UTI, pyelonephritis, ESBL bacteria Flashcards
What effects do ESBL producing organisms have
ESBL producing organisms lead to infections that result in increased virulence, mortality and longer hospital stays, increased hospital expenses.
Risk factors for acquiring ESBL producing organisms are:
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
ESBL stands for
extended spectrum beta lactamase producing bacteria
What antibiotics are used to treat ESBL infections
carbapenems (imipenem, meropenem, doripenem and ertapenem)
ertapenem - no activity against pseudomonas
what carbapenem is preferred in CKD or renal failure
meropenem because easier to dose adjust
do we use aztreonam in ESBL infections?
no because it has higher likelihood of failure.
recurrent UTI are defined as:
> 2 infections in 6 months or >3 infections in one year
recurrence in UTI is from
re infection with same organism E coli
behavioral strategies that reduce UTI recurrences are:
early post coital voiding
avoidance of spermicides and diaphragms
topical vaginal estrogens
ascorbic acid and methenamine salts.
cranberry juice doesn’t help
most effective treatment for recurrent UTI is
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
when to get U/S of renal for recurrent UTI?
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)
risk factors for UTI:
- sexual activity
- structural functional abnormalities
- use of spermicidals agents and diaphragms
- pregnancy
- DM2
- obesity
- urethral catherization or other UTI instrumentation
- immunosuppression and genetic factors
Complicated vs uncomplicated UTI
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
uncomplicated UTI
UTI without structural or neurological abnormalities in a woman
UTI’s occur from an
ascending fashion by one bacteria generally
75-95% of all UTI’s are Ecoli
if we staph in urine and causing UTI then we need to consider
related to instrumentation but should also consider a hematogenous spread of urinary tract infection.
diagnosis of UTI is via
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
urine cultures are always indicated in (in these medical conditions)
pyelonephritis
complicated cystitis
recurrent UTIs
DO we always need imaging for UTI diagnosis and treatment
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.
Imaging study of choice for UTI if needed to be obtained:
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
what is asymptomatic bacteriuria?
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.
Does treatment of asymptomatic bacteruria help?
no it doesn’t decrease frequency of symptomatic infections nor improves other outcomes
leads to antibiotic resistance
when do you treat asymptomatic bacteruria?
- only treat in pregnant women
- Treat in pts scheduled to undergo an invasive procedure involving the urinary tract.
symptoms of uncomplicated cystitis:
urinary frequency
urgency
dysuria
suprapubic discomfort
Treatment of uncomplicated cystitis:
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
antibiotics for treatment of UTI or asymptomatic bacteruria in PREGNANT PT
amoxicillin-clavulanate, cephalosporin and nitrofurantoin
treat for 7 to 10 days
bactrim - only safe in 2nd trimester
treatment duration of UTI in pregnant pt
7-10 days
different from traditional
antibiotics actively contraindicated in pregnant pts:
tetracyclines and fluoroquinolones.
Treatment duration of pyelonephritis for uncomplicated infections
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.
treatment duration for pyelonephritis for complicated infections
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.
Do we need imaging studies for pyelonephritis?
only if pt has prolonged fever >72 hrs or persistent bacteremia which results from obstruction, perinephric or intrarenal abscesses
get contrast CT urography
do we ever get a test for cure (follow up urine culture) after treatment of UTI?
no - for gen population
only for pregnant women
Can we treat pyelonephritis as outpatient?
yes if they are hemodynamically stable
pt is NOT pregnant
no signs of nephrolithiasis
1st line agents are fluoroquinolones for 5-7 days.
