UTI & Pyelonephritis Flashcards
uncomplicated UTI
UTI
no structural or functional abnormalities
no comorbidities
not associated with GU tract instrumentation
patients with uncomplicated UTI
young
healthy
non-pregnant women
normal anatomic and functioning urinary tract
why are women more susceptible to UTI
shorter urethrae for uropathogenic bacteria to ascend
diagnostic criterion for UTI
bacterial colony count 10^5 CFU/mL
obtained via urine C and S
complicated UTI
UTI in patients with functional or structural abnormalities
infection in presence of comorbidities (renal dz, pregnant, DM)
risk factors for complicated UTI
anatomy
cystocele
rectocele
prostate hypertrophy
pregnancy (uterine enlargement)
risk factors for complicated UTI
nursing home/catheter
neonate
comorbid or neurologic diseases
atypical pathogen exposure
clinical features of complicated UTI
may vary or be absent
fever, pain, systemic inflammation may be absent
typically: weakness, malaise, AMS, abdominal pain
organisms of complicated UTI
more likely to be infected with resistant organisms
management of pts is same as pylo
MC pathogen for UTI
e.coli (>80%)
can adhere to wall and ascend via pili
increased risk for UTI
incomplete bladder emptying
post menopausal
incomplete bladder emptying and UTI
disrupt bladder’s ability to eradicate bacteria from mucosal surface
increased susceptibility to infection
esp. found in its with neurogenic bladders, prolapsed uterus, BPH
postmenopausal women and UTI
decreased estrogen
encourages transition from lactobacillus to e.coli colonization
asymptomatic bacteriuria
10^5 CFU in 2 successive cultures without symptoms
found mc in patients with catheters, also in females of nursing homes, males, pregnant women
who gets treatment of asymptomatic bacteriuria
recommended ONLY in pregnancy
acute cystitis
UTI isolated to bladder
acutely symptomatic w/ >10^5 CFU
otherwise healthy, w/o coexisting pyelo, non pregnant females, no obstruction
clinical features of cystitis
frequency urgency suprabuic pain hesitancy visible hematuria
no fever
nature and severity of symptoms are determined by
etiology or organisms
portions of urinary tract involved
patients ability to mount immune and inflammatory response
history of vaginal discharge or irritation is associated with
vaginitis
cervicitis
pID
pyelonephritis
infection of upper urinary tract, involving renal parenchyma
presentation of pyelonephritis
subtle, difficulté to distinguish
FLANK PAIN voiding irritation FEVER (systemic illness) tachycarida n/v
complications of pyelonephritis
missed diagnosis could lead to deterioration or urosepsis
pyelonephritis can progress into three patterns of renal infections:
- acute bacterial nephritis
- renal abscess
- emphysematous pyelo
order imaging if response to tx is inadequate
urosepsis
may or may not exhibit symptoms of UTI
fever or hypothermia
rising HR
elevated respiratory rate
leukocytosis
severe urosepsis symptoms
HoTN organ dysfunciton hypoperfusion oliguria AMS
two methods of collecting a urine sample
clean catch
catheterization
diagnosis of UTI based on history
can be made with moderate probability if pt has dysuria, frequency and urgency
false positive rate is 43%
clean catch
midstream voiding
avoid collection of initial or last voided
catheterization indicated
can’t void spontaneously
too ill
immobilized
extremely obese
only do in these patients bc can cause UTI with cath
storage of urine
should be tested immediately or refrigerated to avoid colonization within the specimen
urine dipstick
preformed on fresh uncentrifuged urine
quick and easy
positive urine dipstick
nitrate or leukocyte esterase
supports diagnosis of UTI (negative test result doesn’t exclude it)
75% sensitive and 60% specific - negative result doesn’t exclude diagnosis bc it can’t detect acinetobacter, enterococcus, peudomonas, staph
`leukocyte esterase
enzyme released by leukocytes
reflects pyuria
nitrite
positivity nitrite indicates presence of enter-bacteria
what can cause false positive in urine dipstick
substances that turn urine red
i.e. Pyridium or ingestion of beets
urine WBC count values
pyuria
<5 suggests alternative diagnosis
> 5 in symptomatic patient indicates + test
problems with UA
false positive can occur when vaginal or fecal contamination present
can’t detect chlamydia infection
contamination of sample must be considered if evidence of squamous cells on UA
diagnostic accuracy is improved with
history + dipstick + UA
urine culture not on who?
patient with typical symptoms of cystitis or uncomplicated UTI and positive findings on UA
pyuria on microscopic exam, postive leukocyte esterase or urine nitrite
majority of these respond to empiric therapy
indications for urine culture
complicated UTI pregnant women adult male relapse or reinfection septic pts
blood culture
indication in patients with suspected clinical sepsis
don’t typically alter management
imaging UTI
NOT typically done
done on male, elderly, diabetic, severely ill pts with pyelo if there is suspect of renal stone or non responsive to initial therapy
kidney US in UTI
evaluate for obstruction and focal parenchymal abnormalities
CT scan UTI
kidney stonesempysematous pyelonephritis
plain film radiography
used to track kidney stones thru urinary tract
uncomplicated UTI treatment
nitrofurantoin (Macrobid)
TMP-SMX (Bactrim)
5 days, no culture req.
complicated UTI treatment, pyelonephritis
cipro, levaquin
urine culture recommended
7 day tx or 14 days for recurrent or pyelonephritis
hospitalized UTI treatment
ceftriaxone/Rocephin IV
complicated UTI treatment, pyelonephritis susceptible by C and S
TMP SMX (Bactrim) Augmentin
urethritis tx
ceftriaxone/rocephin IM
azithromycin (Zithromax) OR Doxy(vibramycin)
culture psotivie for Chlamydia or Gonorrhea
outpatient follow up for whom?
healthy females tolerating fluids and meds
85% discharged
return to ED if: increased pain, fever, vomiting
adjunctive therapies at discharge
increased fluid intake and frequent voiding
bladder anesthetic agents (Pyridium)
post coital voiding
cranberry juice
wipe front to back
admission criteria UTI + adjunct tx
unable to retain fluids/meds
patients with signs of urosepsis
concomitant kidney stone
failed outpatient therapy
systemic analgesics and antiemetics PRN for pyelo patients
ALL PATIENTS GET IV MEDS
chronic cath patients and asymptomatic UTI
almost universal
screening is not indicated
antibiotic tx of asymptomatic patients does not affect outcome - therefore rarely treat
may be protective
when is screening recommended for asymptomatic UTI
pregnancy
prior urological procedures
prevention of catheter associated UTI
avoidance of unnecessary cath
use of sterile technique
removal of cath ASAP
why must we treat UTI in pregnant women
acute pyelo can precpiatet preterm labor, bcaterimia and septic shock
screening for UTI in pregnancy
once a week for 12 weeks
week 16 do urine C and S
treatment of asymptomatic UTI in pregnant pos
nitrofurantoin (microbic) 100 mg PO x 10 days
cephalexain (keflex) 500 mg PO bid x 10 days
ABX not to use on pregnant patients
Bactrim
Fluroquinolones
Tetracycline
tx of pyelonephritis in pregnant patient
hospitalize, hydrate, Rocephin/Ceftriaxone
continue until afebrile 48hrs and flank pain resolved
switch to oral therapy 10-14 days and discharge
UTI in HIV/AIDS
patients are resistant to TMP-SMX so give fluoroquinolone upon initial treatment unless urine culture indicates something else
pediatric UTI
most common serious bacterial infection
possible in all children
very common but children don’t show similar symptoms
gross hematuria
1 mL of whole blood/L of urine
visible to naked eye
microscopic hematuria
not visible
> 3 RBS/HPF
pathophysiology of hematuria
any process that results in infection, inflammation or injury to GU tract can cause
painless after 50 yrs of age increased risk of renal, prostate, bladder CA
uroepithelial cancer risk factors
>50 y/o male smoking family history of bladder CA occupational exposures in chemical, rubber, leather industry
common causes of hematuria
UTI (MC)
kidney stone
neoplasm
trauma
glomerulonephritis
anticoagulation side effect
