UTIs Flashcards
define UTI
- Defined as presence of significant bacteriuria and characteristic signs and symptoms
what are the risk factors for UTIs?
iatogenic/ drugs- catheter, antibiotic use, spermacides
behavioral- voiding dysfunction, frequent or recent sex
physiologic- female, pregnant
genetic- familal tendency, vaginal mucus properties
what can pyleonephritis lead to?
AKI/sepsis- if it becomes systemic
who/ what is classified as an uncomplicated UTI?
- Caused by a usual pathogen in a person with a normal urinary tract and normal kidney
function
– Female (not elderly)
– First presentation
– No signs of pyelonephritis
– Not pregnant
what classifies as a complicated UTI?
- Pregnant
- Male
- Children
- Elderly
- Pyelonephritis
- Recurrent
- Factors present that predispose to persistent or re-current infection or treatment failure
– Abnormal urinary tract
– Virulent organism
– Impaired host defences
– Poorly controlled diabetes
mellitus,
– Immunosuppressive treatment
– Impaired renal function.
what are the typical symptoms of uncomplicated UTI?
- Dysuria
- Frequency
- Suprapubic tenderness
- Urgency
- Polyuria
- Haematuria
why would you suspect an upper UTI?
- +/- UTI Symptoms
- Fever
- Flank, loin or lower back pain
- Can lead to renal failure and
septicaemia - Empirical antibiotics +/-
admission to hospital required
how do you diagnose a UTI?
- Clinical history and symptoms
- Near patient tests?
– Appearance of urine – smell? cloudy? blood?
– Urine microscopy
– Dipstick tests – leucocyte and nitrite - Urine culture
why are urine dipsticks not used?
Dipsticks become more unreliable with increasing age over 65 years. Up to half of older adults, and most with a urinary catheter, will have bacteria present in the bladder/urine without an infection. This “asymptomatic bacteriuria” is not harmful, and although it causes a positive urine dipstick, antibiotics are not beneficial and may cause harm
how do you manage an uncomplicated lower UTI?
- Empirical Antibiotics
– Nitrofurantoin MR 100mg twice daily for THREE days or 50mg QDS - First line treatment option
- Contraindicated in significant renal impairment
- Activity affected by urinary pH
– OR Trimethoprim 200mg twice daily for THREE days
what do complicated UTIs need?
- Complicated infection requires 5- 10 day treatment courses to eradicate bacteriuria
when do you have to be cautious with nitrofurantoin in renal impairment?
- Caution in renal impairment
– eGFR less than 45ml/minute/1.73m2
– Ineffective (inadequate concentration in the urine….site of action)
– 30-45ml/minute/1.73m2 – only if multi-drug resistant(risk/benefit)
– Increased risk of peripheral neuropathy
what patients are already at risk of peripheral neuropathy?
- DM
- Anaemia
- Folate deficiency
- Electrolyte
imbalances
what are some side effects of nitrofuratoin?
– GI
– Pulmonary – cough, chest pain, dysphonea,
hypoxemia….(<1%) – withdraw + corticosteroid
when would you be cautious with trimethoprim in renal impairment?
- Caution in severe renal impairment (accumulation - less of an issue with 3
day courses)
– GFR 15-25 ml/min – normal dose for 3 days then half dose
– GFR <15 ml/min – half normal dose
what is trimethoprim contraindicated with?
- CI with blood dyscrasias – antifolate effects
what interactions does trimethoprim have?
- Interactions (bigger issue with long-term treatment)
– Methotrexate (folate antagonist)
– Azathioprine (increased risk of haematological toxicity)
– Phenytoin (increased levels)
– Digoxin (increased levels)
– Warfarin? (often the case with all Abx)
what should be done if patient is resistant to first line antibiotics?
urine culture
define pyelonephritis
Infection within the renal pelvis, with or without active infection of the renal parenchyma
what are the symptoms of pyelonephritis?
UTI + loin pain and/or fever
what are the common pathogens of pyelonephritis?
Common pathogens:
* Escherichia coli
* Klebsiella pneumonia.
* Proteusspecies
* Pseudomonasspecies
* Enterococcus species
who would you be extra cautious about with pyelonephritis?
- Pregnancy
- Elderly…care homes
- Lack of improvement following antibiotic therapy (24 hours)….close monitoring
- Immunocompromised
- Renal impairment
- Diabetes
what is the management of pyelonephritis?
Primary care
* Co-amoxiclav 625mg TDS 7 days or
* Ciprofloxacin 500mg BD 7 days
* Cautions with above agents???
Secondary Care
* Optionsinclude, gentamicin, tazocin®, meropenem, teicoplanin,
ciprofloxacin
what is defined as a relapsed UTI?
- Same strain of organism within 2 weeks of finishing treatment
what is defined as a reinfection UTI?
- Different strain of organism, most likely if >2 weeks after treatment
how do you manage recurrent UTI?
- Patient initiated self treatment
- Post coital prophylaxis -
- Non antibiotic treatment
– Cranberry products – no longer recommended - Continuous prophylaxis – option, but poor evidence
– e.g. trimethoprim100mg ON
why are UTIs more uncommon in men?
longer urethra
– antibacterial activity of prostatic secretions
what should be done in all men with suspected UTI?
urine culture
how do you treat a UTI in men?
– Seven day course of trimethoprim or nitrofurantoin recommended (HPA)
– Treatment failure should be managed according to urine culture results
– Recurrent UTI in men and febrile UTI often associated with prostate involvement
* Quinolones indicated due to ability to penetrate prostatic fluid
what is bacteriuria in pregnant women associated with?
The presence of bacteriuria (with/ without symptoms) is associated with premature rupture of membranes and pre- term labour
what is done to prevent bacteruria in pregnant women?
- Routine screening for asymptomatic bacteriuria by midstream
urine culture recommended in early pregnancy (NICE)
what can be given for cystitis in pregnancy?
- Paracetamol may be recommended for
symptomatic relief - Alkalizing agents and cranberry should be
avoided - Urine culture + empirical antibiotic therapy
- Fever and loin pain suggests upper UTI
– Hospital admission and IV antibiotics
recommended
how may a UTI present in elderly?
- Chronic genitourinary symptoms may be present and not
associated with acute infection
– Functional decline, increased confusion and non specific
symptoms are often attributed to UTI
how do you diagnose UTI in elderly?
- Diagnosis of UTI in an older person requires the presence of new urinary symptoms.
what must be done for patients with UTIs with indwelling catheters?
- The catheter must be checked for correct
positioning and to ensure it is not blocked. - If the catheter has been in place for more than a week, it may be advisable to change it before starting antibiotic treatment
- Urine culture must be taken prior to initiating
empirical antibiotics - If symptoms are mild, treatment may be delayed to await results of culture & sensitivities
- Seven day courses recommended
why are people with diabetes at higher risk of UTIs?
- Increased risk of asymptomatic bacteriuria
- Higher risk of recurrent infections
- Higher prevalence of atypical pathogens
- Bilateral infections are more common
- Greater likelihood of antimicrobial resistance
- Hospital acquired infections are more common
- Fungal urinary tract infection is more common
- Increased risk of complications like renal failure and
septicaemia
are UTIs common in children?
- Occurs in 3-7% girls and 1-2% boys before the
age of 6 years - 12-30% experience recurrence within a year
- Up to half patients have a structural abnormality
of urinary tract - Pyelonephritis can damage growing kidney
causing scarring
how do infants present with UTIs?
- Fever
- Vomiting
- Lethargy
- Irritability
- Offensive urine
- Poor feeding / failure to thrive
- Jaundice
- Febrile convulsion
- Septicaemia
how do children present with UTIs?
- Dysuria and frequency
- Abdominal pain or loin
tenderness - Fevers +/- rigors
- Lethargy
- Anorexia
- Vomiting, diarrhoea
- Haematuria
- Offensive/ cloudy urine
- Febrile convulsion
- Recurrence of enuresis
what investigations should be done for infants and children?
Infants and children presenting with unexplained fever of 38°C or
higher should have a urine sample tested within 24 hours (NICE)
what indications are there to do a culture?
– Diagnosis of acute pyelonephritis/upper urinary tract infection
– High to intermediate risk of serious illness
– Under 3 years
– Single positive result for leukocyte esterase or nitrite
– Recurrent UTI
– Infection that does not respond to treatment within 24–48 hours
– Clinicalsymptoms and dipstick tests do not correlate
what are the risk factors for UTI in children?
- Incomplete bladder emptying
– Poor urine flow
– Dysfunctional voiding resulting in enlarged bladder
– Obstruction by loaded rectum from constipation
– Neuropathic bladder - Antenatally-diagnosed renal abnormality
- Family history of vesicoureteric reflux (VUR) or renal disease
- History suggesting, or confirmed, previous UTI
- Evidence of spinal lesion
- Poor growth
- High blood pressure
how do you treat children / infants over 3 months?
- Oral antibiotics recommended for children and infant over 3 months:
– Acute pyelonephritis: - 7 days - 10 days
- IV antibiotics for 2– 4 days if oral antibiotics cannot be used followed by oral treatment for 10 days total
– Low UTI: - 3 days
- Re-assess if child remains unwell after 24-48 hours
- Choice of antibiotic
– Trimethoprim, nitrofurantoin, cephalosporin or
amoxicillin
how can you prevents UTIs in children?
- High fluid intake to produce a high urine output
- Regular voiding
- Ensure complete bladder emptying
– Double micturition - Prevention or treatment of constipation
- Good perineal hygiene
- Probiotic??
- Antibiotic prophylaxis
– Not recommended after first infection
– May be indicated in recurrent UTI
– Under 2’s with congenital abnormality
– Severe reflux
– Trimethoprim
