UTI

Question 1

3 Poss Pathogenesis

Answer 1

• 1- MOST COMMON - ascend via urethra
  - E coli, proteus, enterobacter
• 2- Hematogenous (blood –> kidney –> bladder) b/c kidney is highly vascularized
  - Endocarditis/ staph
  - TB from lung
• 3- Fistula b/n bowel and bladder
  - Often poly-microbial w/ pus

Question 2

5 Clinical Conditions that Inc Risk

Answer 2

• Alter normal flora - abx, spermicide, vaginal atrophy
• Retrograde introduction of bacteria - vaginal sex, rectal sex, sex toys
• Urinary stasis
  
  • Neurogenic bladder
  • Reflux into ureters (congenital or pregnancy)
  • Obstruction (stones, pregnancy, BPH)
• Nutrients - high glucose in urine (DM) gives medium for bacteria growth
• Foreign materials = surface for growth (stones, stents, catheters)

Question 3

When to treat asymptomatic bacteria in urine

Answer 3

• DO TREAT in pregnant women … risk of developing pyelonephritis, group B strep meningitis in newborn, premature delivery, low birth weight
• Also done prior to urological surgery

Question 4

2 Alternate Causes of Dysuria

Answer 4

• Vaginitis - low # bacteria and no pyuria
  
  • Candida - fluconazole
  • Trichomonas - STI - use metro
  • Atrophy of vaginal tissues post-menopause - estrogen ointment
• Urethritis - may have pyuria
  
  • Chlamydia, ureoplasma - STIs- doxy or azithro
  • Neisseria gonorrhea - STI - use ceftriaxone AND azithro

Question 5

Acute Uncomplicated Cystitis

Answer 5

• -symptomatic bladder infection in young women who are not pregnant
• Dysuria, hematuria, discomfort in suprapubic area, low fever
• Usually E coli (80-90%), Staph saprophyticus, Proteus or Klebsiella (gram neg rods)
• Tx - usually fosfomycin or nitro (can also use cefuroxime, TMP-SMX, flouroquinolones)

Question 6

Recurrent Cystitis (causes)

Answer 6

• If relapse in < 2 wks w/ same bacteria
  
  • Causes - non-adherence to abx, abx resistance, un-eradicated focus like a stone
• If relapse > 2 wks w/ same or different bacteria
  
  • Causes - due to sex (use abx right after as prophylaxis), vaginal atrophy (use estrogen ointment), BPH or inc residual urine post-voiding

Question 7

Pyelonephritis

Answer 7

• Renal tissue infected –> flank pain, CVA tenderness, fever, maybe bacteremia
• Tx -
  - Mild/moderate - Ceftriaxone
  - Severe/life-threateninf urosepsis - Ceftriazone AND aminoglycoside (gentamicin or tobramycin)

Question 8

Prostatitis (acute v chronic)

Answer 8

• Acute - fever, chills, dysuria, tenderness if palpate prostate; usually easily cured by any abx class
• Chronic - chronic pain and dysuria, recurrent UTI w/ same organism
  • E coli, enterococcus, staph aureus, proteus, providencia
  • Tx - (hard to treat b/c acidic and biofilm so poor penetration) give fluorquinolones/TMP-SMX for 6 wks

Question 9

Cath-Associated UTI

Answer 9

• Biofilm protects against host defense and abx
• Gram neg rods (proteus and providencia), E coli, Peudomonas
• Be careful - can have WBC in urine just from inflammation or irritation from catheter; only UTI if symptomatic (fever)

Question 10

When to Treat Candida in Urine

Answer 10

• Usually associated w/ indwelling catheter
• Treat asymptomatic Candida if…
  • Fungus balls obstructing tract
  • Neutropenia
  • Renal transplant (immunosuppressed)
  • Urological surgery

Question 11

Sterile Pyuria (why might it be sterile?)

Answer 11

• May be sterile b/c already treated w/ abx, just inflammation OR Tb (does not grow on normal culture)
• If suspect genitourinary Tb do PPD test, imaging and tb culture; treat w/ RIPE