UTI & STIs Flashcards
Urinary Tract Infections (UTIs) are defined as…
the presence of microorganisms in the urine that cannot be accounted for by contamination
* microorganisms have the potential to invade urinary tract tissues and adjacent structures/ organs
(urine is sterile coming out & as it exits it becomes contaminated)
Bacteriuria:
presence of bacteria in urine
(amount is what depicts if they’ll be infected or not - but always a % of bacteria in urine)
Abacteriuria:
lack of detectable bacteria in urine
Urinary Tract Infections (UTIs) represent…
a wide variety of clinical inflammatory syndromes:
Lower tract UTI:
* Urethritis (urethra)
* Cystitis (bladder)
* Prostatitis (prostate)
* Epididymitis (testicular epididymis)
Upper tract UTI
* Pyelonephritis (ureters + kidney)
What are the Lower tract UTIs?
- Urethritis (urethra)
- Cystitis (bladder)
- Prostatitis (prostate)
- Epididymitis (testicular epididymis)
What are the Upper tract UTIs?
- Pyelonephritis (ureters + kidney)
Which are the most common UTIs? Lower or Upper tract?
Lower tract
Upper urinary tract has the ____ frequent UTI, with…
LESS
0.4 cases/ 10,000 people / month
Lower urinary tract has the ____ frequent UTI, with…
MOST
1.5 cases/ 10,000 people/ month
What is included in the Upper urinary tract?
- Diaphragm
- Adrenal gland
- Left kidney
- Right kidney
- Ureters
What is included in the Lower urinary tract?
- *Bladder
- *Urethra
- Female cervix
- Male prostate
What is the UTIs Epidemiology?
UTIs vary by age and sex
What is the UTI epidemiology for Newborns – 6 months?
most common in males (1%)
* Due to abnormalities of urinary tract and non-circumcision
What is the UTI epidemiology for >1 year to adulthood (pre-menopause)?
most common in FEMALES
* 1 in 5 women will experience a symptomatic UTI in their lifetime
What are the increased UTI risks in >1 year to adulthood (pre-menopause)?
- during and after pregnancy (put weight on bladder & urethra)
- frequent sexual activity/ multiple partners
- frequent spermicide, condom, diaphragm use
What is the UTI epidemiology for >65 yrs?
EQUAL (50%) among males and females
* (Asymptomatic) increases with hospitalization and nursing home care (ex: diapers)
What is the UTI epidemiology for Prostatitis (prostate infection)?
Rarely occurs in young men, 50% OF MEN >30 YRS will experience in lifetime
(prostate grows as men age)
What is a simple way of saying why female may get more UTIs?
males have more distance b/t urethra & anus
& females may do improper wiping etc. (many other factors) b/c urethra is closer to anus
What are the 2 types of UTIs?
Uncomplicated & complicated
Uncomplicated UTIs:
are due to infections that may interfere with the normal flow of urine or the voiding mechanism
* Does NOT include anatomical or neurologic abnormalities
** Primarily involve ADULT PRE-MENOPAUSAL WOMEN
(majority that’ll be in clinic)
Complicated UTIs:
result of a predisposing lesion of the urinary tract, such as a congenital abnormality or distortion of the urinary tract: stones, indwelling catheter, prostatic hypertrophy, obstruction, or neurologic deficit that interferes with the normal flow of urine and urinary tract defenses
** EVERYONE EXCEPT “healthy” adult pre-menopausal women
(complicated b/c other factors are at play)
Untreated UTIs are the most common cause of _______ _______ (20%)
community-acquired bacteremia
(can lead to sepsis)
Asymptomatic bacteriuria (AB):
is absence of UTI signs or symptoms in a patient whose urine culture satisfies criteria for UTI→found mainly in high-risk patient urine screens (for other causes); RARELY TREATED
* ELDERLY PATIENTS (>65 yrs) FREQUENTLY HAVE AB IN URINE
* Altered mental status, catheterization, incontinence (but hard to say)
(self-resolving)
Recurrent UTIs:
two or more UTIs occurring within 6 months or three or more within 1 year
* caused by REINFECTION or RELAPSE
What are the 2 reasons for recurrent UTIs?
- Reinfections’
- Relapses
What are Reinfections?
are caused by a different organism and account
for the majority of recurrent UTIs
(microorganism isn’t responding to AMT, could be b/c of anti-microbial resistance or failure to identify causative agent)
What are Relapses?
are caused by repeated infections caused by the same initial organism
UTIs usually originate from…
host bowel flora
UTIs primarily due to…
bacterial infections
* Specific virulence factors promote common infections
(viral are rare)
Most ______ UTIs are caused by a SINGLE organism
UNcomplicated
Describe the etiology for UTIs with Escherichia coli
Gram -
80-90% of all community acquired UTIs
top 3 multidrug resistant UTIs (Canada/ World)
Most frequently identified species in hospitalized
patients→accounts for 75% of all UTIs
Describe the etiology for UTIs with Enterococcus spp. Gram +
2nd most commonly identified species in hospitalized patients
May be due to overuse of third-generation cephalosporin antibiotics (not active against enterococci)
- 3rd gen B-lactam antibiotic
List other frequently isolated microorganisms that cause UTIs
- Proteus spp. (Gram -)
- Enterobacter spp. (Gram -)
- Klebsiella pneumoniae (Gram -)
- Pseudomonas aeruginosa (Gram -)
** Staphylococcus spp. (Gram +) –> common skin microorganism
** Candida spp. (Fungi)
Describe Staphylococcus spp. which is a frequently isolated microorganisms that cause UTIs
- S. aureus commonly associated with BACTEREMIA that produce metastatic abscesses in kidneys→MRSA
- could result in PYELONEPHRITIS (serious)
- S. epidermidis should always be REtested if identified→it is a common skin flora
Describe Candida spp. which is a frequently isolated microorganisms that cause UTIs
- common cause of UTIs in critically ill and chronically catheterized patients (complicated UTIs)
(prob: don’t have enough antifungal antimicrobials & if it become resis. doesn’t have many options)
What is the pathophysiology of UTIs?
Route of infection:
2 main routes of UTI entry:
1. Ascending
2. Hematogenous (descending)
Describe the Ascending route of infection for UTIs
bacteria → urethra → bladder → kidneys
- MOST COMMON route of UTI, particularly in females due to anatomy of urethra and its common colonization by FECAL FLORA
Describe the Descending route of infection for UTIs
bacteria → kidneys → bladder
- dissemination of organisms (BACTERMIA) from a distant primary infection in the body to kidneys (PYELONEPHRITIS)
- Uncommon route (less than 5% of documented UTIs) and involve invasive organisms:
- S. AUREUS, CANDIDA spp.,Mycobacterium tuberculosis, Salmonella spp., and ENTEROCOCCI
Describe the Descending route of infection for UTIs
bacteria → kidneys → bladder
- dissemination of organisms (BACTERMIA) from a distant primary infection in the body to kidneys (PYELONEPHRITIS)
- Uncommon route (less than 5% of documented UTIs) and involve invasive organisms:
- S. AUREUS, CANDIDA spp.,Mycobacterium tuberculosis, Salmonella spp., and ENTEROCOCCI
After bacteria reach the urinary tract, 3 factors determine the development of UTI:
- SIZE of the bacterial inoculum (HIGHER TITRE ↑ RISK)
- will overwhelm defenses - VIRULENCE of the microorganism
* adherent bacteria can easily bind to epithelial cells after urination
- if tightly bound, it’ll stay & multiple => infection - COMPETENCY of the natural HOST DEFENSE MECHANISMS
* Most UTIs reflect a failure in HOST DEFENSE MECHANISMS
* urine chemistry under normal circumstances is capable of inhibiting and killing microorganisms (why only 1/5 women get 1)
* Bacterial growth is further inhibited in males by the addition of prostatic secretions (another factor why men have fewer UTIs)
What are the Signs & Symptoms of UTIs?
signs and symptoms of UTIs in adults are recognized easily
* Hematuria – blood in urine
* Dysuria – painful urination
* Pyuria* – pus (white blood cells) in urine
* Presence of microorganisms in urine by Gram stain*
*CANNOT BE USED AS DIAGNOSIS ON ITS OWN
many patients with significant bacteriuria are asymptomatic (AB)
Hematuria:
blood in urine
Dysuria:
painful urination
Pyuria:
pus (white blood cells) in urine
*CANNOT BE USED AS DIAGNOSIS ON ITS OWN
Many patients (with a UTI) with SIGNIFICANT BACTERIURIA are ________
asymptomatic (AB)
* symptoms alone are not reliable to discriminate upper and lower UTIs
* elderly patients often do not exhibit typical UTI symptoms; see altered mental status, changes in eating habits, or gastrointestinal (GI) symptoms
(confirm diagnostic before antimicrobials with urine)
____ _____often do not exhibit typical UTI symptoms; see altered mental status, changes in eating habits, or gastrointestinal (GI) symptoms
Elderly patients
What are the UTI Signs & Symptoms in Adults?
- GROSS HEMATURIA (red, bloody urine)
- LOWER UTI: Dysuria (painful), urgency, frequency, nocturia, and suprapubic heaviness (pain discomfort in lower abdominal region near groin)
- (still check kidneys just to make sure)
- UPPER UTI: Flank pain, fever, nausea, vomiting, and malaise (b/c kidney function)
What is the Physical Examination for Adults with a UTI?
- UPPER UTI: Costovertebral (back bottom ribcage) tenderness
What are the Laboratory Tests: Urinalysis for UTIs in Adults?
- MICROSCOPY: Gram stain of urine
- Urine CULTURING on growth medium
- > 105 BACTERIA/mL [108/L] of urine = significant bacteriuria
- Pyuria:
- in symptomatic patients >10 white blood cells (WBC)
/mm3 [10 × 106/L] = significant bacteriuria - CHEMICAL:
- Nitrite-positive urine→detects nitrate-reducing bacteria
- Leukocyte esterase-positive dipstick urine test
- IMMUNOFLUORESCENT: antibody (immunoglobulin G; IgG)-coated bacteria (UPPER UTI)
- (to see if it’s a kidney inf. –> pyelonephritis)
- PROSTATITIS: test for bacteriuria in EXPRESSED PROSTATIC SECRETIONS (EPS) after prostate massage
- (can determine if it’s in urine tract or prostate)
When are urine culturing on growth medium (for UTIs) good for?
relapsing! b/c want to make sure you identify & why it’s not responding
What is the UTIs treatment?
UTIs are primarily treated with antimicrobial agents
→ UNCOMPLICATED UTIs: E.coli 1st line antibiotic therapies (b/c most common)
* trimethoprim-sulfamethoxazole (TMP-SMX), nitrofurantoin, fosfomycin, or β-lactams (amoxicillin-clavulanate, cefdinir, cefaclor)
* antibiotic treatment is restricted by KIDNEY (GLOMERULAR) FILTRATION RATES and if the drug is ACTIVELY SECRETED INTO THE URINE
What do Antimicrobial therapeutic treatments depend on?
- Gram staining type ( ̶ versus +)
- severity of the presenting signs and symptoms (is there blood etc.)
- the site of infection (upper vs. lower UTI)
- uncomplicated vs. complicated UIT status
- antibiotic susceptibility test results (can look for key genes associated with antimicrobial resistance)
- Past-history of UTIs and antibiotic treatments
UTI Treatment dets
slide 23 (draw it out)
What are STDs/ STIs?
Infections of the genital tract are referred to as Sexually transmitted infections (STIs) or sexually transmitted diseases (STDs)
What are the STDs/ STIs caused by?
- gonorrhea, syphilis, chlamydia, chancroid, trichomoniasis, HUMAN IMMUNODEFICIENCY VIRUS (HIV), herpes simplex virus (HSV), human papillomavirus (HPV) (& monkey pox)
STIs presents with:
- diverse clinical manifestations
- changing drug-susceptibility patterns of some pathogens (gonorrhea, HIV, chlamydia) frequency of multiple STIs occurring
- (diff. to treat & complicate them this way)
- higher simultaneously in infected individuals
The diagnosis and management of patients with STIs are…
much more complex and can be lifelong
* Cures are fewer than treatments→increase in ANTIMICROBIAL DRUG RESISTANCE
How many new infections/yr in the US & what does it cost for STDs/STIs?
20 million new infections/ yr in the United States
* total prevalence of 110 million infections→total medical cost of $116 billion to the US healthcare system
What do the stats look like for STDs/STIs in Canada? & Winnipeg?
IN CANADA: reported cases of chlamydia, gonorrhea, syphilis infectious syphilis have been rising since 2000
* WINNIPEG has a current outbreak of SYPHILIS
* 120 cases in 2015
* >1000 active cases in 2020
New STIs/year is roughly _____ between genders*
EQUAL
* complications of STIs generally are more frequent and severe in WOMEN
* complications associated with pregnancy, and transmission
of infection to the fetus or newborn
STIs ____ damage to reproductive organs and risk of cancer
INCREASE
(such as HPV)
_______ complicate STI treatments/ cures
Co-infections (can become life-long infection)
* 50% of female patients with gonorrhea are coinfected with
chlamydia, only 20% in men
* Frequent co-association between syphilis and HIV infections (b/c it targets & inhibits proper function of immune system (WBCs in particular)
What is the greatest STI risk factor?
is the NUMBER of sexual PARTNERS
* ↑ sexual partners = ↑STI rates
↑ sexual partners =
↑STI rates
With INCREASING age, the incidence of most STIs ______ exponentially
decreases
STIs are reported at higher frequency by…
men who have sex with men (MSM) than in heterosexuals (& even LGBTQ2+)
MSM also have higher rates of ____ _____ STIs eg. ____ _____ and _____ ______
LESS COMMON
ENTERIC PROTOZOAN
BACTERIAL PATHOGENS
Prostitution, illicit drug and needle use ____ STI rate/ risk
↑
What are examples of unique factors that place youth at risk for STIs?
- Insufficient Screening: many young women don’t receive the chlamydia screening CDC recommends
- Confidentiality Concerns: many are reluctant to disclose risk behaviours to doctors
- Biology: young women’s bodies are biologically more susceptible to STIs
- Lack of Access to Healthcare: youth often lack insurance or transportation needed to access prevention services
- Multiple Sex Partners: many young people have multiple partners, which increases STI risk
Serious SEQUELAE of STIs are associated with ____ or _____ infections
congenital
perinatal (passing STI onto fetus/newborn)
(sequelae = long term effects of a temporary disease/injury)
Serious sequelae of STIs are associated with congenital or perinatal infections…
- NEONATAL STIs are acquired at birth, after infant passage through an infected cervix or vagina
- ↑ risk of infant death/ miscarriage
- TRANSPLACENTAL INFECTIONS (syphilis) cause congenital fetal infections (cross placental barrier)
What are ways to Prevent STIs?
- complete ABSTINENCE
- mutually MONOGAMOUS sexual relationship between uninfected partners
- BARRIER CONTRACEPTIVE methods (reduce risk)
- MALE and female CONDOMS → LATEX CONDOMS better than natural skin + water based LUBRICANTS (K-Y jelly, etc.)
- diaphragm, cervical cap, vaginal sponges, vaginal spermicides alone or in combination
(better @ preventing pregnancy than inf.)
Bacterial STIs Etiology:
- Gonorrhea: Neisseria gonorrhea (Gram –negative diplococci)
- becoming drug resistant
- Syphilis: Treponema pallidum (Gram-negative spirochaete)
- Chlamydia: Chlamydia trachomatis (no stain type)
- no PG (or not thick enough associated with mycoplasma)
- Non-specific urethritis: Ureaplasma urealyticum (no stain type)
- no PG (or not thick enough associated with mycoplasma)
- Chancroid: Haemophilus ducreyi (Gram-negative coccobacillus)
Parasite STI (tropical/ equatorial regions) Etiology:
- Trichomoniasis: Trichomonas vaginalis
(equatorial - can spread b/c of travel)
Virus STIs Etiology):
- Human immunodeficiency virus (HIV)
- drug based therapies therefore not curable yet
- Herpes simplex virus (HSV)
- drug based therapies therefore not curable yet
- Human papilloma viruses (HPV) –> vaccine preventables
- Hepatitis A, B, C virus (HAV, HBV, HCV)→targets the liver, A&B are vaccine preventable)
- but can be sexually transmitted (particular C)
What’s the difference b/t Prevalence & Incidence?
Prevalence is the estimated # of infections - new or existing - in a given time
Incidence is the estimated # of new infections - diagnosed or undiagnosed
STI Prevalence and Incidence for HPV
more prevalance
STI Prevalence and Incidence for HSV-2
more prevalance
STI Prevalence and Incidence for Trichomoniasis
more incidence (tourism/immigration)
STI Prevalence and Incidence for Chlamydia
more incidence
STI Prevalence and Incidence for HIV (ages 13 & older)
more prevalance
STI Prevalence and Incidence for Gnorrhea
more incidence
STI Prevalence and Incidence for Syphilis (ages 14 & older)
pretty even but more prevalance
(outbreaks in patients with inaccess to healthcare &/or communities with increase needle/drug use)
STI Prevalence and Incidence for HBV
pretty even but more prevalance
Tend to see more _____ > ______
prevalance > incidence
STI Signs and Symptoms:
- For a many STIs, signs and symptoms *overlap (with non/other one’s) preventing accurate diagnosis without a MICROBIOLOGIC AGENT CONFIRMATION
- Frequently, symptoms are minimal or absent despite infection
PCR is gold standard
Commonly Implicated Pathogens of Urethritis
(inflammation of the urethra)
Chlamydia trachomatis
(chlamydia), herpes simplex virus, Neisseria gonorrhoeae, Trichomonas vaginalis (Trichomoniasis), Ureaplasma spp., Mycoplasma genitalium
Common Clinicial Manifestations of Urethritis
(inflammation of the urethra)
Urethral discharge (pyuria), dysuria
- typ. not associated with non-sexually transmitted inf’s
Commonly Implicated Pathogens of Epididymitis
(inflammation of the coiled tube behind the testicle)
C. trachomatis, N. gonorrhoeae
Common Clinical Manifestations of Epididymitis
(inflammation of the coiled tube behind the testicle)
Scrotal pain, inguinal pain, flank pain, urethral discharge
- similar with UTI
Commonly Implicated Pathogens of Cervicitis/ vulvovaginitis (inflammation of the cervix)
C. trachomatis, Gardnerella vaginalis, herpes simplex virus, human papillomavirus, N. gonorrhoeae, T. vaginalis
-*not really a STI but it can be transmissible sexually if it’s a high enough titre b/t m & f (typ. a normal flora in f’s)
Common Clinical Manifestations of Cervicitis/ vulvovaginitis (inflammation of the cervix)
Abnormal vaginal discharge, vulvar itching/irritation, dysuria, dyspareunia (genital pain that occurs with sex - before, during &/or after)
Commonly Implicated Pathogens of Genital ulcers (painful sores)
Haemophilus ducreyi
(chancroid), herpes simplex virus
Common Clinical Manifestations of Genital ulcers (painful sores)
Usually multiple vesicular/pustular (herpes) or papular/pustular
(H. ducreyi) lesions that can coalesce; painful, with tender lymph nodes
Commonly Implicated Pathogens of Genital ulcers (painless sores) (can be overlooked/unnoticed)
Treponema pallidum (syphilis), Chlamydia trachomatis
Common Clinical Manifestations of Genital ulcers (painless sores) (can be overlooked/unnoticed)
Usually single papular lesion (raised and < 1 cm around); unnoticed
Commonly Implicated Pathogens of Genital/anal warts (condylomas)
Human papilloma virus (HPV)
Common Clinical Manifestations of Genital/anal warts
(condylomas)
Multiple lesions ranging in size from small papular warts to large exophytic condylomas
- large & deep lesions
STIs can also affect _____
eyes, throat and gastrointestinal regions (don’t limit to genitals)
Commonly Implicated Pathogens of Pharyngitis
C. trachomatis, herpes simplex virus, N. gonorrhoeae
Common Clinical Manifestations of Pharyngitis
Symptoms of acute pharyngitis, cervical lymphadenopathy, fever
Commonly Implicated Pathogens of Proctitis
(inflammation of the rectum)
C. trachomatis, herpes simplex virus, N. gonorrhoeae,
T. pallidum
Common Clinical Manifestations of Proctitis
(inflammation of the rectum)
Constipation, anorectal discomfort, tenesmus (need to pass stools - even though you don’t; could be symptom of sexual practice too not just STI), mucopurulent rectal discharge
Commonly Implicated Pathogens of Salpingitis
(inflammation of fallopian tubes)
C. trachomatis, N. gonorrhoeae
Common Clinical Manifestations of Salpingitis
(inflammation of fallopian tubes)
Lower abdominal pain, purulent cervical or vaginal discharge, adnexal swelling, fever
What is the STI Detection?
- Depending on the suspected STI site tests will involve:
- Physical examination and symptom description:
- chancroid, warts, HSV, syphilis
- SWABS: of lesion or mucosal site for MICROBIOLOGICAL CULTURES
SEROLOGY, and PCR TESTING (go-to) →vaginal, anal, or throat * Chlamydia and gonorrhea - URINALYSIS: chlamydia and gonorrhea
- BLOOD TESTS: detect HIV, syphilis, herpes (by flare up) (antibody and PCR tests)
- HIV has point of care blood tests
- PAP SMEAR detect cancerous lesions and cervix swabs
- Cancerous lesions: human papilloma virus (HPV)
- chlamydia and gonorrhea
What is the Treatment for Syphilis (Treponema pallidum) STIs?
primary, secondary, latent stages are treatable
* Parenteral high dose benzathine penicillin G (1st Gen β-lactam)
What is the Treatment for Chlamydia (Chlamydia trachomatis) and Ureaplasma?
- Lacks a peptidoglycan cell wall: tetracyclines, macrolides and some fluoroquinolones
What is the Treatment for Gonorrhea (Neisseria gonorrhea)?
- Few antimicrobial therapies remain effective (v. resistant)→3rd generation
cephalosporin β-lactams: ceftriaxone or cefixime
What is the Treatment for Trichomoniasis (Trichomonas vaginalis)?
- anti-parasitic metronidazole (Flagyl) or tinidazole
- resistant most likely will grow & few med’s for it
STI treatment dets
- Lifelong uncurable but treatable symptoms: HIV, HSV
- No treatment or cure: HPV (vaccine preventable), end-stage tertiary/ neurosyphilis
