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UTI Flashcards

1
Q

Routes of infection

A

1) Ascending route

2) Hematogenous/Descending route

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2
Q

Ascending route

1) Pathogenesis
2) Possible causative organisms

A

1) Colonic/Fecal flora colonize at periurethral area / urethra –> ascend to bladder and kidneys –> invades tissues and causes inflammation & infection
2) E. coli, Klebsiella, Proteus

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3
Q

Descending route

1) Pathogenesis
2) Possible causative organisms

A

1) Organism causing infection at distant primary site enters bloodstream (bacteremia) –> organism invades urinary tract
2) S. aureus, M. tuberculosis

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4
Q

Host defense mechanisms to protect against UTI

A

1) Presence of bacteria in bladder stimulates micturition & increased diuresis –> emptying of bladder –> flush out bacteria from urinary tract
2) Antibacterial properties (antibacterial enzymes) of urine & prostatic secretions –> prevent multiplication of bacteria
3) Anti-adherence properties of bladder mucosa –> prevent attachment of bacteria –> prevents bacteria from invading tissues & causing infection
4) Inflammatory response by polymorphonuclear leukocytes (PMNs) –> phagocytose bacteria

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5
Q

Factors determining development of UTI

A

1) Competency of host defense mechanisms
2) Size of inoculum
- E.g. Urinary retention/Obstruction in urinary tract –> bacteria cannot be passed out –> increase size of inoculum –> increase risk of UTI
3) Virulence of pathogen
- E.g. Bacteria with pili are resistant to washout and anti-adherence mechanisms

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6
Q

Risk factors for UTI

A

1) Females > Males
- Due to shorter urethra

2) Sexual intercourse
- Increase colonization of bacteria at vaginal area, change vagina flora –> increase ascent of bacteria from vaginal area to urethra

3) Abnormalities in urinary tract, leading to urinary retention and/or backflow of urine
- E.g. BPH, urethral stricture, kidney stones, vesicoureteral reflux

4) Diabetes
- High glucose in urine –> increase bacterial growth
- Neuropathy –> urine retention

5) Neurological disorders
- E.g. stroke diabetes, spinal cord injuries
- Malfunction of urinary tract –> urinary retention

6) Catheterization, other mechanical instrumentation

7) Certain types of contraceptives
- E.g. Spermicides / Diaphragms –> alter flora in periurethral area/vaginal area –> increase bacterial colonization
- E.g. Unlubricated condoms / spermicidal condoms –> cause irritation –> increase bacterial growth

8) Positive family history
9) Previous history of UTI
10) Pregnancy

11) Anticholinergic drugs
- Causes urinary retention as a side effect

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7
Q

Subjective evidence for lower UTI (cystitis)

A

1) Dysuria
2) Urgency
3) Frequency
4) Nocturia
5) Gross hematuria
6) Suprapubic heaviness/pain

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8
Q

Subjective evidence for upper UTI (pyelonephritis)

A

1) Fever, rigors
2) Malaise
3) Headache
4) N/V
5) Positive renal punch
6) Abdominal/Flank pain

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9
Q

Objective evidence - Vital signs

A

1) Fever - Temperature ≥ 38 degC
2) Hypotension - SBP < 100 mmHg
3) Respiratory rate > 22 bpm
4) Heart rate > 90 bpm
5) Mental status changes

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10
Q

Objective evidence - Lab tests

A

1) TW > 10 x 10^9 / L OR TW < 4 x 10^9 / L
2) Increased neutrophils (normal: 45 - 75%)
3) Increased procalcitonin
4) Increased CRP (> 10 mg/L)
5) Increased ESR

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11
Q

Objective evidence - UFEME

A

1) Pyuria - WBC > 10 WBCs / mm3
- Indicates presence of inflammation
- Absence of pyuria –> unlikely to be UTI
2) Hematuria - > 5 HPF / gross
- Not specific for infection
3) Presence of microorganisms
4) Presence of WBC casts
- Indicates upper tract infection

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12
Q

Objective evidence - Chemical urinalysis

A

1) Nitrite
- Positive test indicates presence of GN bacteria
2) Leukocyte esterase (LE)
- Positive test indicates esterase activity

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13
Q

Urine collection methods

A

1) Midstream clean-catch
- Throw away first 20-30mL, collect midstream
2) Catheterization
3) Suprapubic bladder aspiration

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14
Q

When are urine cultures needed / not needed

A

May be necessary for:

1) Pregnant women
2) Men
3) Pyelonephritis
4) Catheter-associated UTI
5) Recurrent UTI (within 2 weeks / frequently)

NOT necessary in:
1) Uncomplicated cystitis

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15
Q

Causative organisms in:

1) Uncomplicated / community-acquired UTI
2) Complicated / healthcare-associated UTI
3) Catheter-associated UTI
4) Others

A

Uncomplicated / Community-acquired UTI:

  • E. coli (> 85%)
  • Staphyloccocus saprophyticus (5 - 15%)
  • Enterococcus faecalis, Klebsiella, Proteus

Complicated / Healthcare-associated UTI

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

Catheter-associated UTI

  • Short term (< 7 days): E. coli, Klebsiella (85% single organism)
  • Long term (> 28 days): E. coli, Klebsiella, P. aeruginosa (95% polymicrobial)

Others

  • S. aureus
  • Candida/Yeast
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16
Q

Identifying uncomplicated UTI

A

No complicating factors

Usually in healthy, pre-menopausal, non-pregnant with no history suggestive of abnormal urinary tract

17
Q

Identifying complicated UTI

A 
UTI in men/children/pregnant women
Complicating factors
- Genitourinary instrumentation
- Functional and structural abnormalities of urinary tract 
- DM
- Immunocompromised
18
Q

Identifying nosocomial UTI

A

Onset of UTI > 48h post admission

19
Q

Identifying healthcare-associated UTI

A

UTI in:

  • Hospitalized patients
  • Underwent invasive urologic procedures in last 6 months
  • Indwelling catheter

Healthcare risk factors

  • Hospitalization in last 90 days
  • Current hospitalization ≥ 2 days
  • Nursing home resident
  • Antimicrobial use in last 90 days
  • Home infusion therapy
  • Chronic dialysis
20
Q

Identifying catheter-associated UTI

A

1) Presence of UTI s/sx AND
2) No other sources of infection AND
3) 10^3 cfu/mL of ≥ 1 bacterial species in:
- Single catheter urine specimen in patients with indwelling / intermittent catheter
- Midstream voided urine specimen from patient whose catheter has been removed in past 48h

21
Q

Risk factors for catheter-associated UTI

A

1) Duration of catheterization
2) Colonization of drainage bag, catheter, periurethral segment
3) DM
4) Female
5) Renal impairment
6) Poor quality of catheter care, including insertion

22
Q

Need to treat

A

Treat:

1) Symptomatic
2) Pregnant women (even if asymptomatic)
3) Patient going for invasive urologic procedure
- Antibiotics given as prophylaxis 12-24h before procedure (culture-directed)

Do NOT treat:
1) Asymptomatic

23
Q

Empiric therapy for community-acquired uncomplicated cystitis in women

A

1st line:
PO Cotrimoxazole 800/160 mg BID x 3 days
PO Nitrofurantoin 50 mg QDS x 5 days
PO Fosfomycin 3 g single dose

Alternative:
PO Cephalexin 500 mg BID x 5-7 days
PO Cefuroxime 250 mg BID x 5-7 days
PO Amoxicillin-Clavulanate 625 mg BID x 5-7 days
PO Ciprofloxacin 250 mg BID x 3 days
PO Levofloxacin 250 mg daily x 3 days
24
Q

Empiric therapy for community-acquired complicated cystitis in women

A

Duration: 7 - 14 days

1st line:
PO Cotrimoxazole 800/160 mg BID
PO Nitrofurantoin 50 mg QDS
PO Fosfomycin 3 g every other day x 3 doses

Alternative:
PO Cephalexin 500 mg BID
PO Cefuroxime 250 mg BID
PO Amoxicillin-Clavulanate 625 mg BID
PO Ciprofloxacin 250 mg BID
PO Levofloxacin 250 mg daily
25
Q

Empiric therapy for community-acquired pyelonephritis in women

A

PO Ciprofloxacin 500 mg BID x 7 days
PO Levofloxacin 750 mg daily x 5 days
PO Cotrimoxazole 800/160 mg BID x 14 days
PO Cephalexin 500 mg BID x 10-14 days
PO Amoxicillin-clavulanate 625 mg TDS x 10-14 days

26
Q

Empiric therapy for community-acquired pyelonephritis in women who are severely ill

A

IV Ciprofloxacin 400 mg BID OR
IV Cefazolin 1g q8h OR
IV Amoxicillin-clavulanate 1.2g q8h

+/- IV/IM Gentamicin 5 mg/kg

27
Q

Empiric therapy for community-acquired cystitis (no concern for prostatitis) in men

A

Similar to complicated cystitis in women
Duration: 10-14 days

1st line:
PO Cotrimoxazole 800/160 mg BID
PO Nitrofurantoin 50 mg QDS
PO Fosfomycin 3 g every other day x 3 doses

Alternative:
PO Cephalexin 500 mg BID
PO Cefuroxime 250 mg BID
PO Amoxicillin-Clavulanate 625 mg BID
PO Ciprofloxacin 250 mg BID
PO Levofloxacin 250 mg daily
28
Q

Empiric therapy for community-acquired cystitis (concern for prostatitis) OR pyelonephritis in men

A

Duration: 10-14 days (6 weeks if prostatitis confirmed)

PO Cotrimoxazole 800/160 mg BID
PO Ciprofloxacin 500 mg BID

29
Q

Empiric therapy for nosocomial / healthcare-associated pyelonephritis

A

Duration: 7-14 days

IV Cefepime 2g q12h +/- IV Amikacin 15 mg/kg/day
IV Imipenem 500 mg q6h
IV Meropenem 1g q8h

30
Q

Empiric therapy for nosocomial / healthcare-associated pyelonephritis for less sick patients

A

Duration: 7-14 days

PO Ciprofloxacin 500 mg BID
PO Levofloxacin 750 mg

31
Q

Empiric therapy for catheter-associated UTI

A

Duration: 7 days (prompt resolution of symptoms, defervescence in 72h) OR 10-14 days (delayed response)

IV Cefepime 2g q12h +/- IV Amikacin 15 mg/kg (single dose)
IV Imipenem 500 mg q6h
IV Meropenem 1g q8h

32
Q

Empiric therapy for catheter-associated UTI - Mild infection

A

PO/IV Levofloxacin 750 mg daily x 5 days

33
Q

Empiric therapy for catheter-associated UTI for women ≤ 65 years with catheter-associated UTI without upper urinary tract symptoms after an indwelling catheter has been removed

A

PO Cotrimoxazole 800/160 mg BID x 3 days

34
Q

Prevention of catheter-associated UTI

A

1) Avoid unnecessary catheter use
2) Minimal duration
3) Long term indwelling catheter changed before blockage occurs
4) Closed system
5) Aseptic insertion technique

35
Q

Antibiotics contraindicated in pregnancy

A

1) Ciprofloxacin
2) Cotrimoxazole (1st & 3rd trimester)
3) Nitrofurantoin (at term i.e. 38-42 weeks)
4) Aminoglycosides

36
Q

Empiric therapy for pregnant women

A

Duration:
Asymptomatic / Cystitis: 7 days
Pyelonephritis: 14 days

Choice of antibiotics:
Similar to non-pregnant women (but without antibiotics C/I in pregnancy)

37
Q

Adjunctive treatment

A

1) Paracetamol / NSAIDs
- Reduce pain, fever
2) Rehydration
- For vomiting
3) Phenazopyridine
- Topical analgesic effect on urinary tract mucosa –> symptomatic relief
- 100 - 200 mg TDS, for duration of symptoms
- ADR: N/V, orange-red discolouration of stool & urine
- C/I: G6PD deficiency

Unproven clinical benefit:

1) Urine alkalization
- Relieves discomfort
2) Cranberry juice
- Inhibit adherence of E. coli
- Clinical data suggest decreased incidence of UTI
3) Intravaginal estrogen cream
- Restore vaginal flora, reduce colonization of E. coli
- Decrease incidence of UTI in post-menopausal women
4) Lactobacillus probiotics
- Restore vaginal flora, reduce colonization of E. coli
- Recent small uncontrolled trial showed reduced recurrence in uncomplicated cystitis

38
Q

Non-pharmacological management of UTI

A

Prevention

1) Drink plenty of fluids (6-8 glasses/day)
2) Urinate frequently & when you feel the urge
3) Urinate shortly after sex
4) Avoid diaphragms, spermicides, unlubricated/spermicidal condoms
5) Wipe from front to back after using the toilet, especially after bowel movement
6) Wear cotton underwear & loose fitting clothes

39
Q

Monitoring

A

1) Resolution of signs & symptoms
- Should have improvement within 48-72h after initiation of effective antibiotics
- If patient fails to respond within 48-72h / Persistently positive blood cultures –> must carry out further investigation to exclude bacterial resistance, possible obstruction, renal abscess, other disease
2) Bacterial clearance
- Culture to document clearance of infection needed for pregnant women
3) ADR, allergies

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