UTI/Pyelonephritis Flashcards
Bacteriuruia
bacteria in urine
- Significant bacteriuria- >105 bact/ml
- Asymptomatic bacteriuria- >105 bact/ml, no symptoms - then leave well alone
Lower urinary tract infection (LUTI) definition
bladder ->Cystitis
Upper urinary tract infection (LUTI)
Acute pyelonephritis, renal abscess, renal calculi
KIDNEYS
Uncomplicated UTI
Infection in a healthy patient with normal GU tract and neurology (LUTI)
Acute pyelonephritis definition
Infection of the upper urinary tract involving the kidneys
Chronic pyelonephritis definition
pathological condition with renal scarring and potenitally loss of renal function. Infection may be a contributory cause but the term does not necessarily imply ongoing infection.
other factors include
- diabetes
- veso-ureteric reflux
- urinary obstruction
Pyruria
presence of pus cells (neutrophill polymorphs) is in significant quantities of urine. This represents an inflammatory process in urine and is supportive evidence of the presence of a UTI
Complicated UTI definition
UUTI =/- systemic signs and symptoms
Infection associated with factors that increase chance of acquiring bacteria and decrease efficacy of therapy
Site of infection of UTIs are classified into:
- Bladder – cystitis
- Prostate – prostatitis – this is the most common site of presentation in the male.
- Renal pelvis - Pyelonephritis
Relapse definition
Infection with the same organisms
Recurrent definition
Infection with same or different organism
Urosepsis defintion
complicated UTI:
- Temp >38ºC
- HR>90/min
- RR>20/min
- WBC >15.0 or<4.0
Who gets bacteruria?
- Infants, first 3 months, boys > girls
- Preschool, girls > boys
- Adults
- Non- pregnant females,1-3%
- Males, 0.1%
- Other at risk groups
- Hospitalised patients
- Diabetic patients
- Post renal transplant
- Catheterised
Management of bacteruria
- Treat asymptomatic bacteriuria in
- Preschool children (UTI Abnormalities, pyelonephritis or UTI for life)
- Pregnant patients
- Renal transplant/ otherwise immunocompromised
- Treatment in other asymptomatic patients NOT indicated
Pathogenesis of urinary tract infections occurs in three ways, name them?
- ascending
- descending/haematogenous
- lymphatic
Ascending UTI
- Urethral colonisation
- female>male
- Multiplication in bladder
- Ureteric involvement
- Haematogenous
Haemotgenous
- Blood-born bacteria (infection from other part of the body and seeds into renal tract)
- Involvement of renal parenchyma
- Gram positive bacteria> Gram negative bacteria
UTIs are caused by?
- >95% caused by single organism
- Multiple organisms in
- Long term catheters
- Recurrent infection
- Structural/ neurological abnormalities
- Multi-drug resistant organisms
- Frequent infections
- Multiple antibiotic courses
- Anatomical/neurological abnormalities
- Prophylactic antibiotic use
Clinical features of UTI
- Dysuria: Painful urination
- Urgency, Frequency, Nocturia
- Fever
- Suprapubic discomfort
- Haematuria: Blood in the urine
- Cloudy or smelly urine
- Abdominal pain and vomitting in child
- failure to thrive, jaundice in neonates
- incontinence, confusion in the elderly
Common organsims
Gram negative bacilli
- ecoli
- kebsiella
- proteus
- psuedomonas
Gram positive bacteria
- stretococcus (enterococcuus)
- Staphylococcus
Anaerobes
candida
Mnemonic KEEPS (klebseilla, Enterococcus, Ecoli, Psuedomonas, staphylococcus saphrocyticus)
Simple/Uncomplicated UTI
- female aged 18-65
- 1st presentation
- no signs of pyelonephritis
- not pregnant
Complicated UTI
- Pregnant
- elderly
- children
- male
- recurrent
- pyelonephritis
UTI in non pregnant women clinical features, investigations and treatment
- Dysuria (Pain on passing urine)
- Frequency (passing urine more often than usual)
- Urgency (the feeling that you need to pass urine)
- Suprapubic pain
- Polyuria (Increased volume of urine)
- Haematuria (blood in the urine)
Consider UUTI in patients with fever or back pain
Investigations and treatment
LUTI
- MCU, if cloudy then dipstick
- check previous culuture results
- Treatment
- 3 day course of Nitrofuranticin or trimethoprin
UUTI
- Take culture immediately
- Start antibiotics immediately do not wait culture results
- Treatment
- more aggressive
- 7 day course of ciprofloxacin 7 days or co-amoxiclav 14 days
- change antibiotic once cultures comes back
UTI in pregnancy
Features
- common
- evidence to suggest that asymptomatic bacteruria in pregnancy is associated with increased risk of pyelonephritis and premature delivery
Investigations
- send urine sample at booking scan and with each presentation (MCU)
- Confirm presence of bacteruria with 2nd urine culture
Treatment
- Symptomatic - culture then 7 day course
- Asymptomatic - guidelines then 7 day course
- Treat for 7-10 days
- always refer to guidelines
- amoxicillin and cefalexin relatively safe
- avoid trimethoprin in 1st trimester
- avoid nitrofurantoin near term
- may need hospital admission for IVs if severe
- can develop pyelonephritis (30%)
Recurrent UTI features, investigations and treatment
- >2 episode/year
- Mostly women
Investigations
- Repeat MSU with each episode
- Urological investigation/ rule out UUTI
Treatment
- Self administered single dose/short course therapy
- Single dose post coital
- Books say prophylactic antibiotics
- Most microbiologists say stop
- cranberry products - cranberry tablets more effective (patients taking warfarin shouldnt continue)
- *
Catheter related UTI can be due to:
infection due to:
- disturbance of the flushing system
- colonisation of the urinary catheter
- biofilm production by bacteria
Likely organisms in catheter related UTI’s
- patients flora
- patient-patient transmission
Complications of catheters
- obstruction
- urinary tract stones
- chronic renal inflammation
- renal failure
- long term risk of bladder cancer
Treatment of catheter related UTIs
asymptomatic
- dont treat
Symptomatic
- Start empirical antibiotics
- Remove catheter if needed
- Replace catheter under antibiotic cover
- Historically Gentamicin/ Ciprofloxacin
- Poor Gram positive cover
- Increase in resistant GNB
- Check recent culture results
- May need to use broad spectrum antibiotics
- 7 day course or 10-14 day course if delayed response
- Historically Gentamicin/ Ciprofloxacin
Prevention of catheter infection
- Catheterise only if necessary
- Remove when no longer needed
- Remove/replace if causing infection
- Catheter care
- Hand hygiene
- Review need for catheter regularly
- “Forgotten catheter”
Management of acute pyelonephritis
- Community, Trimethoprim/Ciprofloxacin (NICE)
- Hospital, Ciprofloxacin/broad spectrum abx
- May remain symptomatic for few days
- No response, warrants further investigation
- Uncomplicated pyelonephritis, 14/7 antibiotic
- Complicated pyelonephritis, > 14/7 therapy
Complications of UTI
- perirenal abscess
- renal abscess
Peri-renal abscess Risk factors and common organisms
Risk factors
- Urinary calculi
- Diabetes mellitus
- Bacteraemia, haematogenous spread
Common organisms
- Gram negative bacilli, E.coli, Proteus sp.
- Gram positive cocci, Staph aureus, Streptococci
- Candida sp.
Peri-renal abscess symptoms, investigations and management
Signs and symptoms
- Similar to pyelonephritis
- Localised signs and symptoms
Investigations
- Radiologically confirmed
- ¨Pyuria +/- bacterial growth
- ¨Usually positive blood cultures
- LOTS OF WHITE CELL without bacteria growth in urine SUSPECT ABSCESS
Antibiotic treatment
- Treat empirically as complicated UTI
- Poor response to antibiotic therapy-as ABx wont reach kidneys
- Surgical management
Renal abscess features, treatment and what is emphysematous pyelonephritis?
- Complication of pyelonephritis
- Unilateral
- Similar symptoms to pyelonephritis
Emphysematous pyelonephritis
- life threatening condition caused by Some gas forming e.g. E.coli
- Urgent urology review
- High mortality rate
Treatment
- Treat empirically as complicated UTI
- Poor response to antibiotics
- Gram negative bacilli, likely organisms
Management of all UTI, complicated
- FBC, U+Es, CRP
- Urine sample
- Urethral, Suprapubic, Nephrostomy
- Blood culture if pyrexia or hypothermic
- Renal ultrasound
- CT KUB
- Antibiotic therapy14/7 or more
Urinary microscop interpretation
- Epithelial cells, contamination
- Bacteria with no WBC, contamination
- Bacteria with WBC and no catheter, infection
- Pyuria with no bacteria
- Previous/recent antibiotic
- Tumour
- Calculi
- Urethritis (check for Chlamydia)
- Tuberculosis
Local antibiotic guidleines to treat UTI
Uncomplicated UTI
PO Amoxicillin, Trimethoprim, Nitrofurantoin
- (Co-amoxiclav, Ciprofloxacin, Cefalexin) - c differgic but can be used to treat
Complicated UTI
- Usually IV therapy, e.g. Amoxicillin +Gentamicin
- Initially combination therapy unless result known
- Different antibiotics have different activities
- Do not omit an antibiotic without finding alternatives
- Drug monitoring may be needed, e.g. Gentamicin
Empirical cover
- Gram negative and Gram positive bacteria
When to do a laboratory confirmation of UTI
Do not do cultures from patients who are asymptomatic, non pregnant women whether they have a catheter or not.
do in
- women with mild or symptoms whos dipsitck is inconclusive
- UTI in men
- acute pyelonephritis
- pregnant women
- reccurent UTI
- children with suspected UTI
Mid stream urine sample (MSU)
Collected from non-cathetirsed patients
- discard the first 10-20 ml as anterior urethra is not sterile
- early morning are more likely to be positive from overnight growth
- collected into sterile vessel
- specimens refridgerated and vessels that contain boric acid to prevent bacterial overgrowth
catheter speciemens should be collected from the catheter sampling pot and not from the collecting bag
UTI in adult men investigations and treatment
Investigations
- MCU, no microscopy
- UUTI in men with backpain, fever
- more likely to be prostatits - caused by coliforms
treatment
- Symptomatic - 7 day course of trimpethoprin or nitrofuratin
- if prostate cause likely then quinolones as can penetrate prostatic fluid
Acute bacterial prostatitis features, organisms, investigations, management, complications
Features
- Localised infection
- Usually spontaneous
- May follow urethral instrumentation
- Fever, perineal/back pain, UTI, urinary retention
- Diffuse oedema, micro abscesses
Likely organisms
- ¨Gram negative bacilli, e.g. E.coli, Proteus sp.
- ¨S.aureus (MSSA, MRSA)
- N.gonorrhoea (less common
Investigations
- Urine culture, usually positive
- Blood culture
- Trans-rectal U/S
- CT/MRI
- Obtaining prostatic secretions not advisable
- do not PR extremely sore
Treatment
- Check sensitivity result
- Ciprofloxacin (no streptococcus cover)
- D/W microbiology in systemic infections
Complications
- Prostatic abscess
- Spontaneous rupture
- Urethra, rectum
- Epididymitis
- Pyelonephritis
Chronic bacterial prostatitis features, organisms, investigations, management, complications
Recurring infections in the prostate
Features
- Most asymptomatic
- Rarely associated with acute prostatitis
- May follow Chlamydia urethritis
- Perineal discomfort/back pain
- +/- low grade fever
- UTI symptoms
Organisms
- Gram negative bacilli, e.g. E.coli, Proteus sp.
- Enterococcus sp.
- S.aureus (MSAA, MRSA)
- Recurrent UTIs
- Diagnosis difficult
Investigations
- Quantitative Localised Technique
- Urethral urine
- MSU
- Expressed prostatic secretions (EPS)
- Post massage urine
- Interpretation
- Bacterial count in EPS > ×10 urethral and MSU
Treatment
- Difficult
- Poor antibiotic penetration
Epididymitis featues, causes, symptoms
Features
- Inflammatory reaction of the epididymis (coiled tube that stored and carries sperm)
- Common
Aetiology
- Ascending infection from urethra
- Urethral instrumentation
Symptoms
- Pain, fever, swelling, penile discharge
- Symptoms of UTI/urethritis
Common organisms
- In sexually active men
- Rule out Chlamydia and N.gonorrhoea (urethritis)
- Non sexually transmitted infections
- GNB, enterococci, staphylococci, viruses, TB in high risks
Orchitis features, aetiology. pyogenic, complications
Features
- Inflammation of one or both testicles
- Testicular pain and swelling
- Dysuria
- Fever
- Penile discharge
Aetiology
- Usually viral - mumps
- Bacterial
Pyogenic
- Acutely unwell
- Complication of epididymitis
- Similar bacteria to other GU infections
- Ofloxacin/Doxycycline
- If severe, Intravenous antibiotics
- As per complicated UTI
- Urgent urological review
Complications
- Testicular infarction
- Abscess formation
Fourniers gangrene
features
- Form of necrotising fasciitis
- Affects male genitalia
- Rapid onset, spreading
- Systemic sepsis
- Usually > 50 yrs old
Risk factors
- UTI
- Local sepsis
- Trauma
- Recent Surgery
Common pathogens
- Mixed infections, mainly GNB and anaerobes
Investigation
- Blood cultures
- Urine
- Tissue/pus
- ¨Surgical debridement 1st line management
- Broad spectrum antibiotics initially
- e.g. Pip-tazobactam+ Gentamicin+ Metronidazole+/- Clindamycin
