UTI, pyelonephritis, ESBL bacteria

Question 1

What effects do ESBL producing organisms have

Answer 1

ESBL producing organisms lead to infections that result in increased virulence, mortality and longer hospital stays, increased hospital expenses.

Question 2

Risk factors for acquiring ESBL producing organisms are:

Answer 2

Length of hospital stay or ICU stay
presence of urinary catheter
presence of CVC or arterial lines
presence of feeding tube
prior abx administration
residence in SNF
ventilator usage

Question 3

ESBL stands for

Answer 3

extended spectrum beta lactamase producing bacteria

Question 4

What antibiotics are used to treat ESBL infections

Answer 4

carbapenems (imipenem, meropenem, doripenem and ertapenem)

ertapenem - no activity against pseudomonas

Question 5

what carbapenem is preferred in CKD or renal failure

Answer 5

meropenem because easier to dose adjust

Question 6

do we use aztreonam in ESBL infections?

Answer 6

no because it has higher likelihood of failure.

Question 7

recurrent UTI are defined as:

Answer 7

> 2 infections in 6 months or >3 infections in one year

Question 8

recurrence in UTI is from

Answer 8

re infection with same organism E coli

Question 9

behavioral strategies that reduce UTI recurrences are:

Answer 9

early post coital voiding
avoidance of spermicides and diaphragms
topical vaginal estrogens
ascorbic acid and methenamine salts.

cranberry juice doesn’t help

Question 10

most effective treatment for recurrent UTI is

Answer 10

can retreat of the upper urinary tract with 7-10 days of the same antibiotic as prescribed for previous infection or if bacterial resistance is discovered can pick alternate agent.

daily or post coital antibiotic prophylaxis

can use bactrim, nitrofurantoin, cephalexin
ciprofloxacin

dont need to treat with urological evaluation

Question 11

when to get U/S of renal for recurrent UTI?

Answer 11

only if pts who have persistent and complicated UTI (proteus species),
recurrent pyelonephritis,
slow response to antibiotic treatment
hematuria that persists after UTI tx
concern for structural or functional urinary tract abnormalities (nephrolithiasis)

Question 12

risk factors for UTI:

Answer 12

• sexual activity
• structural functional abnormalities
• use of spermicidals agents and diaphragms
• pregnancy
• DM2
• obesity
• urethral catherization or other UTI instrumentation
• immunosuppression and genetic factors

Question 13

Complicated vs uncomplicated UTI

Answer 13

complicated UTIs are those with:

UTI in men
pregnant women
persons with foreign bodies (indwelling catheter or kidney stone)
immunocompromised
CKD pt
healthcare associated infection
recent abx use

Uncomplicated UTI is any UTI in a woman without structural or neurological abnormalities

Question 14

uncomplicated UTI

Answer 14

UTI without structural or neurological abnormalities in a woman

Question 15

UTI’s occur from an

Answer 15

ascending fashion by one bacteria generally

75-95% of all UTI’s are Ecoli

Question 16

if we staph in urine and causing UTI then we need to consider

Answer 16

related to instrumentation but should also consider a hematogenous spread of urinary tract infection.

Question 17

diagnosis of UTI is via

Answer 17

urinalysis and culture

significant pyuria >10 WBC and bacteruria

see leukocyte casts which support diagnosis of pyelonephritis

can see microscopic or gross hematuria in UTI

nitrates indicate presence of gram neg bacteria capable of converting nitrates to nitrites

Enterococcus, Staph and strep do not convert nitrates to nitrites and so will not have nitrates in urine

Question 18

urine cultures are always indicated in (in these medical conditions)

Answer 18

pyelonephritis
complicated cystitis
recurrent UTIs

Question 19

DO we always need imaging for UTI diagnosis and treatment

Answer 19

no.

only when diagnosis is unclear or when a structural abnormality or complication is suspected

if someone has severe illness or immuncompromised or lack of response to appropriate treatment THEN GET IMAGING.

Question 20

Imaging study of choice for UTI if needed to be obtained:

Answer 20

U/S can show obstruction
non contrast helical CT - best for stones

contrast enhanced CT (CT urography) is needed for suspected intrarenal or perinephric abscess is suspected

Question 21

what is asymptomatic bacteriuria?

Answer 21

this is at least 10^5 of bacteria in two consecutive voided urine specimens in women or one specimen in man

in all cases without local or systemic signs or symptoms of active infection.

Question 22

Does treatment of asymptomatic bacteruria help?

Answer 22

no it doesn’t decrease frequency of symptomatic infections nor improves other outcomes

leads to antibiotic resistance

Question 23

when do you treat asymptomatic bacteruria?

Answer 23

• only treat in pregnant women

- Treat in pts scheduled to undergo an invasive procedure involving the urinary tract.

Question 24

symptoms of uncomplicated cystitis:

Answer 24

urinary frequency
urgency
dysuria
suprapubic discomfort

Question 25

Treatment of uncomplicated cystitis:

Answer 25

1st line therapies

• nitrofurantoin 5 days
• bactrim 3 days
• fosmycin 1 dose (expensive and less efficacious)

in places where bactrim resistance >20% then use a different agent

2nd line therapies

• fluoroquinolones- 3 days (prefer to reserve for only serious bacterial infections)
• amoxicillin-clavulanate, cefdinir, cefaclor, and cefpodoxime-proxetil each 3-7 days

Question 26

antibiotics for treatment of UTI or asymptomatic bacteruria in PREGNANT PT

Answer 26

amoxicillin-clavulanate, cephalosporin and nitrofurantoin
treat for 7 to 10 days
bactrim - only safe in 2nd trimester

Question 27

treatment duration of UTI in pregnant pt

Answer 27

7-10 days

different from traditional

Question 28

antibiotics actively contraindicated in pregnant pts:

Answer 28

tetracyclines and fluoroquinolones.

Question 29

Treatment duration of pyelonephritis for uncomplicated infections

Answer 29

must get urine culture with susceptibilty testing for initiation of empiric antibiotic for pyelonephritis

treat ciprofloxacin for 7 days or levofloxacin for 5 days

if resistance is >10% can give: ceftriaxone 1 g or once daily aminoglycoside

can give bactrim bid for 14 days.

Question 30

treatment duration for pyelonephritis for complicated infections

Answer 30

10-14 days

treat ciprofloxacin or levofloxacin for 10-14 days

if resistance is >10% can give: ceftriaxone 1 g or once daily aminoglycoside

can give bactrim bid for 14 days.

Question 31

Do we need imaging studies for pyelonephritis?

Answer 31

only if pt has prolonged fever >72 hrs or persistent bacteremia which results from obstruction, perinephric or intrarenal abscesses

get contrast CT urography

Question 32

do we ever get a test for cure (follow up urine culture) after treatment of UTI?

Answer 32

no - for gen population

only for pregnant women

Question 33

Can we treat pyelonephritis as outpatient?

Answer 33

yes if they are hemodynamically stable
pt is NOT pregnant
no signs of nephrolithiasis

1st line agents are fluoroquinolones for 5-7 days.