UTI/IC/Acute Pyelonephritis Flashcards
Define Uncomplicated acute cystitis
An uncomplicated UTI in a premenopausal, nonpregnant woman with no known urologic abnormalities or comorbidities
Infection of bladder
What is the most common causative agent for acute cystitis? How does it infect the body?
- E. Coli (86%)
- Also caused by: enterobacter: proteus mirabilis, klebsiella pneumoniae, staphylococcus saprophyticus - Route of infection is typically ascending from urethra (95%), hematogenous spread from bacteremia (5%)
What is the most common bacterial infection in women? Why?
- Acute cystitis (UTI)
A. Shorter urethra
B. Females lack antibacterial action of prostatic secretions
Who is at a higher risk of UTIs?
Sexually active women
What are the risk factors for complicated UTIs?
Diabetes
Pregnancy
Symptoms for seven or more days before seeking care
Hospital acquired infection
Renal failure
Urinary tract obstruction
Presence of an indwelling urethral catheter, stent, nephrostomy tube or urinary diversion
Recent urinary tract instrumentation
Functional or anatomic abnormality of the urinary tract
Renal transplantation
Immunosuppression
What are the pathogens that cause complicated UTIs?
- E. Coli
- Enterobacter:
- Proteus mirabilis
- Klebsiella pneumoniae
- Staphylococcus saprophyticus - Pseudomonas
- Serratia
- Providencia species
- Enterococci
- Staph aureus
- Fungi
What percentage of community acquired UTI’s are caused by E. coli?
86%
What percentage of hospital acquired (nosocomial) UTI’s are caused by E. coli?
50%
What percentage of hospital acquired UTIs are caused by Klebsiella, Proteus, Enterococcus, Serratia?
40%
What are some common hx symptoms for UTIs?
1. Irritative voiding sx’s Frequency, dysuria, urgency, low volume 2. Suprapubic discomfort 3. +/- Hematuria 4. Sx’s often postcoital 5. - Vaginal sx’s: itching, burning, discharge
What are common Physical exam signs for uti?
- Often unremarkable
- +/- Suprapubic tenderness
- Afebrile
- NO CVA tenderness
What are the urine dipstick results in UTIs?
Urine dipstick: Alkaline pH Nitrites Leukocytes \+/- blood
When is urine culture and sensitivity recommended?
Recommended for patients:
- With suspected acute pyelonephritis
- With symptoms that don’t resolve or recur 2-4 weeks after treatment
- Who present with atypical symptoms
What are the C & S results in a UTI?
Culture > 100,000 organisms/ml
Define Minimum Inhibitory Concentration (MIC)
Lowest concentration of an antimicrobial that will inhibit the visible growth of a microorganism after overnight incubation
What other DS may be performed for a UTI?
- UA w/micro: look for casts, crystals, etc.
- Renal/Bladder Ultrasound: look for stenosis and obstruction
- Renal CT scan: look for kidney stone
- Cystoscopy
What antibiotic tx is recommended for an uncomplicated UTI?
1. trimethoprim 160 mg/sulfamethoxazole Bactrim (DS) 1 tab po bid x 3 days 2. ciprofloxacin/Cipro 250-500 mg po bid x 3 days 3. nitrofurantoin/Macrodantin (Macrobid) 100 mg po bid x 5-(7) days
What Urinary analgesic is recommended for an uncomplicated UTI?
- Phenazopyridine /Pyridium
Decreases burning and pressure
When should a UTI pt be referred to Urology?
- UTI persistence despite abx treatment
-Sx’s should improve 48-72 hrs
-Renal sono or CT - Evidence of ureteral/kidney stones
- Evidence of hydronephrosis
- Recurrent UTI’s w/chronic urine incontinence
- Sx’s of urethral stenosis
- Recurrent cystitis
d/t bacterial persistence
What are some preventative measures for UTIs?
- Increase fluid intake
- Empty bladder frequently
- Wipe properly
- Showers rather than baths
- Void after intercourse
When should prophylactic abx be considered? What tx should be used?
- If 3 or more postcoital bouts within 1 year
- Nitrofurantoin (Macrodantin) 100 mg po prn as dir
- trimethoprim/sulfamethazole (Bactrim) 80/400 mg po prn as dir
What abx are recommended for complicates UTIs?
- Fluoroquinolones
- Levofloxane
- Ciprofloxacin
- Ampicilin or amoxicilin if gram positive bacteria
Basically same meds are used for both complicated and uncomplicated UTIs, but the length of the abx treatment course differs
Define Acute pyelonephritis
Infectious inflammatory disease involving the kidney parenchyma and renal pelvis
How does the acute pyelonephritis infection usually enter the body?
Infection usually ascends from the lower urinary tract
How does staph aureus enter the body to cause acute pyelonephritis?
Staph aureus is spread hematogenously
Etiology of acute pyelonephritis
1. F > M A. Shorter urethra B. Females lack antibacterial action of prostatic secretions 2. Pregnant women > general female population 3. Patients w/ DM A. Neurogenic bladder 4. Patients with renal disease A. Compromised renal function
What are the common infectious agents for acute pyelonephritis?
1. Gram (-) Bacilli (>95% of cases) A. E. coli B. Klebsiella 2. Gram (+) Cocci A. Enterococcus
What are the less common infectious agents for acute pyelonephritis?
1. Gram (-) A. Proteus B. Pseudomonas 2. Gram (+) A. Staph aureus
What is the pathophysiology of acute pyelonephritis?
- Infection spreads from bladder to ureters to kidneys
- Vesicoureteral reflux:
Can occur from congenital weakness at junction of ureter and bladder - Hematogenous spread (staph aureus)
- Instrumentation
A. Catheterization B. cystoscopy - Inability to empty bladder:
Neurogenic bladder - Urinary obstruction secondary to tumors, strictures or BPH
What are the sxs of acute pyelonephritis?
- Fever with rigors
- Back pain
- +/- Irritative void sx’s
- Nocturia
- Hematuria
- N/V/D
- Tachycardia
- CVA tenderness
- Flank pain
What special sxs may be seen in the elderly with acute pyelonephritis?
May exhibit GI or pulmonary symptoms rather than febrile illness
What special sxs may be seen in children (<2) with acute pyelonephritis?
Fever, vomiting, vague abdominal pain
Failure to thrive
What are the DS: U/A w/ micro results for acute pyelonephritis?
- Cloudy appearance
- Alkaline pH
- Pyuria, bacteriuria, hematuria
What are the DS: Sediment results for acute pyelonephritis?
Many WBC’s, few RBC’s, few WBC casts
What are the DS: Urine Culture results for acute pyelonephritis?
Cell Count > 100,000 organisms/ml
What other DS tests are indicated for pyelonephritis?
- CBC with differential
- Blood Cx
- BMP (basic metabolic panel)
- Renal U/S
If obstruction suspected - Renal CT
If stone or abscess suspected
What complications result from acute pyelonephritis?
- Sepsis
- Chronic pyelonephritis
- Acute renal failure (ARF or AKI)
when is hospitalization necessary for acute pyelonephritis?
- Sepsis
- Signs of urinary obstruction or significant underlying disease
- Inability to tolerate adequate oral (PO) fluids or medications
- Infants and children younger than 2 years with febrile UTI, presumed pyelonephritis
- All infants younger than 3 months
What are the inpatient treatments for acute pyelonephritis?
- IV antibiotics until afebrile 24-48 hrs, then oral meds (total 14 days)
- Hydration
- Antipyretics
- Anti-emetics
odansetron/Zofran
What are the 1st line therapies for In-pt. Pyelonephritis?
First-line therapy (fluoroquinolone)
1. ciprofloxacin (Cipro) 400 mg IV q12h for 14d or
2. levofloxacin (Levaquin) 250 mg IV q24h for 10d or
3. levofloxacin (Levaquin) 750 mg IV q24h for 5d
All of the above can be administered with or without an aminoglycoside (except in pregnant patients)
What are the second line therapies for in pt. pyelonephritis?
Second-line therapy (cephalosporins or penicillins)
1. ampicillin 1-2 g mg IV q6h or
2. ampicillin-sulbactam (Unasyn) 1.5 g IV q6h or
3. piperacillin-tazobactam (Zosyn) 3.375 g IV q6h or
4. ceftriaxone (Rocephin) 1 g IV q24h or
5. ceftazidime (Fortaz, Tazicef) 2 g IV q8h
All of the above can be administered with or without an aminoglycoside (except in pregnant patients)
What aminoglycosides can be administered in acute pyelonephritis?
- gentamicin 3 mg/kg/day IV in 3 divided doses
or - tobramycin 3 mg/kg/day IV in 3 divided doses or
- amikacin 10 mg/kg/day IV/IM in 3 divided doses
What are the out pt treatments for acute pyelonephritis?
Antibiotic therapy
#1-Fluoroquinolone (+/- ceftriaxone x 1)
ciprofloxacin (Cipro) 500 mg PO BID x 7d
levofloxacin (Levaquin) 750 mg 1 PO QD x 5-7d
#2- Others
amox/clavulanate(Augmentin) 875 mg PO BID x 14d + ceftriaxone 1 gm IM/IV x 1 dose
trimeth/sulfa(Bactrim DS) 1 PO BID x 14d (not in elderly due to nephrotoxicity risk) + ceftriaxone
Hydration
Fever control
Anti-emetic
-Ondansetron/Zofran
What are the recommended therapies for pediatric pyelonephritis?
1. Neonate Klebsiella IV ampicillin + gentamicin 2. 6 weeks-3 yrs E. coli IV ampicillin + gentamicin 3. 3-6yrs E. coli, Proteus in older boys Follow adult guidelines, but avoid fluoroquinolones 4. 6-11 yrs E. Coli Follow adult guidelines, but avoid fluoroquinolones
What are the recommended therapies for pyelonephritis secondary to obstruction?
- Antibiotics less effective
- Surgery to relieve obstruction or correct anomaly
- Vesicoureteral Reflux: Long term proph abx/surgery
- TURP
- Urethral dilation
- Ureteroscopy w/J-stent placement
Define interstitial cystitis/bladder pain syndrome
An unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than six weeks duration, in the absence of infection of other identifiable causes
When is IC/BPS most common? What populations does it affect?
Affects women 5X > men
Most common in 4th decade
What causes the abnormalities in lining of the bladder in IC/BPS?
- Defect in the glycosaminoglycan (GAG) layer that
- Allows urinary irritants to penetrate the urothelium and activate the underlying nerve and muscle tissue leading to tissue damage, pain, and hypersensitivity
What factors can cause IC/BPS?
- UTI
- An episode of vaginitis or prostatitis
- Bladder, pelvic, back, or other type of surgery
- Trauma (eg, fall onto the tailbone [coccyx] or car accident)
What are the sxs of IC/BPS?
- Bladder pain is partially relieved by voiding
- Frequency
- Urgency
- Nocturia
- Suprapubic pain &/or urethral pain
A. Mild burning to severe and debilitating
B. Pain describes as sharp or glass scraping over orifice - Gradual onset w/ increase over months
- May have IBS, dysmenorrhea, endometriosis, vulvodynia, fibromyalgia, or prostatitis
What factors may exascerbate IC/BPS?
- Consuming certain foods or drinks (coffee, alcohol, spicy foods)
- Full bladder
- Luteal phase of the menstrual cycle (days 14-28)
- High stress
- Exercise or sexual intercourse
- Prolonged sitting
What are the diagnostic steps in IC/BPS?
- History
- Physical Exam
A. pelvic/prostate
B.tenderness or tightness of the pelvic floor muscles - UA w/ micro
- Urinary Cystoscopy
- Urine cytology if hematuria
- Measure post void residual volume (USN)
When is cystoscopy indicated?
- Hematuria
A. Hunner lesions :
Reddened lesions on the bladder mucosa with attached fibrin deposits
-Bleed after hydrodistention (stretching of bladder when full causes bleeding) - Glomerulations:
Petechial red areas - Increased numbers of mast cells on histologic examination of bladder biopsy specimens
What is the tx for IC/BPS?
- Behavior modification
- PT
- Counseling
- Diet restrictions
See Handout - Medications
Pentosan polysulfate sodium (Elmiron)
Amitriptyline (Elavil)
Hydroxyzine (Atarax, Vistaril) - Procedures
Dimethylsulfoxide (DMSO)
20 min instillation weekly x 6-8 weeks
Sacral nerve stimulation
