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Renal > UTIs > Flashcards

UTIs Flashcards

Dr. Trotter

1
Q

Epidemiology -Patient population UTIs

A

-younger adults: often in female and childbearing age

-also over age of 65:
->BPH/Obstruction (kidney stones)
->SNF, hospitalization
->neuromuscular disease (stroke)
->Catherization

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2
Q

How does the bacteria usually reach the bladder?

A

-mostly originates from the colon and ascends up the urethra -> to the bladder
-Hematogenous spread is less common

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3
Q

Host defense mechanism

A

-low pH (prevents replication, pH alteration may increase the risk for an infection)
-increased micturition when the bladder is introduced to bacteria (flush out)
-Lactobacillus (in vaginal flora) helps to maintain low pH
-Estrogen (helps with the production of Lactobacillus) -> lack of estrogen in older women causes increased risk for an infection

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4
Q

Classification of UTIs

A

-Asymptomatic Bacteriuria (bacteria in the urine but no symptoms - usually not treated)
-Symptomatic Abacteriuria (symptoms, but not due to bacteria - usually not treated)

-Cystitis (UTI) - Complicated vs Uncomplicated
-Pyelonephritis (infection travels through the Ureter to the kidney - treated more aggressive)

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5
Q

How is complicated Cystitis different from uncomplicated cystitis?

A

Complicated: higher likelihood of severe infection, more difficult to treat, a wider variety of bugs causing them

Uncomplicated: the simplest form of UTI, young and healthy without morbidities

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6
Q

Risk factors for UTIs - Female

A

-Previous UTI
-sexual intercouse
-Diaphagram/spermicides (affects the pH)
-Urologic instrumentation (stents, catheter)
-Pregnancy (anatomical changes)
-diabetes
-estrogen deficiency(reduced lactobacilli in the vaginal flora)
-meds: SGLT2 (glucose in the urine), Anticholinergic, Tricyclic antidepressants -> reduced urination (residual volume, not flushing as much)

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7
Q

Risk factors for UTIs - Male

A

-Previous UTI
-Obstruction (calculi, strictures)
-BPH
-vaginal E.coli colonization in partner

in all patients:
incomplete bladder emptying
neurologic malfunction (stroke)
-fecal incontinence
-vesicoureteral reflux (reflux of urine into the kidneys)

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8
Q

Risk for Pyelonephritis

A

-extremes of age
-anatomic abnormalities
-foreign bodies (catheters)
-immunosuppression
-obstruction
-pregnancy
-inappropriate abx use

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9
Q

Asymptomatic Bacteriuria

A

-more than 10^5 bacteria /ml (10^8/L) without symptoms
-2 specimens when female, one if male
-common in the elderly (ov 65)
-not often treated
-special populations are treated (pregnant or before urological procedure)

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10
Q

Why are asymptomatic Bacteriuria not treated?

A

-no benefit
-doesn’t really clear the bacteria or prevent the progression
-but increases the risk of resistance

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11
Q

Symptomatic Abacteriuria

A

-Symptoms like pyuria (cloudy urine due to WBC) or dysuria (painful urinating) with less than 10^5/ml (10^8/L) of urine

-not so common: (50% of female patients with symptoms)

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12
Q

Uncomplicated cystitis

A

-otherwise healthy
-premenopausal, non-pregannt
-no structural or functional urinary tract abnormalities

-some physicians include postmenopausal women and those who are unlikely to have adverse effects

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13
Q

Complicated cystitis

A

-any other patient
-male (often with structural or neurological abnormalities)
-children
-pregnancy
-HCA
-comorbidities (T2D, CKD, immunocompromised)
-urinary tract abnormalities, catheter

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14
Q

Which type of Cystitis is treated with broad-spectrum antibiotics?

A

Complicated Cystitis
-E.coli (50%)
-Enterococcus faecalis
-Enterobacter
-Proteus spp
-Klebsiella pneumoniae
-Pseudomonas

in uncomplicated cystitis
-Ecoli (90%)
-Staphylus, Klebsiella, Proteus spp

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15
Q

What is the gold standard for UTI diagnosis?

A

-Urine culture
-Urinalysis (if there are indications for an infection -> a urine culture is ordered)

-other ways: Signs/symptoms, physical assessment

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16
Q

Symptoms of Cystitis (UTI)

A

-Dysuria (pain urinating)
-Urgency, frequency
-Nocturia
-Hematuria
-Suprapubic pain
-in the elderly: confusion, delirium

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17
Q

Why is confusion not an indication of Urinalysis?

A

Because delirium in elderly could be due to many other reasons and we don’t want to increase resistance unnecessarily

-rule out other causes before treating with antibiotics

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18
Q

Symptoms of Pyelonephritis

A

-Cystitis symptoms
systemic symptoms
-flank pain
-fever (>100.9 F)
-Nausea/vomiting
-malaise
-costovertebral tenderness (CVAT) on exam

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19
Q

When to collect Urin

A

if symptoms are present -> urine collection

-midstream clean catch (preferred)
-Catherization (need aseptic technique)
-suprapubic aspiration

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20
Q

Urinary test results indicating UTIs

A

-Pyuria: WBC more than 10^6/ml
-nitrite-positive urine (nitrate converted into nitrite by the bacteria
->gram (+) do not produce nitrites - False negative
->Phenazopyridine - False positive

-Leucoctye esterase-positive: indicates presence of WBC

21
Q

When are Urine cultures ordered?

A

-symptoms and urinalysis in complicated UTI
-candidates for treatment of asymptomatic bacteriuria (screening: pregnant, urological procedure)

-Findings: more than 10^5 CFU/L, pathogen, abx sensitivity

22
Q

Non-pharm and Self-care

A

-Fluids
-Cranberry (evidence mixed): acidify (lower) the pH, blocks E.coli adhesion to the bladder wall
-Lactobacillus maintains vaginal flora
-Phenazopyridine (in AZO products): targeting the symptoms -> may mask the real infection, antibiotics usually work within a day (so no point), and it shouldn’t be used w/o antibiotics!

23
Q

Contraindication of Phenazopyridine

A

-renal disease
-severe hepatic disease
-Counsel: orange urine

24
Q

Empiric Treatment for Uncomplicated Cystitis

A

-Nitrofurantoin 100 mg BID x 5 days
-TMP/SMX 160/800 BID x 3 days -> unless the local resistance is greater than 20% or Bactrim was used in the last 3 months
-Fosfomycin 3g, single dose

ß-lactam: Augmentin 500 mg q8h
Cefdinir, Cefaclor, Cefpodoxime-proxetil
-> all 3-7 days

25
Q

When to consider second-line treatment in uncomplicated Cystitis?

A

-poor renal function: avoid Nitrofurantoin (Macrobid) or Bactrim
-cost: Fosfomycin
-pregnancy: avoid bactrim go with ß-lactam

-instead: ß-lactam 3-7 days: Augmentin, cefdinir, cefaclor, cefpodoxime-proxetil
-FQ: AVOID if possible

26
Q

Empiric treatment for Complicated Cystitis

A

-Fosfomycin 3g 48-72h x 2-3 doses (not often used)
-Bactrim 1 tab BID 7-10 days (longer duration than in uncomplicated treatment)
-Levofloxacin 750 mg once daily, x 5 days
-Ciprofloxacin 250-500 mg BID x 7-10 days
-ß-lactams (Augmentin, keflex, cefpodoxime) x 5-7 days

27
Q

Which organism is resistant to Fosfomycin?

A

Klebsiella

28
Q

Considerations for Bactrim

A

-Renally eliminated, (CAUTION: renal impairment, if the kidney is not working the drug will not be filtered into the kidney)
-rising E. coli resistance
-Pro: high urinary concentration

ADE: rash, photosensitivity, renal failure (nephrotoxic)

29
Q

Considerations for Nitrofurantoin (Microbid)

A

-Avoid in CrCl <30 ml/min (CAUTION in renal impairment)
-Macrobid (BID) vs Macrodantin (QID)
-GI intolerance, pulmonary fibrosis, hepatotoxicity with long-term use (Beer’s list)
-lack of resistance

30
Q

Considerations for FQ (Levo, Cipro)

A

-Cipro over Levofloxacin
-Collateral damage (resistance, Cdiff, ADRs)
-ADRs: tendon rupture, QTprolongation
-used in pyelonephritis (but also in complicated cystitis)

31
Q

Considerations for ß-lactams

A

-Augmentin is preferred due to resistance
-watch out for allergies
-safer than FQ (coverage is smaller)

32
Q

Pyelonephritis Treatment

A

-always culture-> tailor the therapy to the results, symptoms are systemic and cause more problems

-start with IV, usually ceftriaxone -> may be changed to PO
-7-14 days

-Nitrofurantoin is not appropriate -> low Vd in the kidney
-Fosfomycin is not appropriate for pyelonephritis bacteremia

33
Q

Outpatient Pyelonephritis Treatment

A

-if mild-moderate and the patient can take PO, is hydrated and otherwise well

-FQ preferred if local resistance is <10%
if >10% initiate IV dose of gentamicin (CAUTION: nephrotoxic) or ceftriaxone
Cipro over Levo

-Bactrim can be used if susceptibility is known (due to resistance)
-beta-lactams are second line due to resistance

34
Q

Inpatient Pyelonephritis Treatment

A

-broad spectrum treatment
-Carbapenem
-FQ
-Aminoglycoside (CAUTION nephrotoxic) +/- Ampicillin (cover enterococcus)

-Pip/tazo (Zosyn): if Pseudomonas, enterococcus, staph is suspected

-change to PO ASAP

35
Q

Which cephalosporins get well into the urine?

A

Cephalexin (keflex), cefuroxime, cefotaxime

36
Q

Catheter-associated UTI

A

-biggest risk factor: duration of catheterization
-difference between CA-asymptomatic bacteriuria and CA-UTI

-Symptoms: flanked/suprapubic pain, costovertebral angle tenderness, catheter obstruction, fever, malaise, hematuria, lethargy, SIRS

37
Q

When to treat Catheter-associated UTI

A

-only when symptomatic, bc they will be colonized anyway
-remove the catheter and take a midstream sample, or through a new catheter or catheter-port

38
Q

Treatment of CA-UTIs

A

-based on past cultures
-narrow the spectrum when culture arrives

-similar to complicated UTIs: Fosfomycin, Bactrim, FQ, ß-lactams

-7-14 days

39
Q

Why are pregnant prone to UTIs?

A

-reduced bladder tone/decreased ureteral peristalsis
-urinary reflux into the kidneys -> risk of pyelonephritis
-risk for asymptomatic bacteriuria

40
Q

Treatment for UTIs in pregnant women

A

-Augmentin
-Cephalexin
-5-7 days (complicated UTI)

41
Q

Consider when treating pregnant women

A

-Avoid Nitrofurantoin (jaundice)
-AVOID FQ
-Avoid Bactrim in the 3rd trimester (weeks 27-40)

42
Q

Recurrent UTIs

A

-often seen in the elderly females
-2 or more infections within 6 months
-3 or more in 1 year

-can be relapse (same organism) or reinfection (after 2-3 weeks, by a different organism)

43
Q

How to treat recurrent UTI

A

-mostly behavioral changes: drinking fluids, avoiding spermicides/diaphragm, avoiding delaying urination, urination after intercourse, wiping front to back

-antibiotics is controversial - reduce recurrence but increase resistance and ADEs
->Nitrofurantoin 50mg daily (low dose) -> avoid long-term
->bactrim 1/2 SS tablet daily (low dose)

44
Q

Other treatments for recurrent UTI

A

-topical estrogen (lactobacillus and pH)
-post-coital antibiotic if infection occurs after coitus
-Methenamine hippurate - not lot of evidence

45
Q

Why should long-term use of Nitrofurantoin be avoided?

A

-causes pulmonary fibrosis and hepatoxicity

46
Q

Hematuria is a symptom in which type of UTI?

A

-Cystitis
-Pyelonephritis
-Catheter-associated UTI

47
Q

Which drug should be avoided in CrCl < 30 ml/min

A

Nitrofurantoin

48
Q

What to consider in patients with signs of Pyelonephritis?

A

-Admission to the hospital? Y/N
-admit if a comorbid condition is present (renal dysfunction, urologic disorder, diabetes, liver or cardiac disease, immunocompromised)
-dehydrated
-hemodynamic instability: hypotension
-male sex
-severe flank and abdominal pain
-sepsis
-high fever >103°F

49
Q

What are the biggest indications for a UTI on a Urinalysis?

A

Nitrite (+)
elevated leukocytes

Renal (21 decks)

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