UTIs Flashcards
RF for UTIs
- indwellnig catheter
- ABX use
- spermicides
- sexual intercourse
- female
- pregnancy
- genetic problems
uncomplicated UTIs
- female (not elderly)
- 1st presentation/infrequent
- no signs of pyelonephritis
- not pregnant
complicated UTI
- pregnant
- male
- children
- elderly
- pyelonephritis
- recurrent
- immuncompromised
- poorly controlled DM
- impaired renal fxn
Sx of pyelonephritis
- pain in abdomen/back
- systemically unwell
- +/- fever
presentation of UTI (typical/uncomplicated)
- dysuria
- frequency
- suprapubic tenderness
- urgency
- polyuria
- haematuria
presentation of upper UTI/pyelonephritis
- +/- UTI Sx
- fever
- flank/loin/lower back pain
- can lead to renal failure, sepsis
What to rule out if UTI Sx?
possible STI
esp if doesn’t respond to Tx
diagnosis of UTI
- Hx and Sx
- urine -> appearance, smell, cloudy, blood?
- urine microscopy
- dipstick test -> leukocytes, nitrites, protein
- urine culture
Should urine dipstick be used for diagnosis of UTI? Why?
no
- elderly can have asymptomatic bacteria in urine/bladder
- especially O65yrs
- or with catheter
- not harmful, ABX not beneficial
Tx for uncomplicated UTI
** Nitrofurantoin MR 100mg BD for 3 days (or 50mg QDS)
- 1st line Tx
- c/i in severe renal impairment (eGFR <45)
- activtaed by urinary pH
alternative:
** trimethoprim 200mg BD for 3 days
- can be used in renal impairment, reduce dose
Tx duration for complicated UTI
5-10 days Tx
How to take nitrofurantoin?
take with food
When to be cautious with nitrofurantoin?
RENAL IMPAIRMENT
- eGFR < 45
- eGFR 30-45 only if multi-drug resistant
INC RISK PERIPHERAL NEUROPATHY (low risk for short course)
- caution if already have inc risk with DM, anaemia, folate deficiency, electrolyte imbalances
at risk of peripheral neuropathy
DM
anaemia
folate deficiency
electrolyte imbalances
s/e of nitrofurantoin
GI
pulmonary - cough, chest pain, dyspnoea, hypoxemia (rare, withdraw, Tx with cs)
trimethoprim and renal impairment
- can be used in severe renal impairment
- need to reduce dose
- GFR 15-25 normal dose for 3 days, then 1/2 dose
- GFR <15 half normal dose
Co-trimoxazole drugs?
TRIMETHOPRIM
+
sulfametaxozole
Interactions with trimethoprim?
- MTX - folate antagonist
- azathioprine - inc risk haematological toxicity
- PHY - inc levels
- digoxin - inc levels
- warfarin
s/e of trimethoprim
GI
blood disorders (LT)
** electrolyte impairment with trimethoprim
HYPERKALAEMIA
(eg, with ACEI)
common pathogens that cause pyelonephritis
- E coli
- Klebsiella pneumonia
- Proteus species
- pseudomonas species
- enterococcus species
complications of pyelonephritis
renal failure/ AKI
sepsis
temperature in sepsis
> 38 degC
or
<36 degC
Sx of sepsis
- high/low temp
- tachycardia
- hypotension
- SOB
- impaired consciousness
- rigors (shivering with high temp then sweating)
- sweating
- pallor
- lack of mobility
- dehydration
- don’t tolerate oral foods/meds
at risk of sepsis
pregnant
elderly
immunocompromised
renal impairment
diabetes
no improvement after 24hr of ABX
Tx for pyelonephritis in primary care
co-amoxiclav 625mg TDS 7 days
or
ciprofloxacin 500mg BD 7 days
co-amoxiclav problems
pen allergy
cholestatic jaundice (rare)
ciprofloxacin problems
tendonitis
reduces seizure threshold, + NSAIDs inc risk of seizure
CYP450 inhibitor
IV ABX for pyelonephritis in secondary care
gentamycin
tazocin
meropemem
teicoplanin
ciprofloxacin
relapse vs reinfection
relapse = same strain of organism within 2 weeks of finishing Tx
reinfection = diff strain of organism, >2 weeks after Tx
What can be used for UTI prophylaxis?
trimethoprim 100mg ON
more common in elderly
poor evidence
Why are UTIs less common in men?
longer urethra
antibacterial activity of prostatic secretions
Tx for UTI in a man
7 day course of trimethoprim or nitrofurantoin
Tx if recurrent UTI in man
- quinolones
- can penetrate prostatic fluid
- (often prostate involvement if recurrent UTI in male)
bacturia risk in pregnancy
premature delivery
What does treating asymptomatic bacturia in pregnancy help with?
- reduces risk of pyelonephritis
- reduces risk of low birth weight
- reduces premature birth
group B streptococcus in pregnancy
prophylactic ABX may be started during labour and delivery
can be passed to baby during birth and needs Tx
Tx for cystitis in pregnancy
- paracetamol for pain relief
- urine culture & empirical ABX
- nitrofurantoin
NOT trimethoprim (anti folate)
NOT cranberry products
- fever & loin pain = pyelonephritis -> admit and IV ABX (risk of premature birth)
UTI in elderly
Sx:
- inc confusion
- functional decline
(non-specific Sx)
- asymptomatic bacturia common, don’t treat
- UTI diagnosis required new urinary Sx
- short course of ABX for older female patients
- nitrofurantoin c/i in severe renal impairment
- nitrofurantoin toxicity more common in elderly
UTI with indwelling catheter
- all pts with LT indwelling catheter have bacturia
- repeated Tx of asymptomatic bacturia inc risk of colonisaiton of drug resistant bacteria
- check for correct positioning and ensure not blocked
- if in place for >1 week, change before starting ABX
- urine culture before ABX
- mild Sx, delay Tx and wait for culture/sensitivity
- 7 day course
RF for UTI in DM patients?
- inc risk asymptomatic bacturia
- higher risk of recurrent infections
- higher prevalence of atypical pathogens
- bilateral infections more common
- inc risk resistance
- hospital acquired infections more common
- fungal causes of UTI more common (glucose in urine)
- inc risk complicaitons (renal failrue, sepsis)
presentation of UTI in children
- dysuria
- frequency
- abdominal pain, loin tenderness
- fever, rigors
- lethargy
- vomiting, diarrhoea
- haematuria
- cloudy urine
- febrile convulsions
- recurrence of enuresis
presentation of UTI in infants
- fever
- vomiting
- lethargy
- irritability
- offensive urine
- poor feeding
- jaundice
- febrile convulsions
- septicaemia
complication of UTI in children
pyelonephritis can damage growing kidney and cause scarring
What to do if unexplained fever of >38 in child/infant?
urine sample tested within 24hrs
RF for UTI in children
- incomplete bladder emptying
- poor urine flow
- dysfunctional voiding resulting in enlarged bladder
- obstruction from constipation
- neuropathic bladder
- renal abnormality
- FHx of VUR/renal disease
- Hx UTI
- spinal lesion
- poor growth
- high BP
Tx for UTI in children
ACUTE PYELONEPHRITIS:
- 7-10 days
- IV ABX 2-4 days if oral can’t be used then oral Tx for 10 days total
LOWER UTI:
- 3 days Tx
- re-assess if child unwell after 24-48hrs
ABX:
trimethoprim, nitrofurantoin, cephalosporin, amoxicillin
preventing UTI
- high fluid intake to give high urine output
- regular voiding
- complete bladder emptying
- prevent/Tx of constipation
- good hygiene
- probiotic?
- ABX prophylaxis -> recurrent UTI, congenital abnormality U2yrs , severe reflux (trimethoprim)
indications for culture of urine in children
- diagnosis of acute pyelonephritis/upper UTI
- high/intermediate risk of serious illness
- U3yrs
- single +ve result for leukocyte esterase or nitrate
- recurrent UTI
- infection that doesn’t respond to Tx within 24-48hrs
- Sx and dipstick tests don’t correlate
low risk over 3yrs child and UTI
can be diagnosed based on Sx and dipstick test
