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PHA 332 > UTI in practice > Flashcards

UTI in practice Flashcards

1
Q

what parts of the urniary system make up the lower urinary tract?

A

Bladder

– Urethra

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2
Q

what parts make up the upper urinary tract- i.e more serious?

A

– Kidneys

– Ureters

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3
Q

how do bacteria enter the urinary tract? what is the usual bacteria found?

A

hrough urethra
• Typically Escherichia Coli (Gram negative),
commonly found in GI tract

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4
Q

what are the bladder symptoms of lower UTI?

A

– Polyuria
– Dysuria
– Lower abdominal discomfort

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5
Q

what are the urethra symptoms of a lower UTI?

A

– Burning on passing urine

– Discharge

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6
Q

why are stis included in differeential diagnosis of UTI?

A

Note that sexually transmitted infections can cause
urethritis due to proximity of uretha to vagina-
therefore differential diagnosis includes STIs such as
chlamydia, gonorrhoea etc

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7
Q

why are UTIs more common in females?

A
  • Shorter urethra

* Urethra proximity to anus

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8
Q

what are the risk factors for UTIs?

A

Post menopausal women
• decline in circulating oestrogen
– Indwelling catheters
• provide an ascending route for bacteria
– Recent antibiotic use
• disrupts normal bacterial flora
– Spermicides can cause irritation & attachment sites for E.Coli
– Sexual intercourse – may introduce bacteria to urinary tract
– Pregnancy

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9
Q

when would you refer UTI?

A

Pregnant woman
– risks include pyelonephritis, premature birth, rupture of membranes
and other complications
• Men
– always “complicated”
• <16 years
• Symptoms of pyelonephritis
– Fever, loin pain, rigors, flu-like illness, nausea/vomiting – symptoms of
upper UTI
• Signs of Sepsis
– See risk stratification tool NICE- high risk signs include altered mental
state/behaviour, increased RR/HR, low BP, anuria, mottled/ashen skin,
cyanosis, non-blanching rash
• Non-response to first antibiotics
– MSU for culture

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10
Q

when would you not use a urine dipstick?

A

Not recommended in the elderly (>65yrs) as
asymptomatic bateriuria is common in this
group and could result in unnecessary
antibiotics

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11
Q

how do you give a urine culture?

A

midstream

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12
Q

what would be suggest a UTI on a urine dipstick?

A

positive nitrate or leukocyte and RBC positive

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13
Q

when do you treat asymptomatic UTI?

A

if pregnant

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14
Q

when considering diagnosis what sort of vaginal and urethral causes of urinary symptoms would you exclude?

A
  • 80% of women with vaginal discharge do not have a UTI
  • Urethritis- inflammation post sexual intercourse, irritants
  • Check sexual history to exclude STI
  • Genitourinary syndrome of menopause (vulvovaginal atrophy)
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15
Q

what are the signs and symptoms of pyelonephritis?

A 
– Kidney 
pain/tenderness in 
back under ribs
– New/different 
myalgia, flu like 
illness
– Rigors or pyrexia 
– Nausea/vomiting
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16
Q

what are the signs of sepsis?

A 
– High risk signs include: 
• Altered mental 
state/behaviour
• Increased RR/HR
• Low BP
• Anuria
• Mottled/ashen skin
• Cyanosis
• Non-blanching rash
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17
Q

when diagnosing UTI what are the 3 key diagnostic fectures?

A

Dysuria, new nocturia, cloudy urine
– If 2 or 3 present UTI likely and dipstick not needed
– If 1 present perform urine dipstick
– If 0 check if other symptoms are present (urgency,
visible haematuria, frequency, suprapubic
tenderness)

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18
Q

what does the urine dipstick tell us?

A

• Negative for nitrites, leukocytes & RBC: UTI
less likely
• Negative nitrite but positive leukocyte
• Could be UTI – send urine culture and consider
treatment depending on symptom severity
• Positive RBC with positive nitrite or leukocyte
• Likely UTI – treat or watch/wait with backup
antibiotic depending on symptom severity

19
Q

how does the guidance for over 65’s differ?

A 
• No urine dipsticks
• New onset dysuria or 
2+ new symptoms UTI 
likely
• Always send urine 
culture  
• Delirium 
considerations/ other 
diagnostics
20
Q

what extra precautions need to be done for pregnant women?

A

• Regular MSU screening as part of antenatal care
• Antibiotics given if bacteriuria confirmed even if
asymptomatic (2 x culture)

21
Q

if suspected UTI in a pregnant women what should be done?

A

– Symptomatic relief with paracetamol
– Prescribe antibiotic 7d (check suitable- often
nitrofurantoin but not recommended at term)
– Send MSU for culture
– Amend prescription if needed
– If a group B streptococcus is isolated, prophylactic
antibiotics will be offered during labour and delivery.

22
Q

what should you take into account when prescribing antibiotics?

A 
how severe are symptoms
risks of complications
previous urine culture results
previous antibiotic use
culture results
23
Q

what do you consider when giving an antibiotic?

A

– Immediate
– Back up (to use if no improvement at 48hr or
symptoms worsen at any time)

24
Q

who have low risk of resistance?

A

• younger women with acute UTI and no resistance risks

25
Q

what are the risk factors for increased resistance?

A

• care home resident,
• recurrent UTI (2 in 6 months; >3 in 12 months),
• unresolving urinary symptoms,
• hospitalisation for >7d in the last 6 months,
• recent travel to a country with increased resistance,
• previous UTI resistant to trimethoprim, cephalosporins, or
quinolones.,

26
Q

if there is a risk of resistance what should you do?

A

always safety net.

send urine for culture & susceptibilities

27
Q

what do antibiotics increase the risk of?

A

Clostridium difficile

28
Q

how do you reduce c. difficle?

A 
Reduce use of
• Ciprofloxacin
• Cephalosporins     
• Co-amoxiclav
Increase use of
● Nitrofurantoin
● Trimethoprim
● Pivmecillinam
29
Q

when is trimethoprim good?

A

still good for UTI in younger patients, or if known results

30
Q

when is co-amoxiclav only recommended?

A
  • Pyelonephritis in pregnancy
  • Facial cellulitis or prophylaxis post dog or human bites
  • Diverticulitis
  • Persistent sinusitis second line
31
Q

what do you consider when choosing an antibiotic?

A

Trimethoprim is narrow spectrum but resistance is
common
• Nitrofurantoin is more broad spectrum but is
concentrated in the area of need & resistance rates
much lower

32
Q

what is the recommended duration of treatment with antibiotics for a UTI?

A

3 day course of empirical antibiotics is recommended for

most women with uncomplicated UTI

33
Q

what is the dose of nitrofuratoin and trimethoprim?

A

100mg modified release twice a day for 3 days

200mg twice a day for 3 days

34
Q

what is the MOA for nitrofurantoin?

A

concentrated in urine- bactericidal- reduced by
bacterial flavoproteins to reactive intermediates
which inactivate/alter bacterial ribosomal proteins

35
Q

when do you avoid nitrofurantoin?

A

Renal impairment: avoid if eGFR
<45ml/min/1.73m2
– not effective in renal impairment as antibacterial
efficacy depends on renal secretion of drug into
urinary tract
– can use 30-44ml/min in exceptional circumstances if
benefits outweigh risks

36
Q

what counselling points should be given with nitrofurantoin?

A

• Take with food to increase bioavailability
• Standard release 50mg QDS
• Modified release 100mg BD
• Can darken urine colour (yellow/brown)
• Contraindications: eGFR low (see previous
slide) G6PD deficiency, acute porphyria,
infants <3months
• Cautions: liver toxicity, pregnancy, diabetes,
pulmonary disease, anaemia, low B12, folate
deficiency

37
Q

what are the adverse effects of nitrofurantoin?

A

GI (nausea, vomiting, loss of appetite, diarrhoea) –
minimised by taking with food or milk
– Dizzy/tired
– Itchy rash/allergic reaction/ swollen salivary glands -
discontinue
– Peripheral neuropathy (therefore caution in pts who
may be susceptible e.g. diabetes)- discontinue if signs
– Pulmonary reactions- stop at first sign of respiratory
problems e.g. breathing difficulties/chest pain
– Discontinue treatment with nitrofurantoin if otherwise
unexplained pulmonary, hepatotoxic, haematological or
neurological syndromes occur.

38
Q

what is the MOA of trimetoprim?

A

nhibits DHFR therefore
blocks the reduction of dihydrofolate to
tetrahydrofolate, the active form of folic acid,
by susceptible organisms
• Inhibitory activity for most gram-positive
aerobic cocci and some gram-negative aerobic
bacilli

39
Q

what does trimethoprim interact with?

A

methotrexate, warfarin
– can cause hyperkalaemia so caution with other
drugs that can increase K+ e.g. ACEI

40
Q

what are the contraindications of trimethoprim?

A

blood dyscrasias, first

trimester pregnancy

41
Q

what are the side effects of trimethoprim?

A

Mild gastrointestinal disturbances e.g.
nausea/vomiting
– Pruritis and skin rash (3-7% patients)
– Blood disorders (long term)

42
Q

what is the role of the pharmacist in UTI?

A 
• Consider diagnosis
• Recognise when mild symptoms could 
respond to self-care and 
• Advise on appropriate self-care 
• Recognise when referral is required
• PHE leaflet may support consultation on this 
• Ensure prescriptions are appropriate and any 
longer term antibiotics are reviewed
43
Q

what self care should be done with UTIs?

A

• Adequate fluid intake
– Help to flush bacteria from urinary tract
– Avoid dehydration
• Paracetamol for pain (or ibuprofen, if appropriate
and lower UTI)
• Cranberry juice or tablets, alkalinising agents (not
likely to be harmful, may help) – no good evidence
• Hygiene- wipe from front to back
• Empty bladder soon after sexual intercourse
• Birth control
• Avoid potentially irritating female products as these
can irritate the urethra

44
Q

when is a PGD used to supply trimethoprim?

A

• Strict inclusion/exclusion criteria
• Safety netting
• Pharmacists must have completed specified training
before administering this PGD
• Record of supply made on patients PMR and GP
notified of supply

PHA 332 (42 decks)

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