UTI's Flashcards
What is a UTI
Presence of microorganisms in the urinary tract causing inflammation such as cystitis, urethritis and prostatitis and upper causing pyelonephritis .
Why are UTI’S more common in women
Women have a shorter urethra thus bacteria has a shorter distance to travel to.
Methods of transmission
Faeces- when wiping
Sex
Incontinence
Poor hygiene
Urinary catheters
Most common microorganisms to cause a UTI
KEEPS
Klebsiella
E coli
Enterococci
Proteus
Staphylcoccus coagulase negative
key diagnostic factors of UTI
Dysuria (pain, stinging or burning when passing urine
New nocturia
Cloudy or foul smelling urine
risk factors
What is FUNDS
Frequency
Urgency
Nocturia
Dysuria
Other diagnostic factors for UTI
-Urgency
-Visible haematuria
- frequency
- suprapubic pain or tenderness
What symptoms would a patient have that would make you suspect pyelonephritis
Fever
Loin/back pain
Nausea/vomiting
Renal angle tenderness on examination
headache
Triad - loin pain, fever, pyuria
Presence of nitrates on urine dipstick would indicate
UTI- with gram -ve bacteria such as ecoli
E coli breaks down nitrates a normal waste product
Leukocytes in urine dipstick test would indicate
Infection or inflammation
presence of leukocyte esterase
What is microscopic haematuria
blood on dipstick but not seen looking at the sample
what is macrscopic haematuria
blood is visible in urine
Most common cause of UTI
E. Coli
gram neg-ve anerobic rod shaped bacteria
Duration of antibiotics
3 days - for simple UTI
5-10 days for immunosuppressed women, abnormal anatomy or impaired kidney function
7 days of antibiotics for men, pregnant women or catheter related UTI’S
UTI during pregnancy increases the risk of ..
pyelonephritis, premature rupture of membranes and pre-term labour.
antibiotic options for pregnancy ..?
Nitrofurantoin (avoid in the third trimester)
Amoxicillin (only after sensitivities are known)
Cefalexin
Nitrofuratoin needs to be avoided in the third trimester why ?
risk of neonatal haemolysis
describe sympathetic and parasympathetic neural control of the LUT
Parasympathetic - Detrusor contraction
Smooth muscle sphincter relaxation
Sympathetic- smooth muscle sphincter contraction
- inhibit detrusor contraction
What is pyelonephritis
Severe infectious inflammation of the parenchyma ( functional tissue )
ascend from the lower urinary tract
most common bacteria that causes pyelonephritis
E COLI
KEY DIAGNOSTIC FACTORS OF pyelonephritis
triad of loin pain, fever and pyuria
1st investigations to order for pyelonephritis
urinalysis
urine culture and sensitivity
fbc
ESR
GS investigation for pyelenephritis
Mid stream Urine and culture
Tx for pyelonephritis
IV Antibiotics- broad spectrum, cefalexin for 7-10 days, co-amoxiclav or gentimiacin
Trimethorpim or amoxicillin if sensitive
Analgesia- paracetamol
Fluid replacement
Drain obstructed kidney
Catheter
What is cystitis
inflammation of the urinary bladder, most common in sexually active women
Rx for cystitis
- sexually active
- DM
- History of UTI
- Pregnancy
Presentation of cystitis
Suprapubic tenderness and discomfort
Dysuria- discomfort , pain burning on urination
Frequency
Cloudy smelly urine
haematuria
Investigations for cystitis
1st line Urine dipstick- nitrates or WBC’S then uti
mid stream urine sample -GS
Management of cystitis
Antibiotics- 3 days trimethoprim BUT AVOID IF PREGNANT
What is prostatitis
Inflammation and swelling of the prostate due to E coli
Presentation of Prostatitis
- VERY tender prostate
FEVER, CHILLS, MALAISE
Management of prostatitis
ciprofloxacin or levofloxacin for 14 days
What is urethritis
Urethritis is inflammation of the urethra commonly caused by neisseria gonorrhoeae and chlamydia trachomatis
presentation of urethritis
Dysuria
Urethral discharge
pruritus at the end of the urethra
skin lesion
two main categories of urethritis
Gonococcal if neisseria is isolated
non gonococcal if neisseria is not isolated
key diagnostic factors of urethritis
presence of risk factors
urethral discharge
urethral irritation or itching
dysuria
risk factors of urethritis
age 15 to 24 years
female sex
Gay men
low socio-economic status
1st line investigation for urethritis
Urine dipstick
GS = Mid stream MC+S
gs for urethritis
mid stream urine sample
Management of urethritis
NG - IM ceftriaxone and azithromyocin
what is epidydo- orchitis
inflammation of the epididymis causing scrotal pain and swelling that develops over the course of a few days and lasts <6 weeks. It is usually unilateral.
The pain is relieved by elevating testes
Cremaster reflex intact
Investigations for Epididymo-orchitis
1st line = urine dipstick + leukocytes/blood/nitrates
GS - Mid stream MC+S
NAAT - detect STI type for treatment if necessary
key diagnostic factors of epidymo orchitis
age >19 years
unilateral scrotal pain
Gradual onset swelling
symptoms <6 weeks’ duration
Rx for epidymo orchitis
- unprotected sexual intercourse
- bladder outflow obstruction
- immunosuppression
Difference between complicated and uncomplicated UTI
An uncomplicated UTI is an infection in the lower urinary tract, the bladder and urethra.
A complicated UTI is when the infection extends beyond the bladder to the kidneys and is more serious
Also deemed complicated in pregnancy
Lower tract infections
UTI
Cystitis
Upper tract infections
Pyelonephritis
Classifications of UTIs
Asymptomatic bacteriuria
Uncomplicated
Complicated
What is Bacteriuria
The presence of bacteria in the urine
-Symptomatic
-Asymptomatic
What is pyuria?
Presence of leucocytes in the urine
Associated with infection
Sterile pyuria
– 10 or more white blood cells per cubic mm
Causes of Pyuria
infections (chamydia, gonorrhoea, HSV, trichomonas)
Pyelonephritis
Papillary necrosis
Diabetes
Renal TB
Renal stones
Cancer
Who does uncomplicated affect?
Non pregnant women
Who does complicated effect?
Pregnant
Men
Catheterised
Children
Recurrent/persistent infection
Immuncompromised
Noscomial infection
Structural abnormality
Urosepsis
Associated urinary tract disease
Which pathogen is associated with renal stones that causes UTI?
Proteus
Which pathogen is assosciated with Hospital/catheter assosciated UTIs?
Klebsiella
Which pathogen affects young women the most for UTIs?
Staph.saprophyticus
What is the average bladder capacity?
500ml
Significant reduction in capacity accompanies acute inflammation and leads to increased frequency.
Symptoms of UTI
UTI: Pain in peeing, needing to pee
LUT: Fever, haematuria
Urinalysis for UTI
Blood
Protein
pH
Ketones
Nitrates
Leucocytes
Glucose
What do we need for urine samples?
MSU
CSU
Bag urine
Early morning urine
SPA aspirate
Clean catch
Why do we use early morning urine?
TB 3 x early morning urine. Highest concentration of bacilli so more likely to see
What do we see on the microscopy for UTIs?
White blood cells
Red blood cells
Casts
Bacteria
Epithelial cells
What are casts?
- Cylindrical protein mouldings formed in the renal tubules
- give clues to renal pathology
- Can be indicative of infection
- Damage to kidney epithelium (glomerulonephritis)
What do RBC casts indicate?
- glomerulonephritis
- renal ischaemia and infarction
Acute tubular necrosis is associated with what types of casts
- granular
- epithelial
Asymptomatic bacteriuria treatment
If >65 then do not treat
Other groups that get asymptomatic bateriuria – pregnant patients, diabetics, transplant patients – all should be treated
What is first-line treatment for uncomplicated
UTIs?
Nitrofurantoin:
Side effects of antibiotics
Not given in thrid trimester –risk of neonatal jaundice/Neonatal haemolysis
Can’t be used in G6PD deficiency
Nausea and vomiting
headaches
dizziness
liver problems
neuropathy
acute and chronic pulmonary reactions
Antimicrobial resistance
How does Fosfomyocin (New antibiotic) work
Prevents formation of N-acetyl muramic acid – component of bacterial cell wall
Pivmecillinam (new antibiotic)
Interferes with bacterial cell wall. Bactericidal.
How to prevent infections of catheter samples
Do not dipstick
Change or remove catheter
when starting treatment
Send a fresh sample (not from bag)
Catheter associated UTI - pathogenesis
Insertion may carry organisms into the bladder
At risk of infection up to 24 hours post removal
Hospitable environment in the catheter
Formation of biofilms
(protected from flow of urine, host
defences and antibiotics)
Incomplete voiding
What can short term catheters cause?
Monomicrobial infections
Long term catheter issues
Polymicrobial infections
Complications:
UTI/Pyelonephritis
Stones
Obstruction
Chronic inflammation
How to prevent catheterisation of UTI?
Intermittent catheterisation
Suprapubic catheterisation
How to prevent bacteriuria
Keep catheter closed
Remove as soon as possible
How to prevent complications
Don’t treat if asymptomatic
Catheter replacement
How does the prevalence of UTI increase in pregnant women?
Age
Parity
Sexual activity
Diabetes
Previous UTI
How to investigate UTI in pregnancy
Culture rather than dipstick
Positive cultures should be confirmed with a second sample
Asymptomatic bacteriuria should be treated(unlike elderly) -20-40% untreated bacteriuria develop acute symptomatic pyelonephritis
Test of cure should be sent 1 week after treatment
Ascending route of infection for pyelonephritis
Urethra colonised with bacteria. Massage of the urethra during intercourse can force bacteria into the female bladder
Haematogenous route of infection of pyeloephritis
S.aureus/Candida
Lymphatic spread is very rare
Complications of pyelonephritis
Renal abscess
Slow/no response to Antibiotics
Imaging
More common in diabetics
Emphysematous pyelonephritis
Rare, gas accumulation in the tissues
Life threatening
May need nephrectomy
Mrs A Vrige (23 years old) has been complaining of dysuria, urgency and frequency passing urine. Similar urinary symptoms over the last few months were treated with 3 days of Cephalexin by another GP. She is in a stable relationship with her husband and takes the oral contraceptive pill.
Using the BIA urinalysis algorithm to help you, you decide to treat empirically for UTI
Which antibiotic do you use while awaiting results?
A. Ciprofloxacin
B. Trimethoprim
C. Nitrofurantoin
D. Tazocin
E. No antibiotic needed
D. Tazocin
Mr C Docalot is a 65 year old man with benign prostatic hyperplasia for which he has been prescribed tamsulosin for several years. He presents with 3 days of increased urinary frequency and lower back pain. On examination he is unwell and agitated: T 390C and BP 90/50 and there is right renal angle tenderness.
What key samples should be taken:
MSU and Blood culture
Sputum and MSU
CSU
Blood culture
All of the above
A - MSU and blood culture
Mr C Docalot is a 65 year old man with benign prostatic hyperplasia for which he has been prescribed tamsulosin for several years. He presents with 3 days of increased urinary frequency and lower back pain. On examination he is unwell and agitated: T 390C and BP 90/50 and there is right renal angle tenderness.
What would you treat with first line and for how long?
A. Trimethoprim 7 days
B. Nitrofurantoin 14 days
C. Co-amoxiclav 14 days
D. Co-amoxiclav 7 days
E. Ciprofloxacin 7 days
C
Mr E.Home is an 84 year-old man who has become confused and agitated. He has been sent to the frailty unit and you assess him. Other than the confusion, the only significant finding from history and examination is that he has a long-term urinary catheter.
The nurse uses a dipstick to assess the urine. This will give her an indication if an infection is present or not:
A. True
B. False
B. false
Mr E.Home is an 84 year-old man who has become confused and agitated. He has been sent to the frailty unit and you assess him. Other than the confusion, the only significant finding from history and examination is that he has a long-term urinary catheter.
The nurse completes the form and sends the urine sample to the Microbiology lab who inoculate some culture plates and dispose of the sample. Should Microscopy be performed on the sample?
A. Yes
B. No
B. No
Mrs B.gravid is a 37 year old, 28 weeks pregnant women in the antenatal clinic who has brought a urine sample with her. She is otherwise well.
Urinalysis shows leukocytes and protein. This indicates:
A. Nothing - this is expected in pregnancy
B. Pre-eclampsia
C. UTI
D. Possibility of pre-eclampsia and UTI
E. Obstetric cholestasis
D
Mrs B.gravid is a 37 year old, 28 weeks pregnant women in the antenatal clinic who has brought a urine sample with her. She is otherwise well.
The microscopy shows epithelial cells but no pus cells, this suggests:
A. Definite infection
B. Pyelonephritis
C. Pre-eclampsia
D. Sample contamination
E. None of the above
D
Mrs B.gravid is a 37 year old, 28 weeks pregnant women in the antenatal clinic who has brought a urine sample with her. She is otherwise well.
Based on this sample, the patient should be treated as a UTI.
A. True
B. False
B. False
The risk of pyelonephritis in untreated asymptomatic bacteriuria in pregnancy is:
A. 5-10%
B. 20-40%
C. 50-60%
D. 60%
E. 70-75%
B
What antibiotic should be avioided in pregnant women
Trimethoprim
