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Renal > UTI/Pyelonephritis > Flashcards

UTI/Pyelonephritis Flashcards

1
Q

Bacteriuruia

A

bacteria in urine

  • Significant bacteriuria- >105 bact/ml
  • Asymptomatic bacteriuria- >105 bact/ml, no symptoms - then leave well alone
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2
Q

Lower urinary tract infection (LUTI) definition

A

bladder ->Cystitis

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3
Q

Upper urinary tract infection (LUTI)

A

Acute pyelonephritis, renal abscess, renal calculi

KIDNEYS

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4
Q

Uncomplicated UTI

A

Infection in a healthy patient with normal GU tract and neurology (LUTI)

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5
Q

Acute pyelonephritis definition

A

Infection of the upper urinary tract involving the kidneys

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6
Q

Chronic pyelonephritis definition

A

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
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7
Q

Pyruria

A

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

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8
Q

Complicated UTI definition

A

UUTI =/- systemic signs and symptoms

Infection associated with factors that increase chance of acquiring bacteria and decrease efficacy of therapy

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9
Q

Site of infection of UTIs are classified into:

A
  • Bladder – cystitis
  • Prostate – prostatitis – this is the most common site of presentation in the male.
  • Renal pelvis - Pyelonephritis
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10
Q

Relapse definition

A

Infection with the same organisms

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11
Q

Recurrent definition

A

Infection with same or different organism

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12
Q

Urosepsis defintion

A

complicated UTI:

  • Temp >38ºC
  • HR>90/min
  • RR>20/min
  • WBC >15.0 or<4.0
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13
Q

Who gets bacteruria?

A
  • 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
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14
Q

Management of bacteruria

A
  • 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
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15
Q

Pathogenesis of urinary tract infections occurs in three ways, name them?

A
  • ascending
  • descending/haematogenous
  • lymphatic
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16
Q

Ascending UTI

A
  • Urethral colonisation
  • female>male
  • Multiplication in bladder
  • Ureteric involvement
  • Haematogenous
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17
Q

Haemotgenous

A
  • 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
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18
Q

UTIs are caused by?

A
  • >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
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19
Q

Clinical features of UTI

A
  • 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
20
Q

Common organsims

A

Gram negative bacilli

  • ecoli
  • kebsiella
  • proteus
  • psuedomonas

Gram positive bacteria

  • stretococcus (enterococcuus)
  • Staphylococcus

Anaerobes

candida

Mnemonic KEEPS (klebseilla, Enterococcus, Ecoli, Psuedomonas, staphylococcus saphrocyticus)

21
Q

Simple/Uncomplicated UTI

A
  • female aged 18-65
  • 1st presentation
  • no signs of pyelonephritis
  • not pregnant
22
Q

Complicated UTI

A
  • Pregnant
  • elderly
  • children
  • male
  • recurrent
  • pyelonephritis
23
Q

UTI in non pregnant women clinical features, investigations and treatment

A
  • 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
24
Q

UTI in pregnancy

A

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%)
25
Q

Recurrent UTI features, investigations and treatment

A
  • >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)
  • *
26
Q

Catheter related UTI can be due to:

A

infection due to:

  • disturbance of the flushing system
  • colonisation of the urinary catheter
  • biofilm production by bacteria
27
Q

Likely organisms in catheter related UTI’s

A
  • patients flora
  • patient-patient transmission
28
Q

Complications of catheters

A
  • obstruction
  • urinary tract stones
  • chronic renal inflammation
  • renal failure
  • long term risk of bladder cancer
29
Q

Treatment of catheter related UTIs

A

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
30
Q

Prevention of catheter infection

A
  • 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”
31
Q

Management of acute pyelonephritis

A
  • 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
32
Q

Complications of UTI

A
  • perirenal abscess
  • renal abscess
33
Q

Peri-renal abscess Risk factors and common organisms

A

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.
34
Q

Peri-renal abscess symptoms, investigations and management

A

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
35
Q

Renal abscess features, treatment and what is emphysematous pyelonephritis?

A
  • 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
36
Q

Management of all UTI, complicated

A
  • FBC, U+Es, CRP
  • Urine sample
    • Urethral, Suprapubic, Nephrostomy
  • Blood culture if pyrexia or hypothermic
  • Renal ultrasound
  • CT KUB
  • Antibiotic therapy14/7 or more
37
Q

Urinary microscop interpretation

A
  • 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
38
Q

Local antibiotic guidleines to treat UTI

A

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
39
Q

When to do a laboratory confirmation of UTI

A

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
40
Q

Mid stream urine sample (MSU)

A

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

41
Q

UTI in adult men investigations and treatment

A

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
42
Q

Acute bacterial prostatitis features, organisms, investigations, management, complications

A

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
43
Q

Chronic bacterial prostatitis features, organisms, investigations, management, complications

A

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
44
Q

Epididymitis featues, causes, symptoms

A

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
45
Q

Orchitis features, aetiology. pyogenic, complications

A

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
46
Q

Fourniers gangrene

A

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

Renal (12 decks)

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