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UTIs Flashcards

1
Q

Define an urinary tract infection (UTI).

A

The inflammatory response of the urothelium to bacterial invasion, usually associated with bacteriuria (bacteria in urine) and pyuria (pus in urine).

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2
Q

What is numerically defined as an UTI?

A

Defined as >105 organisms/ml or fresh mid-stream urine

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3
Q

What are the 5 main pathogens account for nearly ALL ISOLATE from primary care?

A

KEEPS:
* K = Klebsiella spp.
* E = E.coli - MOST COMMON
* E = Enterococci
* P = Proteus spp.
* S = Staphylococcus spp. - coagulase negative

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4
Q

Name 3 UTI causative organisms.

A
  1. Uropathogenic strains of E.coli (UPEC) - 82%.
  2. CNS e.g. s.saprophyticus.
  3. Proteus mirabilis.
  4. Enterococci.
  5. Klebsiella pneumonia.
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5
Q

Give 5 risk factors for UTIs.

A
  1. Sexually active
  2. Catheterised
  3. Enlarged prostate
  4. Renal tract tumour
  5. Renal stones
  6. Urinary retention
  7. Woman
  8. Incontinence
  9. Poor hygiene
  10. Dehydration
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6
Q

What are the 3 different classifications of UTIs?

A
  1. Location:
    * Lower urinary tract vs. Upper urinary tract
  2. Clinical risk:
    * Uncomplicated vs. Complicated
  3. Timing:
    * Single/isolated vs. Unresolved (persistent infection or re-infection)
    * Acute vs. Chronic
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7
Q

Uncomplicated vs complicated UTI?

A

Uncomplicated - healthy non pregnant women
Everyone else - complicated

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8
Q

How to treat uncomplicated UTIs in young women?

A

3 days abx
E.G. nitrofurantoin or trimethoprim

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9
Q

What is the first line treatment for an uncomplicated UTI?

A
  • Trimethoprim or nitrofurantoin for 3 days.
  • Increased fluid intake and regular voiding.
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10
Q

How does trimethoprim work?

A

It affects folic acid metabolism.

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11
Q

How to manage ‘complicated’ UTI?

A

MSU for culture
7 days abx

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12
Q

Describe the management for a complicated UTI.

A

Same as for an uncomplicated UTI but a MCS MSU is essential! The patient would normally take a longer Abx course tailored to sensitivity.

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13
Q

3 things about UTI in pregnancy?

A
  1. Urinalysis is an unreliable test, always send for culture
  2. Asymptomatic bacteriuria is common
  3. Always treat, they are at much higher risk of pyelonephritis
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14
Q

What determines if a UTI is complicated or uncomplicated?

A

A UTI is deemed complicated if it affects:

  • Someone with an abnormal urinary tract.
  • A man.
  • A pregnant lady.
  • Children.
  • The immunocompromised.
  • If it is recurrent.
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15
Q

Give 3 bacterial virulence factors that aid their ability to cause UTI’s.

A
  1. Fimbriae/pili that adhere to urothelium.
  2. Acid polysaccharid coat resists phagocytosis.
  3. Toxins e.g. UPEC releases cytotoxins.
  4. Enzyme production e.g. urease.
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16
Q

Under what circumstances would you see higher rates of adhesion?
Why?

A

Oestrogen depletion due to the loss of lactobacilli and pH change:

  • Seen post-menopause where the pH rises and thus there is increased colonisation by colonic flora and a reduction in vaginal mucus secretion
  • Results in increased susceptibility to UTI
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17
Q

Give 5 host defence mechanisms against urinary tract infection.

A
  1. Antegrade flushing of urine (forward flow of urine).
  2. Tamm-horsfall protein -> has antimicrobial properties.
  3. GAG layer.
  4. Low urine pH.
  5. Commensal flora.
  6. Urinary IgA.
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18
Q

Give 3 methods of avoiding host defences.

A
  1. Capsule
  2. Enzyme production
  3. Toxins
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19
Q

Give an example of enzyme production as a method of avoiding host defences.

A

E.coli release cytokine that are directly toxic

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20
Q

Give an example of toxin production as a method of avoiding host defences.

A

Proteus spp. secrete urease:
* Increases risk of stone formation

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21
Q

Give an example of a gram negative bacteria that releases urease.

A

Gram-negative: Proteus, Klebsiella & Pseudomonas

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22
Q

Give an example of a gram positive bacteria that releases urease.

A

Gram-positive: Staphylococci & Mycoplasma

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23
Q

Give 2 reasons why a post menopausal woman is more susceptible to a UTI.

A
  1. pH rises -> increased colonisation by colonic flora.
  2. Reduced mucus secretion.
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24
Q

The vagina is heavily colonised with lactobacilli. What is the function of this?

A

Helps maintain a low pH = host defence mechanism.

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25
Q

Describe the pathophysiology of UTI’s.

A

Organisms colonise the urethral meatus and ascend via the transurethral route.

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26
Q

Briefly describe the epidemiology of UTIs.

A

More common in women
- Affects 1/3rd in lifetime

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27
Q

Why are women more susceptible to UTIs?

A

More common in women due to short urethra and its proximity to the anus.

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28
Q

What can facilitate bacteria ascent into the urinary tract via the urethra?

A
  1. Sexual intercourse.
  2. Catheterisation.
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29
Q

When would/wouldn’t you treat or test for a UTI?

A

3 UTI symptoms – empirical abx
2 UTI symptoms + nitrates – empirical abx

2 UTI symptoms + leucocytes – send MSU

Symptoms but no leuco/nitr in dipstick or it looks clear - unlikely to be a UTI

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30
Q

Name 4 lower urinary tract infections.

A
  1. Cystitis.
  2. Prostatitis.
  3. Epididymitis / Epididymo-orchitis.
  4. Urethritis.
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31
Q

Name 1 upper urinary tract infection.

A

Pyelonephritis.

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32
Q

Give 5 clinical presentations of UTIs.

A

Frequency
Dysuria
Urgency
Incontinence
Confusion
Suprapubic pain

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33
Q

Give 4 risk factors for UTIs.

A
  • Female
  • Sex
  • Pregnancy
  • Menopause
  • Decrease in host defence
  • Urinary tract obstruction resulting in urine stasis
  • Catheter
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34
Q

Define pyelonephritis.

A

Inflammation secondary to infection of the renal parenchyma and soft tissues of the renal pelvis and upper ureter.

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35
Q

What can cause pyelonephritis?

A

UPEC. Typically P pili.
Infection is usually from the bladder.

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36
Q

What is the likely cause of pyelonephritis in children?

A

Reflux or structural/functional abnormalities.

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37
Q

Give 3 ways in which infection can spread to the upper urinary tract and cause pyelonephritis.

A
  1. Ascending from urethra, common in intercourse
  2. Haematogenous, in sepsis
  3. Lymphatic
38
Q

Give 3 risk factors for pyelonephritis.

A
  • Structural renal abnormalities
  • Calculi (stones)
  • Catheterisation
  • Pregnancy
  • Diabetes
  • Immunocompromised patient
39
Q

Give 3 symptoms of pyelonephritis.

A
  1. Loin pain.
  2. Fever.
  3. Pyuria.

May also have a severe headache and be fluid deplete.

40
Q

What is pyuria?

A

The presence of leukocytes in urine.

41
Q

3 features that suggest pyelonephritis over UTI?

A

1, Loin pain
2. Fever
3. Haematuria

42
Q

What investigations might you do in someone with pyelonephritis?

A
  1. Urinalysis - urine dipstick.
  2. MSU MCS (midstream urine microscopy, culture + sensitivity)
  3. Bloods - raised WCC, ESR and CRP.
  4. Urgent ultrasound.
43
Q

Investigations to diagnose pyelonephritis.

A
  1. Physical examination
    - Tender loin
  2. Urine dipstick:
    * Detects nitrites - bacteria breakdown nitrates to release nitrites
    * Detect leucocyte elastase
    * Foul-smelling urine
    * Dipstick positive for nitrites, leucocytes and protein
  3. Midstream urine microscopy, culture and sensitivity
    - GOLD STANDARD for diagnosis
  4. Bloods:
    * FBC - shows elevated white cell count
    * CRP & ESR may be raised in acute infection
  5. Urgent ultrasound:
    * Detection of calculi, obstruction, abnormal urinary anatomy and
    incomplete bladder emptying
44
Q

Describe the treatment for pyelonephritis.

A
  1. Rest
  2. Cranberry juice and lots of water
  3. Analgesia
  4. Antibiotics:
    * ORAL CIPROFLOXACILLIN or ORAL CO-AMOXICLAV
    * If severe then: IV GENTAMICIN or IV CO-AMOXICLAV
  5. Surgery to drain abscesses or relieve calculi that are causing infection
45
Q

Differential diagnosis for pyelonephritis.

A
  • Diverticulitis, abdominal aortic aneurysm, kidney stones, cystitis,
    prostatitis
46
Q

What is cystitis?

A

Inflammation of the bladder secondary to infection.

47
Q

Give 4 risk factors for cystitis.

A
  1. Obstruction.
  2. Previous damage to bladder epithelium.
  3. Bladder stones.
  4. Poor bladder emptying.
48
Q

Give 3 symptoms of cystitis.

A
  1. Dysuria.
  2. Frequency.
  3. Urgency.
49
Q

What is the gold standard investigation for cystitis diagnosis?

A

MSU MCS
- (sterile) Midstream urine microscopy, culture and sensitivity

50
Q

Investigations for cystitis.

A
  1. MSU MCS - gold standard
  2. Urinalysis - urine dipstick
    - Positive leucocytes, blood and nitrites
51
Q

Treatment for cystitis.

A
  1. Antibiotics:
  • First-line:
  • TRIMETHOPRIM or CEFALEXIN
  • Second-line:
  • CIPROFLOXACIN or CO-AMOXICLAV
52
Q

Define prostitis.

A

Infection and inflammation of the prostate gland.
- Can be acute or chronic.

53
Q

What are the 3 main causes of prostitis?

A
  1. Streptococcus faecalis
  2. E.coli
  3. Chlamydia
54
Q

Give 5 symptoms of acute bacterial prostatitis (type 1).

A
  1. Systemically unwell, fever.
  2. Rigors and malaise.
  3. Voiding LUTS (straining, hesitancy, incomplete emptying, poor flow).
  4. Pelvic pain.
  5. Pain on ejaculation.
55
Q

Give 4 symptoms of chronic bacterial prostatitis (type 1).

A
  1. Recurrent UTI’s.
  2. Pelvic pain.
  3. Voiding LUTS (straining, hesitancy, incomplete emptying, poor flow).
  4. Uropathogens in urine.

The patient should have had the symptoms for >3 months.

56
Q

Give a symptom of type 3 prostatitis.

A

Chronic pelvic pain.

57
Q

Describe the NIDDK classification for prostatitis.

A
  • Type 1: acute bacterial prostatitis.
  • Type 2: chronic bacterial prostatitis.
  • Type 3a: Inflammatory chronic pelvic pain syndrome.
  • Type 3b: non-inflammatory chronic pelvic pain syndrome.
  • Type 4: asymptomatic inflammatory prostatitis.
58
Q

What investigations might you do in someone with prostatitis?

A
  1. Digital rectal exam (DRE)
  2. Urinalysis - Urine dipstick - positive for leucocytes and nitrites
  3. Mid-stream urine microscopy, culture + sensitivity (MSU MCS)
  4. Blood cultures
  5. STI screen - for chlamydia in particular
  6. Trans-urethral ultrasound scan (TRUSS)
59
Q

Describe the treatment for type 1 prostatitis (acute).

A

Type 1 = acute bacterial prostatitis.

First-line:
- IV GENTAMICIN + IV CO-AMOXICLAV or IV TAZOCIN or IV CARBAPENEM
* 2-4 weeks on a quinolone e.g. CIPROFLOXACIN (antibiotic) once a week

Second-line:
* Trimethorpin

  • TRUSS guided abscess drainage if necessary
60
Q

Describe the treatment for type 2 prostatitis (chronic).

A

Type 2 = chronic bacterial prostatitis.
- 4-6 weeks quinolone e.g. ciprofloxacin.
* BUT they don’t tend to respond as well to antibiotics

  • +/- Alpha-blocker e.g. TAMSULOSIN
  • NSAIDs e.g. IBUPROFEN
61
Q

Give a complication of prostatitis.

A

Urinary retention.

62
Q

Define urethritis.

A

Urethral inflammation due to infectious of non-infectious causes.

63
Q

What is the most common cause of urethritis?

A

Chlamydia trachomatis

64
Q

What can cause urethritis?

A

STI’s e.g. gonorrhoea, chlamydia.
A primarily sexually acquired disease.

65
Q

Give 2 non-gonococcal causes of urethritis.

A
  1. Chlamydia trachomatis - MOST COMMON CAUSE
  2. Mycoplasma genitalium
  3. Ureaplasma urealyticum
  4. Trichomonas vaginalis
66
Q

What is the main gonococcal cause of urethritis?

A

Neisseria gonorrhoea

67
Q

Give 2 non-infective causes of urethritis.

A
  1. Trauma
  2. Urethral stricture
  3. Irritation
  4. Urinary calculi
68
Q

Describe the clinical presentation of urethritis.

A
  • May be asymptomatic (90-95% with gonorrhoea, 50% of patients with chlamydia)
  • Dysuria (painful urination) +/- discharge; blood or pus
  • Urethral pain
  • Penile discomfort
  • Skin lesions
  • Systemic symptoms
69
Q

Investigations for urethritis.

A
  1. Nucleic acid amplification test (NAAT):
    * Female - self collected vaginal swab (best), endocervical swab, first void
    urine
    * Male - first void volume
    * High specificity and sensitivity
  2. Microscopy of gram-stained smears of genital secretions
  3. Blood cultures
  4. Urine dipstick - to exclude UTI
  5. Urethral smear
70
Q

What is the treatment for urethritis caused by gonorrhoea?

A
  • IM CEFTRIAXONE with ORAL AZITHROMYCIN
  • Partner notification
71
Q

What is the treatment for urethritis caused by chlamydia?

A
  • ORAL AZITHROMYCIN STAT or 1 WEEK ORAL DOXYCYCLINE
  • Tests for other STIs
72
Q

What is the treatment for urethritis caused by chlamydia for a pregnant female?

A

ORAL ERYTHROMYCIN for 14 days or ORAL AZITHROMYCIN
STAT

73
Q

What is epididymo-orchitis?

A

Inflammation of the epididymis and testicle.

Acute epididymo-orchitis is a clinical syndrome of pain, swelling and inflammation of the epididymis that can extend into the testis

74
Q

Describe the aetiology of epididymo-orchitis.

A
  1. If <35 y/o = STI e.g. chlamydia.
    1. If >35 y/o = UTI (causes: KEEPS mnemonic).
75
Q

Give 3 symptoms of epididymo-orchitis.

A
  1. Sudden onset tender swelling.
  2. Dysuria.
  3. Sweats/fever.
76
Q

What investigations might you do on someone who you suspect has epididymo-orchitis?

A
  1. Nucleic acid amplification test (NAAT):
    * Female - self collected vaginal swab (best), endocervical swab,, first void urine
    * Male - first void volume
    * High specificity and sensitivity
    * If intracellular gram-NEGATIVE DIPLOCOCCI are present, then this is suggestive of GONORRHOEA
  2. Urethral smear + swab.
  3. MSU dipstick - for UTI smptoms
  4. Ultrasound to rule out abscesses
  5. STD screening

Rule out testicular torsion!

77
Q

Describe the treatment for epididymo-orchitis.

A
  1. If STI aetiology suspected; refer to GUM and maybe give doxycycline.
  2. If UTI aetiology suspected give quinolone (ciprofloxacin).
78
Q

What is the treatment for epididymo-orchitis caused by chlamydia?

A
  • ORAL DOXYCYCLINE 7 DAYS or STAT AZITHROMYCIN
79
Q

What is the treatment for epididymo-orchitis caused by gonorrhoea?

A
  • IM CEFTRIAXONE + STAT ORAL AZITHROMYCIN
  • ORAL CIPROFLOXACIN or ORAL OFLOXACIN
80
Q

Give a differential diagnosis of epididymo-orchitis, and symptoms that might suggest it.

A

TESTICULAR TORSION - UROLOGICAL EMERGENCY:
* MUST RULE THIS OUT
* If in any doubt then SURGICAL SCROTAL EXPLORATION

  • Features suggestive of torsion:
  • Short duration of pain - sudden onset
  • Associated nausea/abdominal pain
  • High-riding/bell-clapper testis
81
Q

Define recurrent UTI.

A

> 2 episodes in 6 months of > 3 in 12 months.

82
Q

Give 3 causes of recurrent UTI’s.

A
  1. Re-infection.
  2. Bacterial persistence.
  3. Unresolved infection.
83
Q

What investigations might you do on someone who you suspect has a UTI?

A
  1. Take a good history.
  2. Urinalysis - multistix SG.
  3. Microscopy; culture and sensitivity of mid-stream urine.
  4. In recurrent/complicated UTI renal imaging is important.
84
Q

Describe the management for someone who is having recurrent UTI’s.

A
  1. Increase fluid intake.
  2. Regular voiding.
  3. Void pre and post intercourse.
  4. Abx prophylaxis.
  5. Vaginal oestrogen replacement.
85
Q

What do type P pili bind to?

A

Glycolipids on urothelium.

86
Q

What do type 1 pili bind to?

A

Uroplakin.

87
Q

What type of pili would you associate with a lower UTI?

A

Type 1.

88
Q

What type of pili would you associate with an upper UTI?

A

Type P.

89
Q

What do nitrates suggest?

A

Gram neg bacteria e.g. E coli

90
Q

What do urine casts suggest?

A

Damage to epithelium/tubular necrosis/glomerulus

91
Q

What does epithelium in MSU suggest?

A

Poorly taken sample, may be contaminated

92
Q

What number of bacteria in an MSU is significant?

A

10^5
(10^4 may be contamination)

Genitourinary (17 decks)

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