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CLIN MED PA 581: GU > UTIs > Flashcards

UTIs Flashcards

Objectives

1
Q

Anatomy of the Urinary Tract (male)

A
  • Upper Tract
    • Kidneys (2)
      • Retroperitoneal
      • At level of ribs 11 & 12
    • Ureters (2)
  • Lower Tract
    • Bladder
    • Urethra (1)
    • Prostate
    • Epididymis
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2
Q

Urine Flow

A
  • Collecting ducts→Renal calyces→Renal pelvis→Ureter→Bladder→Urethra
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3
Q

GU Review

A
  • Urine is normally sterile
  • The urinary system consists of kidneys, the drainage system (including the renal calyces, pelvis and the ureter), and the bladder (storage of urine)
  • In the female, the urethra exits the bladder near the contiguous vaginal area
  • In the male, the urethra exits the bladder, passes through the prostate, and then through the penis)
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4
Q

Urinary tract infection

A
  • symptomatic urothelial inflammation due to microbial invasion
    • usually bacterial
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5
Q

Term “UTI” = nonspecific

A
  • Can refer to infections of the lower or upper urinary tract
  • Therefore UTI could be referring to
    • simple cystitis (bladder infection)
    • pyelonephritis (kidney infection)
  • But in clinical practice “UTI” is usually synonymous with cystitis
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6
Q

Lower tract infections

A
  • Invasion of the urethra →urethritis
  • Invasion of the bladder →cystitis
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7
Q

Upper tract infections

A
  • Invasion of the ureters →ureteritis
  • Invasions of the kidneys → pyelonephritis
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8
Q

Uncomplicated UTI

A
  • Infection in otherwise healthy, nonpregnant females with urinary tracts of normal structure and function
  • MAJORITY of UTIs
  • By age 24, 1 in 3 women are treated for an uncomplicated UTI
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9
Q

Complicated UTI

A
  • Male gender
  • UTI associated with an underlying condition that increases the risk of treatment failure:
    • Pregnancy
    • Diabetes
    • HIV
    • Immunosuppression
    • Functional or anatomic abnormalities of urinary tract
    • Renal insufficiency
    • Renal transplant
    • Obstruction of the urinary tract
    • Presence of instrumentation
    • Infection with a MDR pathogen
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10
Q

Recurrent UTI

A
  • 2 uncomplicated infections within 6 months or 3 within 12 months
  • Clearance of initial infection shown via negative urine culture
  • On average, a patient has a 25% chance of developing a second UTI within 6 months
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11
Q

Asymptomatic bacteriuria

A
  • Presence of bacteria in an appropriately collected urine sample from a patient without any signs or symptoms of a UTI
  • Does not warrant any treatment EXCEPT in Pregnancy and in patients undergoing urologic procedures
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12
Q

UTI epidemiology

A
  • Most commonly encountered bacterial infection in the community setting in the U.S.
    • Over $2 billion in health care costs/year
  • Approximately 40% of all nosocomial infections are UTIs (most are associated with the use of urinary catheters)
  • UTIs are the leading cause of gram-negative sepsis
  • Among infants up to 6 months of age, UTI is more common in boys, who have a higher incidence of abnormalities of the urinary tract than girls
  • Among persons between 1 and 65 years of age, UTI predominantly occurs in female patients
  • Among persons over age 65, bacteriuria affects men and women roughly equally, with the majority of infections being asymptomatic
    • Routine screening and treatment has not been found to decrease morbidity or mortality in this population
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13
Q

UTI incidence

A
  • Females: 1,200 cases per 100,000 persons annually
  • Males: 30 cases per 100,000 persons annually
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14
Q

Natural Defenses of Urinary Tract

A
  • Periurethral and Urethral Region
    • Normal flora in these regions contain
      • lactobacilli
      • coagulase negative staph
      • corynebacterium
      • streptococci that form barriers against colonization
  • Changes in estrogen, low vaginal pH affect colonization by normal flora
  • Urine
    • high osmolality and low pH are protective.
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15
Q

Natural Defenses in bladder

A
  • Epithelium expresses Toll-like receptors (TLRs) that recognize bacteria and initiate immune/inflammatory response (PMNs, etc)
  • Adaptive immune response then takes over (T and B lymphocytes). Induced exfoliation of cells also occurs to allow excretion of infection.
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16
Q

UTI Pathophysiology

A
  • Colonization of the urethra by uropathogens from the fecal flora, followed by ascension via the urethra into the bladder
    • Majority of UTIs
  • Pyelonephritis when pathogens ascend to kidneys via the ureters
  • Also can be caused by seeding of the kidneys from bacteremia (usually seen with endocarditis)
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17
Q

Contributory or Predisposing risk factors for UTI

A
  • Female gender is an independent risk factor for UTI
  • Recent sexual intercourse
  • Use of spermicides or diaphragm for contraception
  • Pregnancy
  • Lack of estrogen, whether menopausal, surgical, or congenital
  • Antecedent antibiotic use
    • antimicrobials used 15 to 28 days before a UTI may alter urogenital normal flora in favor of pathogen-dominated flora
  • Vesicoureteral reflux
  • Urinary catheterization
  • Mechanical instrumentation
  • Obstruction of the urinary tract
  • Incomplete bladder emptying
  • Men who have sex with men
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18
Q

Vesicoureteral reflux

A
  • (retrograde urinary reflux) is associated with an increased risk of acute and chronic pyelonephritis
    • Most cases are detected now in childhood; however, many adults who were born before the institution of more rigorous childhood screening may have vesicoureteral reflux and usually have a history of recurring UTI in childhood
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19
Q

Obstruction of the urinary tract

A
  • such as that resulting from…
    • BPH
    • tumors
    • calculi
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20
Q

Incomplete bladder emptying

A
  • caused by…
    • neurologic pathology, such as stroke
    • spinal cord injuries
    • neurogenic bladder in the setting of diabetes, spina bifida, or cerebral palsy
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21
Q

E.Coli

A
  • E. coli causes 75 to 95% of uncomplicated cystitis and pyelonephritis across all settings, all ages
    • Also responsible for 65% of hospital-acquired UTIs
  • Uropathogens like E. coli and others in the Enterobacteriaceae family (like Klebsiella and Proteus) have increased adhesion, colonization and tissue invasiveness compared to non-uropathogenic bacteria
  • Uropathogenic E. coli (UPEC) possess a specific type of pili that promotes biofilm formation
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22
Q

UTI gram-negative pathogens

A
  • Escherichia coli
  • Klebsiella pneumoniae
  • Proteus and Providencia species
  • Pseudomonas aeruginosa
  • Enterobacter and Serratia species
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23
Q

UTI gram-positive organisms

A

**not as common

  • Staphylococcus saprophyticus
  • Enterococcus faecalis
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24
Q

Rare Pathogens for UTI

A
  • More often seen in UTI due to a bloodstream infection:
    • Salmonella species
    • Staphylococcus aureus
    • Candida species
  • Immunocompromised patients, critically ill, and patients with chronic catheters:
    • Candida species
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25
Q

Urinalysis

A
  • Midstream, clean-catch method preferred to minimize contamination
  • Dipstick may be positive for:
    • Hemoglobin
    • Nitrite
    • Leukocyte esterase
    • Low-grade proteinuria
  • Microscopy may be positive for:
    • WBCs, RBCs, bacteria
    • 10 or more WBCs per HPF strongly suggests UTI
    • WBC casts confirm an upper UTI
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26
Q

Pyuria Dx

A
  • Presence of leukocytes (pus)
  • Presence of a least ≥5 leukocytes/mm3 of midstream urine
  • Abnormal numbers of leukocytes are most associated with infection in either the upper or lower urinary tract, but may also be seen with acute glomerulonephritis, interstitial nephritis or nephrolithiasis, so cannot use pyuria alone to make diagnosis of UTI
27
Q

Leukocyte Esterase Dx

A
  • Leukocyte esterase is an enzyme found in WBCs
  • Leukocyte esterase positivity is a sign of pyuria (excessive WBCs in the urine)
28
Q

Nitrite Dx

A
  • Certain bacteria are able to convert the nitrate in urine to nitrite
  • A positive nitrite test indicates that bacteria are present in significant numbers in urine
29
Q

A urine culture is usually NOT needed in …

A
  • women of child-bearing age with normal urinary anatomy, who have signs and symptoms of a UTI, and a positive urinalysis (can stop there)
30
Q

A urine culture with susceptibility testing is NEEDED in…

A
  • Pregnant women
  • Empirical treatment failure
  • Upper tract infections
  • Complicated UTIs
  • Recurrent UTIs
31
Q

Blood culture reserved for pt w/….

A
  • Suspected sepsis due to UTI
  • Hospitalized patients suspected of UTI due to a bloodstream infection
  • Patients with complicated UTI requiring hospitalization
32
Q

GU Imaging

A
  • Unnecessary for cystitis and pyelonephritis EXCEPT if obstruction is suspected or anatomic abnormality is suspected
  • CT is imaging study of choice for detecting stones, abscesses, or obstruction
  • Renal ultrasound used for patients who cannot have CT
33
Q

Empiric antibiotic therapy od UTIs should be initiated on the basis of…

A
  • the patient’s symptoms and urinalysis results before urine culture results are obtained
  • The initial choice of drug depends on the patient’s history (eg, recent or frequent infections, recent antibiotic therapy) and the prevalence of resistant organisms in the community.
  • Treatment may be modified based on the results of urine culture
34
Q

Follow-up urine culture is not necessary in…

A
  • non-pregnant adults with uncomplicated UTI
  • clinical response to therapy
35
Q

Further workup and possible referral to a urologist for …

A
  • additional testing to identify structural or functional abnormalities is needed in patients with persistent infection that does not resolve after appropriate therapy or who experience recurrent infections
36
Q

Hospitalization depends on the individual patient, like…..

A
  • Pregnant patients with pyelonephritis
  • Immunocompromised
37
Q

Septic shock (medical emergency!) can result from complicated urinary tract infections (UTIs) and is indicated by …

A
  • Presence of a perinephric or renal abscess
  • Patients with instrumentation in place or an obstruction present
38
Q

Antimicrobials for Acute, Uncomplicated Cystitis

A
  • Nitrofurantoin (Macrobid®)
  • TMP/SMX (Bactrim DS, Septra DS®)
  • 3g PO X 1
39
Q

Nitrofurantoin (Macrobid®)

A
  • Dosing: 100mg po BID x 5 days
  • Do not use in pt w/CrCl <60ml/min
40
Q

TMP/SMX (Bactrim DS, Septra DS®)

A
  • Dosing
    • 2 DS tablets as a single dose
    • 1 DS tablet BID x 3 days
  • AVOID in sulfa allergic patients
  • In some areas there is up to a 20% resistance rate
41
Q

Fosfomycin (Monurol®)

A
  • 3g po X 1
42
Q

DO NOT USE For Uncomplicated Cystitis

A
  • Fluoroquinolones
    • Ciprofloxacin (Cipro®) 250 mg BID x 3 days
43
Q

THERAPY FOR UNCOMPLICATED URINARY TRACT INFECTIONS

A
44
Q

Antimicrobials for Acute, Uncomplicated Pyelonephritis – Outpatient Treatment

A
  • Fluoroquinolones
  • TMP/SMX (Bactrim, Septra DS®)
45
Q

Fluoroquinolones

A
  • Ciprofloxacin (Cipro®) 500 mg BID x 7 days
  • Levofloxacin (Levaquin®) 750mg Q day x 5 days
46
Q

TMP/SMX (Bactrim, Septra DS®)

A
  • Dosing: 1 DS tablet BID x 14 days
47
Q

THERAPY FOR UNCOMPLICATED URINARY TRACT INFECTIONS

A
48
Q

Urinary Analgesic

A
  • Phenazopyridine
    • Rx: Pyridium® 100 mg & 200 mg tablets
      • Dosage: 200 mg PO TID with food
    • OTC-95 mg (AZO-Gesic, AZO-Standard, & Uristat); 97.2 mg (UTI Relief)
  • Use: symptomatic relief of pain, burning, urgency, frequency arising from irritation of the lower urinary tract (from instrumentation, irritation, or infection)
    • Useful with initiation of antimicrobial (symptomatic relief until antimicrobial controls infection)
  • Adverse Effects
    • Red-Orange discoloration of urine
49
Q

Patient education/maintenance/prevention of UTIs

A
  • Practice good hygiene – wipe front to back
  • Urinate after sex
  • Avoid alteration of the normal flora
  • Cranberry juice will NOT treat a UTI but there is mild evidence to suggest it may be helpful in prevention
  • Antibiotic prophylaxis may be indicated for recurrent UTIs
50
Q

UTIs in children are often a …

A
  • a sign of underlying structural or functional abnormalities that predispose them to recurrent infections.
  • Some studies have shown that recurrent UTIs in children are associated with long-term renal dysfunction.
  • Recommend close follow-up in young children
51
Q

Pregnant women with asymptomatic bacteriuria are known to be at significant risk of developing….

A
  • pyelonephritis later in pregnancy.
  • Some studies have noted an association between asymptomatic bacteriuria during pregnancy and premature birth, low birth weight, and pre-eclampsia.
  • Thus, bacteriuria in pregnancy, whether symptomatic or not, is treated and followed-up more aggressively than in other settings
  • i.e. Always treat asymptomatic bacteruria in pregnancy !
52
Q

Treatment options in pregnancy

A
  • B-Lactams
    • Amoxicillin or Amoxicillin/Clavulanate (Augmentin®)-if ­ resistance to Amoxicillin
    • Cephalosporins- Cephalexin (Keflex)
  • Trimethoprim/Sulfamethoxazole or Nitrofurantoin
    • AVOID both in 1st trimester
    • AVOID both in 3rd trimester
    • AVOID Tetracyclines & Fluoroquinolones DURING ANY STAGE OF PREGNANCY
  • Follow up urine culture:1-2 weeks after completion of therapy
53
Q

UTIs in Chronically Catheterized Patients

A
  • UTIs are very common in these patients; so is colonization
  • Bacteria may be introduced into the bladder with insertion of urinary catheter or bacteria may ascend to the bladder
  • Asymptomatic
    • remove catheter & hold antimicrobials
  • Symptomatic
    • remove catheter & antimicrobials
  • If discontinuation of catheter is not possible, change catheter (esp. if > 2 weeks)
54
Q

UTIs in Elderly

A
  • MAY NOT HAVE ANY SYMPTOMS
    • Must compare to baseline, look for minor changes
  • Altered mental status may be only symptom
  • Treat as indicated, but 30% are recurrent/chronic
    • Less able to excrete acid and urea – change in osmolality
    • Males with prostatic issues
  • Pyelonephritis carries HIGH risk, immediate dx and tx
55
Q

Urethritis

A
  • sexually transmitted infection-induced inflammation of the urethra
  • Divided into:
    • Gonococcal urethritis (GU)
    • Non-gonococcal urethritis (NGU)
56
Q

Urethritis Etiology

A
  • Transmitted sexually
  • Gonoccocal urethritis – Neisseria gonorrhoeae
  • Non-gonococcal urethritis –
    • Most commonly Chlamydia trachomatis
    • But can include Ureaplasma urealyticum, Mycoplasma genitalium, or Trichomonas vaginalis
57
Q

Urethritis Epidemiology

A
  • Affects about 4 million Americans per year
  • About a 65% transmission rate to partners
    • Can lead to infertility in women
58
Q

Urethritis sexual hx

A
  • No condom use
  • Earlier age of first intercourse
  • Multiple sexual partners
  • Homosexual men
  • Prior STDs
59
Q

Urethritis Symptoms

A
  • May be asymptomatic
  • Urethral discharge
  • Dysuria
  • Frequent or urgent urination
  • Orchalgia (heaviness of the genitals)
  • Inguinal lymphadenopathy
60
Q

Urethritis is indicated by the presence of 1 or more ….

A
  • Mucopurulent or purulent urethral discharge
  • Urethral smear with at least 5 leukocytes per microscopy field
  • Urine specimen with leukocyte esterase on dipstick test or at least 10 WBCs per microscopy field
61
Q

To determine organism causing urethritis

A
  • Gram stain
    • What does N. gonorrhoeae look like ??
  • Nucleic acid amplification test (NAAT)
  • Urethral culture – not usually done
62
Q

Patients with proven gonococcal urethritis should be empirically treated for..

A

Chlamydia trachomatis

63
Q

Patients with proven gonococcal urethritis should be empirically treated with…

A
  • Azithromycin 1g x 1 dose + Ceftriaxone 250mg IM x 1 dose
    • Treats both gonococcal and non-gonococcal urethritis

OR:

  • Ceftriaxone 250mg IM x 1 dose + Doxycycline 100mg PO BID x 7 d
64
Q

N. gonorrhoeae

A

gram-negative diplococci

CLIN MED PA 581: GU (7 decks)

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