UTI booklet Flashcards by Peter Savage

What are the classical symptoms of UTI?

Dysuria
Frequency of urination
Suprapubic tenderness
Urgency
Polyuria 
Haematuria

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What is cystitis?

Inflammation of bladder

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What is bacterinuria?

Presence of bacteria in urine (not associated with micturition)

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What is pyuria?

Presence of significant quantities of pus (neutrophil polymorphs) in the urine

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Pyuria suggests what?

Inflammatory response - supports UTI

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What is sterile pyuria?

Significant pus cells with a negative culture

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What is chronic pyelonephritis?

Renal scarring - potential loss of renal function

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What non-infective factors can lead to chronic pyelonephritis?

Diabetes
Vesico-ureteric reflux
Urinary obstruction

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How does UTI typically present in women?

Dysuria
Frequency
Urgency 
Suprapubic pain
Polyuria 
Haematuria

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The criteria suggests which female possible UTI patients should be given antibiotics?

3 or more symptoms OR severe symptoms

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When should a middle-stream urine test be used on a patient?

Mild or 1, 2 symptoms

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How can you assist the patient in providing a clean specimen?

Washing/swabbing with sterile saline

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When should the urine be tested by dipstick?

When cloudy

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What contents in urine suggest UTI?

Nitrites
Protein
Leucocytes

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Why can UTIs cause nitrites in the urine?

Nitrites are a metabolic product of some bacteria

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Why can UTIs cause proteins in the urine?

Proteins are a sign of inflammation or renal pathology

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Why can UTIs cause leucocytes in the urine?

Marker of an inflammatory response

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If the patient is positive only for leucocyte esterase, how do you proceed?

Urine culture

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When should blood/protein in urine be investigated further?

When the dipstick is negative for leucocytes and nitrites

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Why does the risk of UTI increase with age in men?

Increased likelihood of prostatic hypertrophy

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Recurrent UTI in men is often a sign of what?

Prostatitis

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Prostatitis is typically due to what in older men?

Coliform organisms

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Prostatitis is typically due to what in younger men?

Chlamydia trachomatis

Neisseria gonorrhoeae

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Bacterial infection of the upper tract is most common in which group?

Women of child bearing age

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What is the typical presentation of Acute Pyelonephritis?

Loin pain Fever Urinary symptoms: Frequency, dysuria

What is a severe complication of severe acute pyelonephritis?

Bacteraemia

What are the signs of sepsis?

Rigors | Nausea and vomiting

How should suspected pyelonephritis be managed?

Urine culture Immediate antibiotics - review when organisms known Extended for 7 days

How should recurrent acute pyelonephritis be investigated?

Urinary tract investigation for abnormalities/calculi

What is the risk of bacteriuria in patients with indwelling catheters?

5% per day - cumulative

When should patients with indwelling catheters be investigated?

Only when they show SYMPTOMS/SIGNS of UTI

How does the incidence of asymptomatic bacteriuria vary with age?

Incidence increases with age

When should patients with asymptomatic bacteriuria be treated?

Pregnancy Urological surgery Surgery involving artificial prosthesis implantation

Asymptomatic bacteriuria is associated with what?

Pyelonephritis | Premature delivery

What would cause pyuria in the absence of a positive culture?

Undeclared presence of antibiotic in sample Renal tuberculosis Chlamydia

What is recurrent sterile pyuria a sign of?

Renal tract stone Interstitial Cystitis Urological malignancy Chronic prostatitis

How do you test for renal tuberculosis?

3x morning urine ZN stain TB culture

Untreated vesico-ureteral reflux can lead to what?

Renal scarring

Most cases of chronic pyelonephritis in adult life are a result from what?

Damage done during childhood

How do patients with chronic pyelonephritis present?

Vague abdominal discomfort Hypertension Sterile pyuria

How does chronic pyelonephritis present radiologically?

Clubbing of calyces | Scarring of cortices

If ureters appear dilated in a renal radiogram, how do you proceed?

Micturating Cystogram

How is vesicoureteric reflux diagnosed?

Micturating cystogram

Which factors predispose people to developing UTIs?

``` Females - short urethra, sex, pregnancy, childbirth Anatomical abnormalities Renal cysts Pre-existing parenchymal damage Stones Immunosuppresion Instrumentation Foreign body ```

How does pregnancy increase a womans risk of UTI?

Progesterone dilates ureters | Physical pressure from foetus

What is an uncomplicated UTI?

UTIs in healthy, sexually active women

What are complicated UTIs?

UTIs in children, men, patients with abnormal renal tracts, immunosuppression, foreign bodies, retention

What are the typical causes of uncomplicated UTIs?

E. coli Skin commensals: Staph. saprophyticus

How are complicated UTIs different?

Require additional investigations Upper renal tract assessment Urinary flow studies (find a cause)

When should cultures be taken in suspected UTIs?

``` Women with inconclusive dipstick test Suspected UTI in men/children Suspected pyelonephritis Pregnant women After failed antibiotics Recurrent UTI ```

How are recurrent UTIs defined?

>2 UTIs 6 months OR >3 UTIs 1 year

How is mid-stream urine taken?

Discard first 10-20mls Ideally in morning Boric acid containers

How are catheter specimens taken?

Catheter sampling port | NOT from bag

How is urine collected from children?

Clean catch urine sample

How should urine be collected from children if clean catch is not possible?

Non-invasive: Collection pads (high false -ve) If fails: Suprapubic aspiration

How are urine culture results expressed?

Organisms/ml

What is the most common organism responsible for UTI?

E. coli

What are the less common species responsible for UTI?

``` Proteus sp. Enterococcus faecalis Klebsiella sp. Pseudomonas sp. Staph. saprophyticus ```

How do UTI pathogens differ in community vs hospital acquired pneumonia?

E. coli less common in hospital | 'Uncommon' pathogens more common in hospital

What causes E. coli to be good at causing UTI?

Presence of P fimbriae - adhere to uroepithelium

Staph. saprophyticus is what type of bacterium?

Coagulase negative

What causes Proteus spp. to be good at causing UTI?

Produces enzyme Urease Urease causes urea -> ammonia Makes urine alkali Encourages Stone formation

Staph. saprophyticus is a more common UTI pathogen in which groups?

Sexually active women

Which pathogens are more common in hospital patients?

'uncommon' | Proteus, Klebsiella, Pseudomonas

'uncommon' pathogens in UTI are associated with what?

Indwelling catheters/instrumentation

How do 'uncommon' pathogens differ from E.coli?

More antibiotic resistant | esp. Pseudomonas spp

Stones in the urinary tract are associated with which species?

Proteus sp | Klebsiella

Proteus and Klebsiella should always be managed how?

(UTI Rx) | Upper renal tract imaging to exclude stones

When is the '10^5 rule' used?

Asymptomatic patients

What concentration of pus cells is defined as significant pyuria?

>10 WBC/mm3

What lab tests are performed on urine tests?

Culture | Microscopy

What must be determined before antibiotic therapy is given for UTI?

Distinguish whether the patient has cystitis or acute pyelonephritis?

How is suspected lower UTI in women treated? (simple cystitis)

Cheap/simple antibiotic 3 day course Trimethoprim Nitrofurantoin

When is trimethoprim contraindicated?

Pregnancy

Which pathogen is resistant to Nitrofurantoin?

Proteus spp

How should patients who do not respond to a 3 day simple cystitis Rx be managed?

Take urine cultures

How should suspected lower UTI in men be treated?

14 days Quinolone (covers prostatitis) | 7 days Nitrofurantoin/Trimethoprim

How should UTI in pregnancy be treated?

``` 7 days therapy Sensitivity testing Pregnant women: - Ciprofloxacin - Cephalexin ```

How should catheter related UTI be treated?

Symptomatic Pts only Change catheter Antibiotics

How should asymptomatic bacteriuria be treated?

No treatment unless: Pregnancy Planned urinary tract surgery

How should recurrent UTI be managed?

Careful history - hygiene, fluids after sex Gynae examination Long term antibiotic prophylaxis One dose antibiotic after sex

What is the long term antibiotic prophylaxis recommended for recurrent UTI?

1 tablet/night up to a year Nitrofurantoin Trimethoprim

What is the management of acute pyelonephritis?

7 day therapy Sensitivity testing Review after urine cultures and sensitivity testing Check resolution with sample after 1 week

When should you suspect bacteraemia in acute pyelonephritis?

Vomiting

When should acute pyelonephritis be managed?

Single episode in men | Repeat episodes in women