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PHA223 > UTI in practice > Flashcards

UTI in practice Flashcards

1
Q

2 parts of the lower urinary tract

A

bladder

urethra

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2
Q

Where can a UTI affect?

A

any part of the urinary system

- kidneys, ureters, bladder, urethra

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3
Q

typical bacteria that cause UTI

A

E coli (Gram negative)

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4
Q

How do bacteria enter the GIT?

A

through the urethra

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5
Q

symptoms of bladder UTI (cystitis)

A

polyuria
dysuria
lower abdominal discomfort

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6
Q

symptoms of urethra UTI (urethritis)

A

burning on passing urine

discharge

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7
Q

risk factors for UTI

A
  • females (shorter urethra, urethra proximity to anus)
  • post menopausal women (dec oestrogen)
  • catheters (route for bacteria)
  • recent antibiotics (disrupts normal bacteria)
  • spermicides (irritation and attachment sites for E. Coli)
  • sexual intercourse (bacteria to UT)
  • pregnancy (progesterone stimulates SM relaxation to bladder and uterus and compression of ureters by uterus)
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8
Q

when to refer UTI

A
  • pregnancy
  • men
  • < 16yrs
  • symptoms of pyelonephritis
  • signs of sepsis
  • non respondant to first antibiotics
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9
Q

risks for UTI in pregnancy

A

pyelonephritis
premature birth
rupture of membranes

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10
Q

symptoms of pyelonephritis (upper UTI)

A 
fever
loin pain (kidney pain/tenderness in back under ribs)
rigors (temp rises quickly)/ pyrexia
flu-like illness/myalgia
nausea/vomiting
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11
Q

What is pyelonephritis?

A

upper UTI

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12
Q

high risk signs of sepsis

A 
altered mental state/behaviour
increased RR/HR
low BP
anuria (not passing urine)
mottled/ashen (grey) skin
cyanosis (blue skin/lips)
non-blanching rash (doesn't go with pressure)
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13
Q

When is urine dipstick not recommended and why?

A

elderly (>65yrs)

asymptomatic bacteriuria is common in elderly and could result in unnecessary antibiotics

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14
Q

When is urine culture not necessary?

A

if uncomplicated first UTI in women

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15
Q

What to do if urine culture done and bacteria is resistant?

A

amend antibiotics (if still symptomatic)

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16
Q

When not to treat a UTI?

A

if it’s asymptomatic (unless pregnant)

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17
Q

What causes need to be excluded before diagnosis?

A

vaginal and urethral causes

  • urethritis: post sexual intercourse, irritants
  • sexual Hx to exclude STI
  • genitourinary syndrome of menopause
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18
Q

3 key signs of UTI

A

dysuria
new nocturia
cloudy urine

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19
Q

When is dipstick not needed (UTI likely)?

A

2 or 3 symptoms present

dysuria, nocturia, cloudy urine

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20
Q

When to perform dipstick?

A

1 symptom present

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21
Q

What to check if no symptoms are present?

A 
urgency
visible haematuria
frequency
suprapubic tenderness
-> yes to these then dipstisk
-> no, UTI unlikely
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22
Q

urine dipstick negative for nitrites, leukocytes, RBC

A

UTI less likely

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23
Q

urine dipstick negative for nitrates but positive for leukocytes

A

could be UTI

send urine culture and consider treatment depending on symptom severity

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24
Q

urine dipstick positive for RBC, positive nitrite/leukocyte

A

likely UTI

treat or watch/wait with backup antibiotic depending on symptom severity

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25
Q

difference in treatment for over 65

A
  • no urine dipsticks
  • new onset dysuria or 2+ new symptoms UTI likely
  • always send urine culture
  • delirium considerations/other diagnostics
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26
Q

When are antibiotics given for UTI in pregnancy?

A

bacteriuria confirmed even if symptomatic

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27
Q

treatment for suspected UTI in pregnancy

A
  • paracetamol for symptomatic relief
  • prescribe antibiotic 7 days (often nitrofurantion, not at term)
  • MSU for culture
  • amend prescription if needed
28
Q

MSU

A

midstream specimen of urine

29
Q

group B streptococcus isolated in pregnant woman

A

prophylactic antibiotics offered during labour and delivery

-> risk to baby

30
Q

Why are antibiotics given if asymptomatic UTI in pregnancy?

A

pyelonephritis and premature delivery risk

31
Q

What to consider before giving antibiotics?

A

how severe the symptoms are
risk of complications
previous urine culture results
previous antibiotic use

32
Q

When are back up antibiotics used?

A

if no improvement after 48hrs or symptoms worsen at any time

33
Q

Who have a low risk factor for antibiotic resistance?

A

younger women with acute UTI and no resistance risks

34
Q

risk factors for increased resistance

A
  • care home resident
  • recurring UTI (2 in 6mths, >3 in 12mths)
  • unresolving symptoms
  • hospitalisation for >7d in last 6mths
  • recent travel to a country with inc resistance
  • pevious UTI resistant to trimetoprim/cephalosporins/
    quinolones
35
Q

What antibiotics can increase clostridium difficile infections?

A

ciprofloxacin
cephalosporins
co-amoxiclav
(3 Cs)

36
Q

What antibiotics should be used for UTIs to reduce clostridium difficile?

A

nitrofurantoin
trimethoprim
pivmecillinam

37
Q

When should co-amoxiclav only be used?

A
  • pyelonephritis in pregnancy
  • facial cellulitis or prophylaxis post dog/human bites
  • diverticulitis
  • persistent sinusitis 2nd line
38
Q

trimethoprim (spectrum/resistance)

A

narrow spectrum

resistance is common

39
Q

nitrofurantoin (spectrum/resistance)

A

broad spectrum
concenctated in the area of need
resistance rates are lower

40
Q

recommended treatment for most uncomplicated UTIs

A

3 day course of empirical antibiotics

41
Q

How effective is a 3 day course of empirical antibiotics for uncomplicated UTI?

A
  • more effective than single doses

- as effective as 5-10 day course

42
Q

1st line choice for UTI O16, not pregnant

A

nitrofurantoin 100mg MR BD for 3 days

- if eGFR > 45

43
Q

1st line choice UTI O16, not pregnant (after nitrofurantoin)

A

trimethoprim 200mg BD for 3 days

- if low risk resistance

44
Q

FIRST 2nd line UTI O16, not pregnant

-> when no improvement in symptoms on 1st line after 48hrs OR 1st line not suitable

A

nitrofurantion 100mg MR BD for 3 days

- eGFR >45 and not 1st choice

45
Q

SECOND 2nd line UTI O16, not pregnant

-> when no improvement in symptoms on 1st line after 48hrs OR 1st line not suitable

A

pivmecillinam 400mg initial dose

then 200mg TDS for 3 days

46
Q

THIRD 2nd line UTI O16, not pregnant

-> when no improvement in symptoms on 1st line after 48hrs OR 1st line not suitable

A

fosfomycin 3g single dose sachet

47
Q

MOA of nitrofurantoin

A
  • concentrated in urine
  • bactericidial
  • reduced by bacterial flavoproteins to reactive intermediates which inactivate/alter bacterial ribosomal proteins
48
Q

nitrofurantoin and renal impairment

A

avoid if eGFR < 45
not effective in renal impairment as bacterial efficacy depends on renal secretion of drug into urinary tract
-> kidneys can’t concentrate it enough

49
Q

When can you use nitrofurantoin in renal impairment?

A

can use 30-44ml/min in exceptional circumstances if benefits outweigh risks

50
Q

How to take nitrofurantoin?

A

take with food to increase bioavailability

51
Q

STD/MR nitrofurantoin dose

A

standard release 50mg QDS

MR 100mg BD (preferred, better adherance)

52
Q

What can nitrofurantoin do to urine?

A

can darken urine - yellow/brown

53
Q

contraindications of nitrofurantoin

A

eGFR low
G6PD deficiency
acute porphyria
infants < 3mths

54
Q

nitrofurantoin cautions

A 
liver toxicity
pregnancy
diabetes
pulmonary disease
anaemia
low B12
folate deficiency
55
Q

adverse effects of nitrofurantoin

A
  • GI - nausea, vomiting, loss of appetite, diarrhoea
  • dizzy/tired
  • itchy rash/allergic reaction/swollen salivary glands
  • peripheral neuropathy
  • pulmonary reactions (breathing difficulty/chest pain)
56
Q

How to minimise GI s/e of nitrofurantoin?

A

take with food or milk

57
Q

When to discontinue nitrofurantoin?

A
  • itchy rash/allergic rxn/swollen salivary glands
  • peripharal neuropathy (pins and needlles etc.)
  • pulmonary rxns (resp. problems)

-> unexplained pulmonary, hepatotoxic, haematological, neurological signs occur

58
Q

What patients may be susceptible to peripheral neuropathy with nitrofurantoin?

A

diabetes (discontinue if signs)

59
Q

MOA of trimethoprim

A
  • inhibits DHFR which blocks reduction of dihydrofolate to tetrahydrofolate (the active form of folic acid) by susceptible organisms
  • > ANTIFOLATE (not with methotrexate)
  • inhibitory activity for most G+ aerobic cocci and some G- aerobic bacilli
60
Q

dose of trimethoprim

A

200mg BD

61
Q

trimethoprim and renal impairment

A

some dose reductions may be needed in severe renal impairment

62
Q

interactions with trimethoprim

A

methotrexate
warfarin
can cause hyperkalaemia, caution with drugs that inc K (ACEIs)

63
Q

contraindications with trimethoprim

A

blood dyscrasias

1st trimester pegnancy

64
Q

adverse effects of trimethoprim

A

mild GI disturbance - n/v (mild, reversible)
pruritis and skin rash (mild, reversible)
blood disorders (long term)

65
Q

self care for UTIs

A
  • adequate fluid intake - flush bacteria from UT, avoid dehydration
  • paracetamol for pain (or ibuproben)
  • cranberry juice/tabs, alkalinising agents (no evidence)
  • hygeine - wipe from front to back
  • empty bladder after sex
  • birth control (spermicides could inc. risk)
  • avoid potentially irritating female products, can irritate urethra
66
Q

What antiboitic can be supplied on PGD for UTI?

A

trimethoprim

67
Q

PGD supply of trimethoprim for UTI

A
  • pharmacist must have completed specific training before admin of the PGD
  • record of supply made on patient’s PMR
  • GP notified of supply

PHA223 (43 decks)

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