UTIs Flashcards
What is the pathophysiology and risk factors associated with UTIs?
Normal bowel flora: Bacteroides, GM+ bacilli (anaerobes; clostridium), GM+ cocci, GM- enteric organisms, E. faecalis
most common route is ascending colonization of urethra by fecal flora, can ascend to bladder and kidneys
Risk factors: age (young, elderly; BPH, lower estrogen), female gender, pregnancy, DM, estrogen deficiency, catheter/obstruction/renal dysfunction, neurologic dysfunction, previous ABX use, sexual intercourse, use of diaphragm and spermicides
What are the different types of UTIs? And how do you differentiate them?
Lower UTIs: cystitis – bladder infection (most common)
- Dysuria, increased urgency, suprapubic pain, hematuria
Upper UTI: pyelonephritis
- UTI symptoms PLUS flank pain, fever, chills, N/V, CVA tenderness
Urosepsis: significant systemic symptoms and/or bacteremia secondary to UTI
- Fever, tachycardia, tachypnea, hypotension
Prostatitis: intermittent dysuria, recurrent UTIs, ejaculatory pain, fever, myalgia (can be asymptomatic)
What are the common causes of UTIs?
- Polyuria: diuretics, lithium, phenytoin, diltiazem, metronidazole
- Fever: allopurinol, amphoB, ABX, other infection
- Hypotension: BP meds, anticholinergics, typical antipsychotics
What are the common pathogens in uncomplicated and complicated UTIs? What about asymptomatic?
Uncomplicated: E. coli, P. mirabilis, K. pneumoniae, S. saprophyticus, Enterococcus spp.
Complicated: Pseudomonas, Acinetobacter, E. colli, P. mirabilis, E. faecalis, Staphylococcus spp.
Asymptomatic: E.coli
What is an uncomplicated UTI?
Non-pregnant female patients without structural abnormalities or immunocompromise
What is a complicated UTI?
Structural abnormalities, males, children, pregnant women, DM, catheters, immunocompromised
How do you define recurrent UTIs?
2+ episodes of an uncomplicated UTI in the past 6 months or 3 episodes in the past 12 months
How do you diagnose UTIs?
symptoms +/- UA and culture
- Only culture if suspect for complicated UTI, pregnancy or diagnosis uncertainty
o Uncomplicated if failure to respond to empiric therapy or early recurrence (<1 month)
What are important non-drug measures to treat UTIs?
- Surgical procedures to correct deformities
- Fluid hydration to increase voiding (residual volume of 10ml can alter eradication
- Probiotics to decrease vaginal pH, reduce colonization if E. coli
- Cranberry juice/extract (~may reduce rate of recurrence
What are the first and second line therapies for the treatment of uncomplicated UTIs?
1: SMP-TMP (or TMP alone) 1 DS PO x 3 days OR
Nitrofurantoin 100mg PO BID-QID x 5 days OR
Fosfomycin 3g PO x 1 dose
2: FQ (Cipro/Levo/Norflox) PO x 3 days OR
Beta-lactams x 3-7 days (avoid ampicillin, amoxicillin alone due to E. coli resistance)
What are the first and second line therapies for CA-complicated UTIs?
1: SMP-TMP PO OR Amoxi-clav OR Cefixime OR FQ [duration increased to 7-10 days; up to 14 for FQs]
2: *Dependent upon culture results and risk of resistance
What are the first and second line therapies for uncomplicated pyelonephritis?
Uncomplicated: mild-mod illness, manageable dehydration, tolerates PO
1: FQ (Levo or Cipro) x 5-7 days respectively
2: Amoxi-clav PO OR TMP-SMX PO OR TMP PO
[duration increased to 10-14 days]
How do you treat complicated pyelonephritis?
AG IV + (ampicillin if Enterococcus suspect) x 10-14 days OR FQ IV x 7-14 days OR
3GC, Cefepime or Pip-tazo x 10-14 days OR
Carbapenems IV x 10-14 days
What are some important considerations for pyelonephritis?
- Fluids + antipyretic PRN, improvement in 72 hrs
- Consider additional coverage for hospital acquired UTIs (as above + vancomycin, linezolid, dapto for resistant enterococcus)
What are the symptoms of acute bacterial prostatitis? How do you treat it?
Symptoms: chills, perineal and low back pain, fever, irritative/obstructive voiding, prostate is tender/swollen
TMP-SMX or FQ x 2-4 weeks
If STI-related: Ceftriaxone + Doxy
[don’t use beta-lactams; poor penetration]
What are the symptoms of chronic bacterial prostatitis? How do you treat it?
Symptoms: intermittent urinary tract infection presenting as cystitis, history of recurrent UTIs, prostate exam is usually normal
Same treatment as acute, treat for 4-6 weeks
How do you treat recurrent UTIs?
- Short-course self therapy
- Post-intercourse ppx: single dose within 2 hours after intercourse (TMP-SMX, TMP, nitrofurantoin, cephalexin, FQ)
- Long-term low-dose ppx: TMP-SMX (1st line), nitrofurantoin, cephalexin, Fosfomycin, FQ, vaginal estrogens
What is difference between relapse and reinfection?
Relapse/persistence: same bacteria, can occur during or < 2 weeks after therapy
Reinfection: same or different bacteria, occurs > 2 weeks after completion of therapy
What are some important considerations for pregnancy and UTIs?
Treat to reduce complications once confirmed on 2 consecutive cultures (even if asymptomatic!)
- Safe: amoxicillin, amoxi-clav, cephalexin, ceftriaxone, Fosfomycin
- Avoid: nitrofurantoin (3rd trimester), TMP-SMX/TMP (1st trimester, last 6 weeks of pregnancy), FQs
What are some important considerations for breastfeeding and UTIs?
FQs, nitro, TMP-SMX, amoxicillin, cephalosporins
- treat for longer duration: 7-14 days uncomplicated/asymptomatic, 14 days for pyelo
What are some important considerations for children and UTIs?
What are some important considerations for catheter-associated UTIs?
source control, don’t treat if asymptomatic
Mild-mod symptoms: FQ or ceftriax x 7 days
What are some important considerations for DM or candiduria in UTIs?
don’t treat if asymptomatic
- Symptoms: choice of antifungal (usually Fluconazole)
What are your monitoring parameters for the treatment of UTIs?
S&S: Improve within 24 hours, resolved in 72 hours
Urine culture (pregnancy): No bacteria, 2 weeks later, then monthly until birth
Safety Endpoints: prevent ADRs during therapy
