A

1) presence of signs and symptoms compatible with UTI
2) With no other identified source of infection
3) With 10^3 cfu/mL of 1 or more bacterial species in a single catheter urine specimen
4) in patients with indwelling urethral, suprapubic or intermittent catheterization or in a midstream voided urine specimen from a patient whose catheter has been removed within the previous 48h

21
Q

Risk factors for development of catheter-associated UTI?

A
  1. Duration of catheterisation
  2. Colonisation of drainage bag, catheter and periurethral segment
  3. Diabetes mellitus
  4. Female
  5. Renal function impairment
  6. poor quality of catheter care, including insertion
22
Q

When should antibiotics be initiated for catheter-associated UTI?

A

Antibiotics should only be initiated for symptomatic infection for catheter-associated UTI
* symptoms include new onset or worsening of fever, rigors, altered mental status, malaise, or lethargy with no other identified cause; flank pain; costovertebral angle tenderness; acute hematuria; pelvic discomfort
* if patient is stable and fever is low grade, consider observation rather than immediate antibiotics therapy

Urine (+/- blood) culture must be taken before antibiotics is given

23
Q

What are some empiric treatment options for catheter-associated UTI? What is the duration of treatment?

A

1) IV Cefepime 2g Q12H +/- IV Amikacin 15mg/kg (1 dose)
2) IV imipenem 500mg Q6H or IV meropenem 1g Q8H
3) PO/IV levofloxacin 750mg x5d (for mild CA-UTI)
4) Co-trimoxazole 960mg BD x3d (for women 65y/o or younger, with CA-UTI without upper urinary tract symptoms after an indwelling catheter has been removed)

Duration of treatment: usually 7 days in those with prompt resolution of symptoms (i.e. deferverse in 72h) and 10-14 days of treatment for those with delayed response

24
Q

Is chronic suppressive therapy recommended for catheter-associated UTI?

A

NO

25
Q

Which class of antibiotics is first-class option for UTI management in pregnancy?

A

Beta-lactams

26
Q

What is the duration of treatment of asymptomatic bacteruria or cystitis in pregnant women?

A

4-7 days

27
Q

What is the duration of treatment for pyelonephritis in pregnant women

A

14 days

28
Q

Which classes of antibiotics should be avoided in the treatment of UTI in pregnant women? Why?

A

1) Fluoroquinolones (avoid)
* reports of fetal cartilage damage and arthropathies in animal studies and occassional human case reports in children; not confirmed in humans
2) Co-trimoxazole (avoid in 1st and 3rd trimester)
* Avoid in 1st trimester as folate antagonism of TMP can cause neural tube defects
* avoid use close to term in 3rd trimester due to theoretical risk of kernicterus in newborns from competitive binding between bilirubin and sulfonamides to plasma albumin
* Concern for fetus being G6PD deficient
3) Nitrofurantoin (avoid at term 38-42 weeks)
* concern for fetus being G6PD deficient
4) Aminoglycosides used with caution
* 8th cranial nerve toxicity in fetus reported with older aminoglycosides (kanamycin, streptomycin), not reported for newer aminoglycosides so far

29
Q

List 2 adjunctive agents to help manage urinary symptoms in patients with UTI

A

1) Phenazopyridine (Urogesic)
* Dose: 100-200mg TDS
* An azo dye and exerts topical analgesic relief on the urinary tract mucosa to provide symptomatic relief
* treatment should be limited to the duration of symptoms
* DO NOT USE IN G6PD DEFICIENCY
* ADR: nausea, vomiting, orange-red discolouration of urine and stool
2) Urine alkalinizer: relief discomfort in mild UTI, unproven benefit

30
Q

In which group of patients do we need to do a repeat culture to document clearance of UTI?

A

Pregnant women

PR3151 Infection: Optimising Prevention & Treatment (10 decks)

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