UTI Flashcards
1
Q
What is UTI?
A
infection of bladder (also known as cystitis) usually caused by bacteria from the gastrointestinal tract
2
Q
What is the usual natural course of acute uncomplicated UTI?
A
usually resolves within a few days
3
Q
What are 5 risk factors for complicated UTI?
A
- older age - post-menopause
- Healthcare-associated UTI
- Presence of symptoms for more than a week before presentation
- pregnancy
- urinary catheterisation, other urologic instruemntation
- atypical or resistant infecting organisms
- pre-existing urological conditions e.g polycystic kidneys, renal transplant, calculi, obstruction, neurogenic bladder
- co-morbidities such as immunosuppression, diabetes mellitus
4
Q
What are 5 complications of UTI?
A
- Ascending infection: pyelonephritis, renal and per-renal abscess
- Impaired renal function, renal failure
- Urosepsis
- In pregnancy: pre-term delivery
- Low birthweight
5
Q
What are 6 clinical features of lower UTI?
A
- Dysuria
- Frequency
- Urgency
- Change in urine appearance - cloudy, change colour, frank haemturia
- Odour to urine
- Nocturia
- Suprapubic discomfort
6
Q
In which particular group may typical features be absent in UTI? How might it present instead?
A
underlying cognitive impairment - may present with delirium and reduced functional ability
7
Q
What are 2 other genitourinary conditions which may cause urinary symptoms?
A
- STIs
- Vaginal atrophy
8
Q
In which group of patients can urine dipstick be used to aid diagnosis of UTI?
A
women <65 years who do not have risk factors for complicated UTI
9
Q
What result on a urine dipstick makes UTI likely?
A
positive for nitrite or leukocyte and red blood cells
10
Q
What urine dipstick result suggests UTI is equally likely to other diagnoses?
A
negative for nitrite and positive for luekocyte
11
Q
What urine dipstick result suggests UTI is less likely?
A
negative for nitrite, leukocyte and RBC
12
Q
When should urine dipstick not be used to diagnose UTI? 2 situations
A
- Catheterised women
- Women over 65 years
13
Q
What are 8 situations when you should sent a urine sample for culture in suspected UTI?
A
- Pregnancy - and repeat sample following treatment should be sent to confirm cure
- Age >65 years
- Persistent symptoms or treatment failure
- Recurrent UTI
- Catheterised or recently been catheterised
- Risk factors for resistant or complicated UTI
- Visible or non-visible haematuria
- Atypical symptoms
14
Q
What are the 4 key aspects of management of acute uncomplicated lower UTI?
A
- Giving advice on self-care measures (such as analgesia and hydration)
- Treatment with antibiotics (in most cases) - delayed script may be appropriate in non-pregnant women with mild symptoms and no risk factors for complicated infection
- Giving advice on when to seek medical review
- Reviewing choice of antibiotic when results are available
15
Q
What additional investigation does the management of UTI in pregnancy involve?
A
repeat sample sent for culture following treatment to confirm
16
Q
When might a delayed script for suspected UTI be suitable?
A
non-pregnant women with mild symptoms and no risk factors for complicated infection
17
Q
What is the management of UTI in pregnancy? 3 aspects
A
- Women with asymptomatic bacteruria and suspected or proven UTI should be treated promptly with a 7-day course of antibiotics and followed up
- Urgent specialist advice should be sought for recurrent UTI, catheter associated UTI, atypical pathogens or if an underlying cause is suspected
- Antenatal services must be informed if group B streptococcal bacteriuria is identified
18
Q
What are 4 situations when urgent specialist advice should be sought for UTI in pregnancy?
A
- Recurrent UTI
- Catheter-associated UTI
- Atypical pathogens
- Underlying cause is suspected
19
Q
What is the management of persistent haematuria following treatment of UTI?
A
must be followed up; possible underlying causes e.g. malignancy should be considered, and appropriate referral made
20
Q
What is the management of recurent UTI? 2 key aspects
A
- Referral should be made if: cause unknown, woman catheterised, malignancy suspected
- Preventative measures such as behaviour and personal hygiene should be discussed - topical vaginal oestrogen and antibiotic prophylaxis may be appropriate
21
Q
What is the definition of uncomplicated UTI?
A
UTI caused by typical pathogens in people with normal urinary tract and kidney function, and no predisposing co-morbidities
22
Q
What is the definition of complicated UTI?
A
increased likelihood of complications such as persistent infection, treatment failure and recurrent infection
23
Q
What are 5 risk factors for complicated UTI?
A
- Structural or neurological abnormalities
- Urinary catheters
- Virulent or atypical infecting organisms
- Poorly contorlled diabetes mellitus
- Immunosuppression
24
Q
What is upper UTI?
A
infection of upper part of urinary tract: ureters and kidneys (i.e. pyelonephritis)
25
What is the definition of recurrent UTI?
**two** or more episodes of UTI in **six months** OR
**three** or more episodes in **one year**
26
What are 2 reasons that recurrent UTI can occur?
1. Relapse - infection due to same strain of organism
2. Reinfection - infection due to different organism
27
What is the definition of catheter associated UTI?
symptomatic infection of the bladder or kidneys in a person who is **catheterised** or who has had a urinary **catheter in place within the previous _48 hours_**
28
What is the recommended management of asymptomatic bacteriuria in **non**-pregnant women with a catheter in situ/in past 48h?
does **not** routinely need treatment
29
What is the definition of asymptomatic bacteriuria?
presence of significant levels of bacteria in the urine in a person without signs of symptoms of UTI
30
What factor increases the likelihood of bacteria being found in the urine of a catherised woman?
longer it has been in, more likely bacteria will be found
31
What are 3 ways that bacteria can enter the urinary tract?
1. Retrograde - ascent through urethra
2. Via blood stream - if immunosuppressed
3. Direct - e.g. insertion of catheter, instrumentation, surgery
32
What is the most common pathogen causing UTI?
Escherichia coli (70-95%)
33
What are 5 additional causative agents of UTI in addition to E. Coli?
1. **Staphylococcus saprophyticus** (5-10%)
2. **Proteus mirabilis** (males - renal tract abnormalities e.g. calculi)
3. **Klebsiella**
4. Lancefeld Group B streptococci (in some women)
5. Candida - catheters/immunosuppressed/contamination
34
In which group is proteus mirabilis a possible cause of UTI?
Males, associated with renal tract abnormalities, particularly calculi
35
What are 3 situations when candida species might (rarely) cause UTI?
1. Indwelling catheters
2. Immunosuppression
3. Contamination from genital tract
36
What are 3 risk factors for recurent UTI in young and pre-menopausal women?
1. Sexual intercourse
2. Past medical histoyr of UTI in childhood
3. Mother with history of UTI
37
What are 6 risk factors for recurrent UTI in post-menopausal and elderly women?
1. History of UTI before menopause
2. Urinary incontinence
3. Atrophic vaginitis
4. Cystocele
5. Increased post-void urine volume
6. Urine catheterisation and reduced functional status in elderly institutionalised women
38
What proportion of women who have UTI will have recurrence?
20-30%
39
How long does acute, uncomplicated UTI take to resolve?
3.32 days if treated with antibiotic pathogen is sensitive to, 4.73 days if treated with antibiotic not sensitive to, 4.94 days when not treated with antibiotic
40
What is the risk of asymptomatic bacteriuria in pregnancy?
can develop UTI and pyelonephritis, associated with pre-term delivery and low-birthweight
41
What is done due to the risk of complications to the fetus of UTI/pyelonephritis in pregnancy?
all pregnant women offered routine screening for asymptomatic bacteriuria in early pregnancy
42
What are 4 possible symptoms of UTI in elderly women with underlying cognitive impairment?
1. Delirium
2. Lethargy
3. Reduced ability to carry out activities of daily living
4. Anorexia
43
How should a working diagnosis of UTI be made in elderly women with underlying cognitive impairment?
alternative sources of infection and causes of delirium other than UTI must be excluded first
44
What are 3 symptoms that should make you suspect pyelonephritis?
1. Fever
2. Loin pain
3. Rigors
45
What are 5 red flags to ask about in suspected UTI?
1. Haematuria
2. Loin pain
3. Rigors
4. Nausea/ vomiting
5. Altered mental state
46
What are 4 background questions to ask about in the history for suspected UTI?
1. Family history of urinary tract disease such as polycystic kidney disease
2. Possibility of pregnancy in women of childbearing age
3. Bladder catheterisation/ other risk factors for recurrence
4. Recent antibiotic use
47
What are 4 aspects of examination to perform in suspected UTI?
1. Vital signs - temperature, BP, HR, RR
2. Palpate for flank or suprapubic tenderness and pelvic or abdominal masses
3. Check for blockage if urinary catheter in situ
4. Assess other symptoms depending on suspected cause e.g. genital examination if vulvovaginal atrophy or herpes simplex possible
48
What time of sample is most reliable for urine to be sent off for culture and sensitivities?
morning sample
49
If \<65years and no risk factors for complicated UTI, when should you send a urine sample for culture?
if previous antibiotic treatment has failed or possibility of antibiotic resistance
or
urine dipstick negative for nitrite and positive for leukocyte so UTI equally likely to other diagnosis
50
How should the urinary catheter be sampled for urine culture?
if catheter has been changed, sample should be collected from newly placed catheter - using aseptic technique drain a few ml from residual urine from tubing then collect a fresh sample from catheter sampling port
ensure form sent off states suspected catheter-associated infection
51
What further investigations are sometimes considered in secondary care for UTI?
cystoscopy or imaging if underlying cause suspected
52
What is the management of acute lower UTI without haematuria in woman not pregnant or catheterised? 7 aspects
1. self care: analgesia e.g. paracetamol
2. fluid intake to avoid dehydration (don't recomend cranberry)
3. PIL
4. consider need for abx depending on symptom severity, risk of complications, previous urine culture results and abx use.
5. consider delayed script
6. advise to seek urgent medical review if symptoms worsen, fail to imrpove in 48h
7. if sample sent for culture, review choice of antibiotic and change according to susceptibility if symptoms not improving
53
How should you decide what antibiotic to give for UTI without haematuria/catheter/pregnancy?
* treat according to sensitivities from recent culture, otherwise treat empirically taking account of local antimicrobial resistance patterns
54
What are the first and second line empirical choices for antibiotic to treat UTI without haematuria/pregnancy/catheter?
first line - 2 options
second line - 3 options
First line:
* **nitrofurantoin** 100mg modified-release bd for 3 days (if eGFR \>45)
* **trimethoprim** 200mg bd 3 days
second line:
* **nitrofurantoin** 100mg bd 3 days if not used for first line
* **pivmecillinam** 400mg initial dose, then 200mg three times a day for 3 days
* **fosfomycin** 3g single dose sachet
55
How can a delayed script for uncomplicated UTI be prescribed?
advise woman to start antibiotics if symptoms do not improve within 48 hours or worsen at any time
56
When can you consider a delayed script?
if symptoms are mild and no risk factors for complicated infection
57
What should be different about the management of UTI if there is visible or non-visible haematuria?
* re-test urine after completing treatment with appropriate antibiotic - if persistent, consider possible underlying causes
* if **urological** or **gynaecological** **cancer** suspected arrange 2 week wait referral
* if **CKD** suspected arrange further investigations, consider need for referral to secondary care
* if cause unclear, discuss with urology
58
What is the management of visible or non-visible haematuria that persists after treatment in women who are pregnant?
urgently discuss management with ostetrics
59
What are 5 aspects of management of recurrent UTI (no pregnancy/haematuria/catheter?
1. Make sure culture sent before antibiotics started
2. Refer/seek specialist advice on further investigation and management with underlying cause unknown or malignancy suspected (2ww)
3. Discuss behavioural and personal hygiene measures
4. Consider prescribing vaginal oestrogen in postmenopausal women
5. Consider antibiotic prophylaxis if underlying cause investigated and other measures ineffective
60
What are 4 behavioural and personal hygiene measures to recommend for recurrent UTI?
1. Avoid douching and occlusive underwear
2. Wipe from front to back after defecation
3. Avoid delay of habitual and post-coital urination
4. Maintain adequate hydration
61
What should you do before prescribing vaginal oestrogen for recurrent UTI?
discuss risks and benefits of treatment includign adverse effect of tenderness and vaginal bleeding (which may require investigation), and uncertainty of endometrial safety with long-term or repeated use
62
What type of dose of vaginal oestrogens should be used when treating recurrent UTI?
lowest possible dose
63
When should treatment with vaginal oestrogens be carried out?
12 months
64
When should you consider antibiotic prophylaxis to treat recurrent UTI?
if underlying cause has been investigated and behaviour/personal hygiene measures and vaginal oestrogen (in postmenopausal women) are ineffective or inappropriate
65
What are 6 factors to take into account when considering antibiotic prophylaxis for recurrent UTI?
1. Severity of symptoms
2. Frequency of symptoms
3. Risk of complications
4. Previous urine culture and susceptibility results
5. Previous antibiotic use
6. Woman's preference
66
What are 2 things that should be done before starting prophylactic antibiotics to treat UTI?
1. Discuss risks of long term antibiotics including resistance and possible adverse effects
2. Ensure any current UTI has been adequately treated
67
Whatare 2 types of antibioitc prophylaxis for recurrent UTI?
1. single dose when exposed to an identifiable trigger
2. daily antibiotic prophylaxis
68
What are the first and second choice when use of single dose antibiotic prophylaxis after exposure to a trigger is indicated?
* First choice: **trimethoprim** 200mg single dose or **nitrofurantoin** (if eGFR \>45) 100mg single dose
* Second choice: **amoxicillin** 500mg single dose or **cefalexin** 500mg single dose
69
When is daily antibiotic prophylaxis indicated for recurrent UTI?
if no improvement after single-dose prophylaxis or no identifiable triggers
70
What are the 2 first choice and 2 second choice options for daily antibiotic prophylaxis for recurrent UTI?
1. First choice: trimethoprim 100mg at night or nitrofurantoin 50-100mg at night
2. Second choice: amoxicillin 250mg at night or cefalexin 125mg at night
71
When should follow up be carried out if a woman is taking antibiotic prophylaxis for recurrent UTI?
3-6 months later
72
What should be done if acute UTI occurs whilst taking antibiotics for prophylaxis for recurrent UTI?
use different antibiotics to treat
check effectiveness of prophylaxis, consider changing to alternative, reinforce behavioural and personal hygiene measures
73
What are 8 aspects of the management of UTI without haematuria in pregnancy?
1. Arrange urgent assessment in secondary care
2. Seek urgent specialist advice on further management of pregnancy women
3. If uncomplicated first lower UTI in pregnant woman, give advice on self care
4. Send midstream urine sampe for culture and sensitivies
5. Offer immediate antibiotic prescription
6. Advise to seek urgent review if worsening symptoms or failure to improve
7. Follow up reviewing choice of antibiotic when results available, change accordingly.
8. Send urine for culture once treatment completed to ensure clearance
74
When should you arrange an urgent assessment in secondary care for pregnant women with UTI?
if any features of serious or systemic illness such as sepsis or pyelonephritis
75
What are 5 situations when you should seek urgent specialist advice on further management of pregnant women with UTI?
1. Recurrent lower UTI
2. Catheter-associated UTI
3. If culture reveals atypical bacteria
4. Underling structural or functinoal abnormality or co-morbidity which increases risk of complications or treatment failure
5. Suspected underlying malignancy or renal disease
76
What are 3 self-care measures to be used during UTI in pregnancy?
analgesia e.g. paracetamol, encourage intake of fluids, PIL
77
What should the immediate antibiotic prescription take into account when prescribed for women with UTI that are pregnant?
previous urine culture and susceptibility results, previous antibiotic use (may have led to resistant bacteria) and local resistance paterns - if unsure discuss with a specialist
consider nitrofurantoin as first choice (avoid at term)
second choice - amoxicillin, cefalexin
78
What first choice and second choice antibiotics should be considered for immediate antibiotic treatment of UTI in pregnancy (before culture results back)?
* First line: nitrofurantoin 100mg modified release bd for 7 days
* Second line: (no imrpovement with first choice for at least 48h or not suitable) amoxicillin 500mg tds 7 days; cefalexin 500mg bd 7 days
79
When should nitrofurantoin be avoided in pregnancy?
at term
80
When should nitrofurantoin be avoided generally?
if eGFR \<45
81
When should you make sure to always avoid trimethoprim in pregnancy?
first trimester
82
What is the management of asymptomatic bacteriuria during pregnancy?
1. Seek specialist advice if at risk of complicated UTI (catheter or structural abnormality)
2. Offer immediate antibiotic prescription, confirm with repeat sample for culture - same as treatment for UTI in pregnancy
83
What should you do if the urine sample shows group B streptococcal bacteriuria in pregnancy?
ensure antenatal services made aware - intrapartum antibiotic prophylaxis will be required
84
What are 9 aspects of management of UTI with a catheter?
1. Urgent assessment in secondary care if seriously ill
2. Refer/ seek specialist advice if risk of complications/recurrent/atypical/cancer suspicion
3. Advise on self care measures
4. If catheter in place \>7days, check for blockage and consider removal or changing ASAP
5. Send MSU sampe for culture
6. Offer abx
7. Advise to seek urgent medical review if symptoms worsen
8. Follow up urine culture and susceptibility results
9. Ensure good practice in management of long-term catheter
85
What are 2 aspects of the management of UTI if the catheter has been in place for more than 7 days?
1. Check for blockage, consider removing or changing ASAP. don't delay abx treatment in interim
2. Before abx taken send sample from MSU if catheter has been removed or from new catheter if changed - ensure laboratory aware of previous antibiotic use and this is suspected catheter associated UTI (CAUTI)
86
What are the first and second line antibiotics to offer for CAUTI?
1. First line: nitrofurantoin 100mg bd 7 days or trimethoprim 500mg tds 7 days
2. Second line: pivmecillinam 400mg initial dose then 200mg tds 7 days
87
What are 3 aspects of good practice from the GP in maangement of long-term urinary catheters?
1. **Regularly** **assess** **need** **for catheterisation** - should be carried out by appropriately trained healthcare workers using aseptic technique
2. **Don't routinely offer abx prophylaxis** to prevent CAUTIs when changing catheters in women with long term catheter
3. **Do not** routinely treat catheter-associated asymptomatic bacteriuria
