UTI Flashcards
_________) is a common problem
affecting all ages and accounts for approximately
1% of all attendances in general practice
Urinary tract infection (UTI
T OR F
Organisms causing UTI in the community are
usually sensitive to most of the commonly used
antibiotics.
T
Screening of asymptomatic women has shown that
about ______ have bacterial UTI
5%
About 1% of neonates and 1–2% of schoolgirls
have _____
asymptomatic bacteriuria
About one-third of women have been estimated to
have symptoms suggestive of_______ at some stage
of their life
cystitis
Ascending infection accounts for ______
of UTIs.
93%
All males and females less than 5 years old
presenting with a UTI require investigation for an
underlying ________
abnormality of the urinary tract
Infants less than six months old with a UTI have a
significant risk of ____
bacteraemia
Consider the ________ as a cause of
non-infective cystitis
NSAID tiaprofenic acid
This is defined as the presence of pus cells but a
sterile urine culture.
Sterile pyuria
Common causes of Sterile pyuria
• contamination of poorly collected urine
specimens
• urinary infections being treated by antibiotics,
i.e. inadequately treated infections
1 2 3 4 5 6 7
- analgesic nephropathy
- staghorn calculi
- other kidney disorders (e.g. polycystic kidney)
- bladder tumours
- tuberculosis
- chemical cystitis (e.g. cytotoxic therapy)
- appendicitis
This is defined as the presence of a significant growth
of bacteria in the urine (concentration >10 8 colonyforming
units/L), which has not produced symptoms
requiring consultation
Asymptomatic bacteriuria
Screening for and treatment of asymptomatic
bacteriuria is not recommended except for:
1
2
• pregnant women because of the risk of
pyelonephritis and pregnancy complications
• patients before urological procedures (e.g.
TURP
This is defined as the presence of frequency, dysuria
and loin pain alone or in combination, together with
a significant growth of organisms on urine culture
Symptomatic bacteriuria
The clinical differentiation between cystitis
or lower UTI and kidney or upper UTI cannot be
made accurately on the basis of symptoms, except
in those patients with _____ and _____
well-defined loin pain and/or
tenderness
Inflammation of the bladder and/or urethra is
associated with dysuria (pain or scalding with
micturition) and/or urinary frequency
Acute cystitis (dysuria-frequency syndrome)
In severe cases of acute cystitis
, _______may be present, and
the urine may have an offensive smell.
haematuria
T or F,
Constitutional symptoms are minimal or absent in pts with acute cystitis
T
Other causes of dysuria and frequency include
1
2
3
urethritis, prostatitis and vulvovaginitis, all of
which can normally be distinguished clinically
Acute bacterial infection of the kidney produces
loin pain and constitutional upset, with fever,
rigors, nausea and sometimes vomiting
Acute pyelonephritis
This is cystitis occurring in the uninstrumented nonpregnant
female without structural or neurological
abnormalities.
Uncomplicated urinary tract infection
This is associated with anatomical or functional
abnormalities (e.g. diabetes, urinary calculi) that
increase the risk of serious complications or
treatment failure
Complicated urinary tract infection
The _________ (sometimes termed abacterial
cystitis) is that where the patient presents with
dysuria and frequency but does not show a positive
urine culture
urethral syndrome
urethral syndrome
_______ of adult women with urinary symptoms
have this syndrome
30–40%
organisms in pts with urethral syndrome
The organisms may be anaerobic or fastidious in
their culture requirements
Specific organisms in pts with urethral syndrome
The organisms may include Ureaplasma,
Chlamydia and viruses
This is an uncommon but important cause of the
urethral syndrome
Interstitial cystitis
What are the classic sx of Interstitial cystitis?
The classic symptoms are frequency day and
night and a dull suprapubic ache relieved briefly
by bladder emptying
classic feature of Interstitial cystitis?
The feature is small haemorrhages on distension
of the bladder
What is the tx of Interstitial cystitis?
Treatment is hydrodistension ± a course of
tricyclics, for example amitriptyline
Collected urine is stored for 24 hrs in what temp?
4 ° C to prevent bacterial multiplication
How to get Clean catch midstream specimen of urine (MSU).
This is best collected from a full bladder, to allow
at least 100 mL of urine to be passed before
collection of the MSU
How to get Catheter specimen of urine (CSU)
a short open-ended
catheter can be inserted and a specimen collected
after 200 mL has flushed the catheter
This is an extremely reliable way to detect bacteriuria in
neonates and in patients where UTI is suspected
but cannot be confirmed because of low colony
counts or contamination in an MSU
Suprapubic aspirate of urine (SPA
How to obtain Suprapubic aspirate of urine (SPA
Under local anaesthetic, a needle (lumbar puncture needle in adults) is inserted into the very full bladder
about 1–2 cm above the pubic symphysis, and
20 mL is collected by a syringe. Any organisms in
an SPA specimen indicate UTI
Urine specimen collection in children
• Bag specimen: cannot diagnose UTI
• ________—usually by 3–4 years when cooperative
• ______—practical and reliable
• ______—reliable and the best option
• _______—for failed SPA or those unable to void on
request
MSU
MCC
SPA
CSU
_______findings of urinary leucocytes or nitrite
are suggestive of UTI and may be an indication for
empirical treatment if asymptomatic
Dipstick
__________ dipsticks
are useful in detecting pyuria and give a good guide
to infection with a specificity of 94–98% (2–6%
false positive) and 74–96% sensitivity (4–26% false
negatives). 5
Leucocyte esterase
_______dipsticks give a useful guide
to the presence of bacteria
Positive nitrite
How to detect pyuria using microscopy?
The urine is examined under a microscope to detect
pyuria (more than 10 pus cells—WBCs—per highpowered
field) but should be examined in a counting
chamber to calculate the number of WBCs/mL of urine.
In the counting chamber pyuria is _____ WBC/mL
in phase-contrast microscopy. Pyuria is a very
sensitive sign of UTI.
> 8000
Vaginal squames and debris indicate _____
contamination.
The_____ and _______ of organisms present in the
urine are the most useful indicators of UTI
nature and number
MC organisms seen in urine culture
Most common are enteric organisms
____ and ______
are responsible for over 90% of UTI
Escherichia
coli (especially) and Staphylococcus saprophyticus
Gram negative organisms responsible for UTI
Gram-negative organisms ( Klebsiella
sp. and Proteus sp.), enterococci sp . and Grampositive
cocci ( Streptococcus faecalis and other
staphylococci) also responsible.
Infections due to organisms other than E. coli
(e.g. Pseudomonas sp.) are suggestive of an
underlying _______
kidney tract abnormality
If _______ colony forming units (cfu) per mL of
bacteria are present in an MSU, it is highly likely
that the patient has a UTI
> 10 5
On the other hand, it is most important to realise
that up to 30% of women with acute bacterial
cystitis have less than 10 5 cfu/mL in the MSU.
For this reason, it is reasonable to treat women
with ______ and ______ even if they have
<10 5 cfu/mL of organisms in an MSU.
dysuria and frequency
Significant levels for UTI:
• _________ WBC >10 per m L (10 × 10 6 /L)
• ______: counts >10 5 cfu/mL (10 8 /L)
Microscopy:
Culture
UTI: basic management
Urine dipstick • Microculture (clean catch) • First-line antibiotics—\_\_\_\_\_\_\_ • \_\_\_\_\_ for severe dysuria • High fluid intake • Check sensitivity—leave or change ABs • Repeat MCU within 48 hours after AB course
trimethoprim or cephalexin
Alkaliniser
Investigation of urinary tract infections
Investigations are indicated in:
All children
All males
All women with: 1 2 3 4
- acute pyelonephritis
- recurrent infections: >2 per year
- confirmed sterile pyuria
- other features of kidney disease, e.g. haematuria
Basic investigations for UTI include:
1
2
3
- MCU—microscopy and culture (post-treatment)
- Kidney function tests: plasma urea and creatinine, eGFR
- Intravenous urogram (IVU) and/or ultrasound
Special considerations for UTI:
In children: _____
In adult males: consider prostatic infection studies if IVU
normal
In severe pyelonephritis:______
In pregnant women: ultrasound to exclude obstruction
micturating cystogram
ultrasound or IVU (urgent) to
exclude obstruction
Treatment (non-pregnant women) of UTI
_____ therapy is preferred to _____
therapy.
Multiple dose
single dose
Treatment (non-pregnant women) of UTI
Use for _____ days in women (trimethoprim—3 days).
Use for ___ days in women with known urinary
tract abnormality
5
10
Abx for Treatment (non-pregnant women) of UTI
1
2
3
• trimethoprim 300 mg (o) daily for 3 days (first choice) or • cephalexin 500 mg (o) daily for 5 days or • amoxycillin/ + clavulanate 500/125 mg (o) 12 hourly for 5 days or
Abx for Treatment (non-pregnant women) of UTI
4
5
• nitrofurantoin 50 mg (o) 6 hourly for 5 days
or
• norfloxacin 400 mg (o) 12 hourly for 3 days
(if resistance to above agents proven and if
susceptible)
Cautions for use of norfloxacin
Caution about tendonopathy, including rupture
When to do MCU after abx tx
Follow-up: MCU 1–2 weeks later.
Abx for Treatment (non-pregnant women) of UTI
Avoid using important________as first-line agents
quinolones—norfloxacin
or ciprofloxacin—
Abx for Treatment (non-pregnant women) of UTI
_____ is not first line because it has no
advantage over trimethoprim and has more side
effects.
Cotrimoxazole
Abx for Treatment (non-pregnant women) of UTI
Treatment failures are usually due to a _______ or ______
resistant
organism or an underlying abnormality of the
urinary tract.
________ should always be excluded
during early pregnancy because it tends to be blown
into a full infection
Asymptomatic bacteriuria
Treatment of acute cystitis (empirical) in pregnancy:
1
2
3
• cephalexin 500 mg (o) 12 hourly for 5 days
or
• nitrofurantoin 100 mg (o) 12 hourly for 5 days
or
• amoxycillin + clavulanate 500/125 mg (o) 12
hourly for 5 days
Asymptomatic bacteriuria in pregnancy should be treated with a ______ course
week-long
Investigations for UTI in males
Investigations: MCU, U&E, ultrasound.
Abx for UTI in males
1
2
3
• trimethoprim 300 mg (o) daily for 14 days
or
• cephalexin 500 mg (o) 12 hourly for 14 days
or
• amoxycillin + clavulanate 500/125 mg (o) 12
hourly for 14 days
all males with a UTI should be investigated
to exclude an underlying______
abnormality, e.g. prostatitis,
obstruction.
Mild cases can be treated with oral therapy alone
using double the dosage of drugs recommended for
uncomplicated cystitis, except for trimethoprim
when the same dosage is recommended
Acute pyelonephritis
Duration of Tx of acute pyelonephritis
10 days
_____ or ______ is used for 10 days if resistance to these
drugs is proven.
Ciprofloxacin
(500 mg (o) 12 hourly) or norfloxacin (400 mg (o)
12 hourly)
acute pyelonephritis
For severe infection with suspected septicaemia,
admit to hospital and treat initially with parenteral
antibiotics for ______days after taking urine for
microscopy and culture and blood for culture
2 to 5
IV abx for acute pyelo
1
2
• amoxycillin 2 g IV 6 hourly 4
plus
• gentamicin 4–6 mg/kg/day, single daily IV dose
Follow with oral therapy for a total of 14 days
IV abx for acute pyelo
Gentamicin can be replaced with IV ___ or ____
cefotaxime or
ceftriaxone
_____ indicate that the organism is resistant to the
antimicrobial agents employed or that there is an
underlying abnormality such as a kidney stone or a
chronically infected prostate in the male patient
Persistent (chronic) UTIs
Abx for Recurrent or chronic urinary tract
infections:
A 10- to 14-day course of: 1 2 3 4
• amoxycillin/potassium clavulanate (500/125 mg) (o) 12 hourly or • trimethoprim 300 mg (o) once daily or • cephalexin 500 mg (o) 12 hourly or • norfloxacin 400 mg (o) 12 hourly (if proven resistance to above agents)
In some female patients with recurrent UTI a
single dose of a suitable agent within_______hours after
intercourse is adequate but, in more severe cases,
courses may be taken for____ months or on occasions
longer
2
3–6
Abx for prevention of recurrent UTI
1
2
3
• trimethoprim 150 mg (o) nocte or • cephalexin 250 mg (o) nocte or • norfloxacin 200–400 mg (o) nocte (if proven resistance to others
A recent Cochrane review on the use of _____________ for the prevention of UTI
concluded that there was evidence to recommend
for the prevention of
recurrent symptomatic UTIs in women,
cranberries
Vaccinium macrocarpon
T or F
There is poor
evidence for the use Cranberry juice in the treatment of UTI, in the
management of asymptomatic bacteriuria, or in the
prevention of UTIs in children.
T
The genitourinary tract is involved in _______ of cases
of tuberculosis.
3–5%
The genital and urinary tracts are
often involved in TB together as a result of ____
miliary spread.
MC presentation of GU TB
The commonest presenting complaints are
dysuria and frequency, which can be severe
Urine culture results of GU TB
Routine
urine culture shows sterile pyuria.
Xray findings of GU TB
typical X-ray appearance of distorted calyces
and medullary calcification
The presence of Candida albicans in the urine is
common. Antifungal therapy is not recommended
if associated with indwelling catheters but is
recommended if associated with____ or _____
upper UTIs and/or
systemic candidiasis
Tx of Candiduria
Use fluconazole 200 mg (o) daily for 7 days
Consider _______in men with few urinary
symptoms (frequency, urgency and dysuria), flu-like
illness, fever, low backache and perineal pain
bacterial prostatitis
Abx for mild to moderate bacterial prostatitis
amoxycillin + clavulanate
500/125 mg (o) bd for 4–6 weeks.
Abx for moderate to severe bacterial prostatitis
If severe, use
amoxy/ampicillin 2 g IV 6 hourly plus gentamicin (
Treat or not?
women with dysuria and frequency
merely because there are <10 5 cfu/mL in an
MCU
Treat
Overtreating women with acute cystitis and
normal urinary tracts; single-dose therapy is
effective in 70–80% of cases, and overtreatment
often leads to _____ and _____
vaginal candidiasis or antibioticinduced
diarrhoea
Most symptomatic UTIs are _____ occurring
in sexually active women with anatomically normal
urinary tracts
acute cystitis
A 3-day course of trimethoprim 300 mg daily is a
suitable first choice for ______
acute uncomplicated cystitis
in women.
The _______ examination may not detect calculi,
small tumours, clubbed calyces and papillary
necrosis.
ultrasound
In males the _____ is the most common source of
recurrent UTI
prostate
UTI is commonly associated with _______ (occasionally macroscopic haematuria).
microscopic
haematuria
Due to the rising level of E. coli resistance,
____ is no longer recommended unless
susceptibility of the organism is proven
amoxycillin
