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UTI Flashcards

1
Q

What is UTI?

A

infection of bladder (also known as cystitis) usually caused by bacteria from the gastrointestinal tract

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2
Q

What is the usual natural course of acute uncomplicated UTI?

A

usually resolves within a few days

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3
Q

What are 5 risk factors for complicated UTI?

A
  1. older age - post-menopause
  2. Healthcare-associated UTI
  3. Presence of symptoms for more than a week before presentation
  4. pregnancy
  5. urinary catheterisation, other urologic instruemntation
  6. atypical or resistant infecting organisms
  7. pre-existing urological conditions e.g polycystic kidneys, renal transplant, calculi, obstruction, neurogenic bladder
  8. co-morbidities such as immunosuppression, diabetes mellitus
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4
Q

What are 5 complications of UTI?

A
  1. Ascending infection: pyelonephritis, renal and per-renal abscess
  2. Impaired renal function, renal failure
  3. Urosepsis
  4. In pregnancy: pre-term delivery
  5. Low birthweight
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5
Q

What are 6 clinical features of lower UTI?

A
  1. Dysuria
  2. Frequency
  3. Urgency
  4. Change in urine appearance - cloudy, change colour, frank haemturia
  5. Odour to urine
  6. Nocturia
  7. Suprapubic discomfort
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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

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7
Q

What are 2 other genitourinary conditions which may cause urinary symptoms?

A
  1. STIs
  2. Vaginal atrophy
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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

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9
Q

What result on a urine dipstick makes UTI likely?

A

positive for nitrite or leukocyte and red blood cells

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10
Q

What urine dipstick result suggests UTI is equally likely to other diagnoses?

A

negative for nitrite and positive for luekocyte

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11
Q

What urine dipstick result suggests UTI is less likely?

A

negative for nitrite, leukocyte and RBC

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12
Q

When should urine dipstick not be used to diagnose UTI? 2 situations

A
  1. Catheterised women
  2. Women over 65 years
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13
Q

What are 8 situations when you should sent a urine sample for culture in suspected UTI?

A
  1. Pregnancy - and repeat sample following treatment should be sent to confirm cure
  2. Age >65 years
  3. Persistent symptoms or treatment failure
  4. Recurrent UTI
  5. Catheterised or recently been catheterised
  6. Risk factors for resistant or complicated UTI
  7. Visible or non-visible haematuria
  8. Atypical symptoms
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14
Q

What are the 4 key aspects of management of acute uncomplicated lower UTI?

A
  1. Giving advice on self-care measures (such as analgesia and hydration)
  2. 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
  3. Giving advice on when to seek medical review
  4. Reviewing choice of antibiotic when results are available
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15
Q

What additional investigation does the management of UTI in pregnancy involve?

A

repeat sample sent for culture following treatment to confirm

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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

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17
Q

What is the management of UTI in pregnancy? 3 aspects

A
  1. Women with asymptomatic bacteruria and suspected or proven UTI should be treated promptly with a 7-day course of antibiotics and followed up
  2. Urgent specialist advice should be sought for recurrent UTI, catheter associated UTI, atypical pathogens or if an underlying cause is suspected
  3. Antenatal services must be informed if group B streptococcal bacteriuria is identified
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18
Q

What are 4 situations when urgent specialist advice should be sought for UTI in pregnancy?

A
  1. Recurrent UTI
  2. Catheter-associated UTI
  3. Atypical pathogens
  4. Underlying cause is suspected
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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

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20
Q

What is the management of recurent UTI? 2 key aspects

A
  1. Referral should be made if: cause unknown, woman catheterised, malignancy suspected
  2. Preventative measures such as behaviour and personal hygiene should be discussed - topical vaginal oestrogen and antibiotic prophylaxis may be appropriate
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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

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22
Q

What is the definition of complicated UTI?

A

increased likelihood of complications such as persistent infection, treatment failure and recurrent infection

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23
Q

What are 5 risk factors for complicated UTI?

A
  1. Structural or neurological abnormalities
  2. Urinary catheters
  3. Virulent or atypical infecting organisms
  4. Poorly contorlled diabetes mellitus
  5. Immunosuppression
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24
Q

What is upper UTI?

A

infection of upper part of urinary tract: ureters and kidneys (i.e. pyelonephritis)

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25
Q

What is the definition of recurrent UTI?

A

two or more episodes of UTI in six months OR

three or more episodes in one year

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26
Q

What are 2 reasons that recurrent UTI can occur?

A
  1. Relapse - infection due to same strain of organism
  2. Reinfection - infection due to different organism
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27
Q

What is the definition of catheter associated UTI?

A

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

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28
Q

What is the recommended management of asymptomatic bacteriuria in non-pregnant women with a catheter in situ/in past 48h?

A

does not routinely need treatment

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29
Q

What is the definition of asymptomatic bacteriuria?

A

presence of significant levels of bacteria in the urine in a person without signs of symptoms of UTI

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30
Q

What factor increases the likelihood of bacteria being found in the urine of a catherised woman?

A

longer it has been in, more likely bacteria will be found

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31
Q

What are 3 ways that bacteria can enter the urinary tract?

A
  1. Retrograde - ascent through urethra
  2. Via blood stream - if immunosuppressed
  3. Direct - e.g. insertion of catheter, instrumentation, surgery
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32
Q

What is the most common pathogen causing UTI?

A

Escherichia coli (70-95%)

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33
Q

What are 5 additional causative agents of UTI in addition to E. Coli?

A
  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
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34
Q

In which group is proteus mirabilis a possible cause of UTI?

A

Males, associated with renal tract abnormalities, particularly calculi

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35
Q

What are 3 situations when candida species might (rarely) cause UTI?

A
  1. Indwelling catheters
  2. Immunosuppression
  3. Contamination from genital tract
36
Q

What are 3 risk factors for recurent UTI in young and pre-menopausal women?

A
  1. Sexual intercourse
  2. Past medical histoyr of UTI in childhood
  3. Mother with history of UTI
37
Q

What are 6 risk factors for recurrent UTI in post-menopausal and elderly women?

A
  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
Q

What proportion of women who have UTI will have recurrence?

39
Q

How long does acute, uncomplicated UTI take to resolve?

A

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
Q

What is the risk of asymptomatic bacteriuria in pregnancy?

A

can develop UTI and pyelonephritis, associated with pre-term delivery and low-birthweight

41
Q

What is done due to the risk of complications to the fetus of UTI/pyelonephritis in pregnancy?

A

all pregnant women offered routine screening for asymptomatic bacteriuria in early pregnancy

42
Q

What are 4 possible symptoms of UTI in elderly women with underlying cognitive impairment?

A
  1. Delirium
  2. Lethargy
  3. Reduced ability to carry out activities of daily living
  4. Anorexia
43
Q

How should a working diagnosis of UTI be made in elderly women with underlying cognitive impairment?

A

alternative sources of infection and causes of delirium other than UTI must be excluded first

44
Q

What are 3 symptoms that should make you suspect pyelonephritis?

A
  1. Fever
  2. Loin pain
  3. Rigors
45
Q

What are 5 red flags to ask about in suspected UTI?

A
  1. Haematuria
  2. Loin pain
  3. Rigors
  4. Nausea/ vomiting
  5. Altered mental state
46
Q

What are 4 background questions to ask about in the history for suspected UTI?

A
  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
Q

What are 4 aspects of examination to perform in suspected UTI?

A
  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
Q

What time of sample is most reliable for urine to be sent off for culture and sensitivities?

A

morning sample

49
Q

If <65years and no risk factors for complicated UTI, when should you send a urine sample for culture?

A

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
Q

How should the urinary catheter be sampled for urine culture?

A

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
Q

What further investigations are sometimes considered in secondary care for UTI?

A

cystoscopy or imaging if underlying cause suspected

52
Q

What is the management of acute lower UTI without haematuria in woman not pregnant or catheterised? 7 aspects

A
  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
Q

How should you decide what antibiotic to give for UTI without haematuria/catheter/pregnancy?

A
  • treat according to sensitivities from recent culture, otherwise treat empirically taking account of local antimicrobial resistance patterns
54
Q

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

A

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
Q

How can a delayed script for uncomplicated UTI be prescribed?

A

advise woman to start antibiotics if symptoms do not improve within 48 hours or worsen at any time

56
Q

When can you consider a delayed script?

A

if symptoms are mild and no risk factors for complicated infection

57
Q

What should be different about the management of UTI if there is visible or non-visible haematuria?

A
  • 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
Q

What is the management of visible or non-visible haematuria that persists after treatment in women who are pregnant?

A

urgently discuss management with ostetrics

59
Q

What are 5 aspects of management of recurrent UTI (no pregnancy/haematuria/catheter?

A
  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
Q

What are 4 behavioural and personal hygiene measures to recommend for recurrent UTI?

A
  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
Q

What should you do before prescribing vaginal oestrogen for recurrent UTI?

A

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
Q

What type of dose of vaginal oestrogens should be used when treating recurrent UTI?

A

lowest possible dose

63
Q

When should treatment with vaginal oestrogens be carried out?

64
Q

When should you consider antibiotic prophylaxis to treat recurrent UTI?

A

if underlying cause has been investigated and behaviour/personal hygiene measures and vaginal oestrogen (in postmenopausal women) are ineffective or inappropriate

65
Q

What are 6 factors to take into account when considering antibiotic prophylaxis for recurrent UTI?

A
  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
Q

What are 2 things that should be done before starting prophylactic antibiotics to treat UTI?

A
  1. Discuss risks of long term antibiotics including resistance and possible adverse effects
  2. Ensure any current UTI has been adequately treated
67
Q

Whatare 2 types of antibioitc prophylaxis for recurrent UTI?

A
  1. single dose when exposed to an identifiable trigger
  2. daily antibiotic prophylaxis
68
Q

What are the first and second choice when use of single dose antibiotic prophylaxis after exposure to a trigger is indicated?

A
  • 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
Q

When is daily antibiotic prophylaxis indicated for recurrent UTI?

A

if no improvement after single-dose prophylaxis or no identifiable triggers

70
Q

What are the 2 first choice and 2 second choice options for daily antibiotic prophylaxis for recurrent UTI?

A
  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
Q

When should follow up be carried out if a woman is taking antibiotic prophylaxis for recurrent UTI?

A

3-6 months later

72
Q

What should be done if acute UTI occurs whilst taking antibiotics for prophylaxis for recurrent UTI?

A

use different antibiotics to treat

check effectiveness of prophylaxis, consider changing to alternative, reinforce behavioural and personal hygiene measures

73
Q

What are 8 aspects of the management of UTI without haematuria in pregnancy?

A
  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
Q

When should you arrange an urgent assessment in secondary care for pregnant women with UTI?

A

if any features of serious or systemic illness such as sepsis or pyelonephritis

75
Q

What are 5 situations when you should seek urgent specialist advice on further management of pregnant women with UTI?

A
  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
Q

What are 3 self-care measures to be used during UTI in pregnancy?

A

analgesia e.g. paracetamol, encourage intake of fluids, PIL

77
Q

What should the immediate antibiotic prescription take into account when prescribed for women with UTI that are pregnant?

A

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
Q

What first choice and second choice antibiotics should be considered for immediate antibiotic treatment of UTI in pregnancy (before culture results back)?

A
  • 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
Q

When should nitrofurantoin be avoided in pregnancy?

80
Q

When should nitrofurantoin be avoided generally?

A

if eGFR <45

81
Q

When should you make sure to always avoid trimethoprim in pregnancy?

A

first trimester

82
Q

What is the management of asymptomatic bacteriuria during pregnancy?

A
  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
Q

What should you do if the urine sample shows group B streptococcal bacteriuria in pregnancy?

A

ensure antenatal services made aware - intrapartum antibiotic prophylaxis will be required

84
Q

What are 9 aspects of management of UTI with a catheter?

A
  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
Q

What are 2 aspects of the management of UTI if the catheter has been in place for more than 7 days?

A
  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
Q

What are the first and second line antibiotics to offer for CAUTI?

A
  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
Q

What are 3 aspects of good practice from the GP in maangement of long-term urinary catheters?

A
  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

GP (43 decks)

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