UTIs Flashcards
what is a UTI?
the presence and multiplication of microorganisms in the urinary tract
give examples of clinical syndromes caused by UTIs
cystitis prostatitis Epididymitis/orchitis Urethritis Pyelonephritis
what a re the classifications of UTIs?
Asymptomatic bacteriuria
Uncomplicated
Complicated
what is the difference between bacteriuria and pyuria?
bacteriuria is the presence of bacteria in the urine and pyuria is the presence of leucocytes in the urine
what is sterile pyuria?
presence of white cells in the urine but a pathogen cannot be cultured
what is the most common age group to get asymptomatic bacteriuria?
over 65s
what percentage of people with a catheter will have asymptomatic bacteriuria?
100%
describe the prevalence of asymptomatic bacteriuria
increases with age in both genders
higher in women at all ages
rapid and marked increase with pregnancy
what is the popln that comes under uncomplicated bacteriuria
non pregnant women
what is the popln that comes under complicated bacteriuria
Pregnant Men Catheterised Children Recurrent/persistent infection Immuncompromised Noscomial infection Structural abnormality Urosepsis Associated urinary tract disease
in children who are girls or boys more likely to get UTIs?
girls
if it happens in boys, it is a sign of structural abnormality which needs to be reviewed
what percentage of women experience a UTI in their life?
10-20%
what is the complication of asymptomatic bacteriuria in renal transplant pts?
pyelonephritis
what are some of the causative organisms for UTI?
E. coli - most common causative organism Proteus Klebsiella Enterococci Staph. saprophyticus S. aureus Pseudomonas aeruginosa
which of the bacterial causes is associated with renal stones?
proteus - as it produces ureas which causes an increase in the pH of the urine and this is the pH that stones form at
where does Klebsiella come from?
the gut - it is an Enterobacteriaceae
who does Staph saprophyticus most commonly affect?
young women
what needs to be checked for when we have a pt with Staph aureus bacteriuria?
endocarditis, abscesses, prosthetic joint infections, likes to seed places, can be in the kidneys - so the pt needs to be investigated for a deep infections
What are the G+ cocci that cause UTIs?
Enterococcus
Staph. saprophyticus
Staph aureus
What are the G- bacteria that can cause UTIs?
Neisseria
Enterobacteriaciae ie E.coli and Kelbsiella, Proteus
Bacteroides
what are the culture negative causes of UTI?
mycobacteria Chlamydia Fungi eg Candida albicans Mycoplasma Ureaplasma urealyticum
explain the pathogenesis of UTIs
colonic flora colonises the vagina, then the urethral meatus and then the bacteria ascend further till they cause a UTI
What factors predispose to UTI?
obstruction from prostatic hypertrophy bladder stones or tumour low urinary volume ureteric stones stasis during pregnancy ureteric reflux female short urethra catheterisation low urinary volume eg due to dehydration
what factors make uropathogenic E.coli virulent?
adherence molecules ie fimbriae
toxins that cause extensive tissue damage
What happens post-menopause for the risk of UTI to increase?
after menopause, the pH rises and there is increased colonisation by colonic flora
reduction in vaginal mucus secretion means there is increased vaginal mucosal receptivity to uropathogenic E. coli
How is the normal acidic vaginal pH maintianed?
the normal vagina is heavily colonised with lactobacilli, which metabolise glycogen to lactate which is acidic
What are the symptoms of a UTI?
frequency
dysuria
fever
haematuria
What are the investigations that are done to diagnose a UTI?
collect a urine sample
urinalysis
microscopy
culture and sensitivity
What may be found on urinalysis in a UTI?
blood protein pH change glucose and ketones as diabetics are more prone to UTIs leukocytes nitrates
What are the different types of urine sample?
MSU CSU - catheter specimen of urine early morning urine - for TB SPA - suprapubic aspirate clean catch - clean down below before giving the sample
What may be seen on microscopy with a UTI?
WBCs RBCs casts bacteria epithelial cells
What doe epithelial cells in the sample indicate?
poorly taken specimen ie not MSU
how is asymptomatic bacteriuria treated in over 65s?
do not treat, as not likely to get pyelonephritis and more likely to get problems with bacterial resistance
how are uncomplicated UTIs treated
give 3 days antibiotics give advice: - increase fluid intake - void pre and post intercourse - hygiene
what is a complicated UTI?
Any UTI in the presence of a structurally or functionally abnormal urinary tract, with or without host compromise
how are complicated UTIs treated?
always send sample for culture
give antibiotics for 7 DAYS
How are recurrent/complicated UTIs investigated?
MSU DRE or PV (vaginal exam) post void bladder scan (incomplete bladder emptying) USS of renal tract/pelvis X-ray KUB, NCCT KUB to rule out stones flexible cystoscopy to look at bladder
what are the first line antibiotics used for UTI?
Nitrofurantoin
Trimethoprim
when should nitrofurantoin not be given and why?
final trimester of pregnancy as it causes neonatal haemolysis
Renal function eGFR <45
end of the RANT = final trimester
when should trimethoprim not be given
first trimester of pregnancy
what are the new antibiotics that can be given for UTI?
fosfomycin
pivmecillinam
should you dipstick a catheter sample?
No
what structure do bacteria form on catheters?
biofilms - difficult for antibiotics to penetrate this
what are the complications of a long term catheter?
UTI/Pyelonephritis
Stones
Obstruction
Chronic inflammation
how do we prevent community a community acquired uti?
do not catheterise or if you must use intermittnet catheterisation or suprapubic
keep catheter closed and reove as soon as possible
replace the catheter and do not treat if asymptomatic as can produce resistance
what should women be screened for in pregnancy in terms of UTIs?
asymptomatic bacteriuria
what are the risk factors for UTIs in pregnancy?
increasing age parity sexual activity diabetes previous UTI
how are UTIs in pregnancy investigated?
- culture rather than use a dipstick
- Positive cultures should be confirmed with a second sample before recommending treatment
- Asymptomatic bacteriuria should be treated(unlike elderly) to prevent pyelonephritis
- Test of cure should be sent 1 week after treatment
what is prostatitis?
Inflammation/swelling of the prostate gland
what are the symptoms of chronic bacterial prostatitis?
pain in the urogenital regions eg perineum, suprapubic, testicles, penis, lower back, abdomen, rectum, groin etc
urinary symptoms -
LUTS and urethral burning
sexual dysfunction - ejaculatory dysfunction and loss of libido
psychosocial symptoms - depression, anxiety
how does acute bacterial prostatitis present?
Systemically unwell, fever, rigors, significant voiding LUTS, pelvic pain, comes on v. quickly
how does chronic bacterial prostatitis present?
Symptoms >3 months, recurrent UTI’s
Pelvic pain, voiding LUTS
Uropathogens in urine +/- blood
how does chronic pelvic pain syndrome present?
Chronic pelvic pain +/- LUTS +/- UTI’s
what are the causative organisms for prostatitis?
E. coli
Proteus
Klebsiella
what is the pathogenesis of prostatitis?
Ascending infection from the urinary tract
or Haematogenous spread
how is prostatitis diagnosed?
Urinalysis and MSU Bloods (FBC< U+E, CRP) including cultures STI screen Urodynamic tests TRUSS +/- CT abdo and pelvis
when do you need to admit a pt with acute prostatitis?
Unable to take oral antibiotics. - vomiting
Severely ill.
In acute urinary retention
how is acute prostatitis treated?
- start antibiotics immediately: quinolone ie ciprofloxacin or ofloxacin for 28 DAYS (give triomethoprin if unable to take quinolones)
- treat the pain
how do you treat chronic prostatitis?
Pain relief Paracetamol/ibuprofen Stool softener Antibiotics 4-6 weeks, quinolone \+/- α blocker
what is the symptom of urethritis?
dysuria = Painful/difficult urination
what are the causative organisms of urethritis?
It is sexually transmitted: Gonococcal vs non gonococcal Chlamydia trachomatis Ureaplamsa urealyticum Trichomonas vaginalis Mycoplasma genitalium HSV
How do you manage urethritis?
Requires sexual health referral =GUM antibiotics depending on the cause Ceftriaxone Azithromycin Oflaxacin Doxycycline
How does epidiymo-orchitis present?
Presents with acute onset of pain and swelling
What is the pathophysiology of Epididymo-orchitis?
Sexually transmitted pathogens ascending from the urethra or non-sexually transmitted uropathogens spreading from the urinary tract
this depends on age, if <35 then more likely to be an STI than a UTI and vice versa if over 35 so take a sexual history
what are the sexually transmitted causes of Epididymo-orchitis?
Chlamydia trachomatis
Neisseria gonorrhoeae
Gram negative enteric organisms – anal intercourse
what are the non-
sexually transmitted causes of Epididymo-orchitis
Gram negative enteric organisms (urinary tract surgery/instrumentation)
Mumps
Tuberculosis – can be associated with renal TB
Brucellosis
Candida
what are the non-
infectious causes of Epididymo-orchitis
Amiodarone
Behcets disease
What are the symptoms of Epididymo-orchitis?
Acute onset –usually unilateral scrotal pain +/- swelling
Urethritis symptoms
UTI Symptoms
What are the signs of Epididymo-orchitis?
unilateral swelling and tenderness of epididymis +/- testes, urethral discharge, hydrocoele, erythema +/- oedema of scrotum, pyrexia
what must be ruled out before making a diagnosis of epididymo-orchitis?
TESTICULAR TORSION
what are the features suggestive of testicular torsion?
Short duration of pain
Associated nausea/abdo pain
Previous short duration orchalgia (pain in the tesitis)
How do we investigate epididymo-orchitis?
Urethral smear looking for STI - eg gonorrhoea and NAAT
dipstick
MSU - culture and sensitivity
CRP and ESR to monitor infection and response to treatment
what is the treatment of epididymo-orchitis?
• Analgesia
• Antibiotics - if sexually transmitted Ceftriaxone and Doxycycline for 14 days and refer to GUM
if non-sexually transmitted - Ofloxacin or Ciprofloxacin - quinilone for 14 days
• Sexual abstinence
• Supportive underwear
• Contact tracing
what is the classical triad of symptoms for pyelonephritis?
loin pain
fever
pyuria
what are the modes of infection of pyelonephritis?
• Ascending
Urethra colonised with bacteria and this enters urethra in intercourse
• Haematogenous - S.aureus/Candida
• lymphatic spread
what are the investigations done for pyelonephritis?
• Abdominal examination
- Tender loin
- Renal angle tenderness
- PV: rule out tubal/ovarian/appendix pathology
• Bloods (FBC, U+E, CSR) including cultures
•U/S scan - Rule out obstruction in upper tract
•MSU
how is pyelonephritis treated?
Fluid replacement – increased losses
IV Abx – Broad spectrum eg. Co-amoxiclav/Ciprofloxacin +/- Gentamicin
Drain obstructed kidney
Catheter – to monitor fluid balance, part of sepsis 6 Analgesia
Complete 7-14 days (depending on choice of antibiotic)
what are the complications of pyelonephritis?
renal abscess
Emphysematous pyelonephritis- gas accumulation in the tissues of the kidney which is life-threatening
