W2 Infections And Inflammations (Felkins) Flashcards
Cystitis
Most common pathogen
Kidney stone infections a/w which pathogens? (2)
What are complicated cases of cystitis
Be familiar with symptoms, signs and pertinent negatives
E. coli (enteric)-most common (from the anus)
Nephrolithiasis associated infection
—Proteus
—Klebsiella
Complicated — risk for pyelonephritis and sepsis
—male
—pregnant
—hospitalised, catheter
—DM (you’ll see glucose spillage in the UA)
Signs
—chlamydia can present like UTI so always ask about vaginal or penile discharge
Cystitis
What will you see on urine dip? 3
Don’t forget to order a ______ test
Which pain management?
Which antibiotics?
When do you send for culture?
Urine Dip
• + Leukocytosis
• + Nitrites
• +/- blood
If you see a lot of protein — kidney injury — pyelonephritis
Urinalysis with microscopy — not really necessary in o/p clinic
• + white blood cells on microscopy
Order a pregnancy test!
Send for culture for any complicated case (male, etc)
Pain management
• phenazopyridine (Pyridium) “Azo”
Antibiotics
💊 Bactrim DS 1 tab PO BID x 3 days (caution sulfa allx)
💊 Macrobid (nitrofurantoin) 100mg PO BID x 5 d
🚫 Ciprofloxacin avoid as first line in uncomplicated UTI: unless someone has a hx of abx resistance, or a patient who is demanding it
Pyelonephritis
What is it?
MC pathogen?
Risk factors?
S/S
Upper Urinary Tract Infection involving the kidney, can be an infected kidney stone
Pathogen: Escherichia Coli (80%-90%) b/c it comes up from the bladder
Risk factors
—Frequent sexual intercourse and new sexual partner
—Diabetes mellitus, indwelling urinary catheter, urologic abnormalities, recent antibiotic use within the last 3 months
S/S
—fever
—chills
—flank
—N/V
—acute cystitis
signs
—fever
—tachycardia
—CVA tenderness
Pyelonephritis
Labs
Caution with which pain medication ?
Which outpatient abx?
What are come complications?
Urine Dip — same findings as cystitis
• + Leukocytosis
• + Nitrites
• +/- blood
Urinalysis with microscopy
• + WBC casts
Urine Culture
+/- blood culture
CBC
BMP: Creatinine, BUN and GFR
Hcg!
Pain management: small amount of NSAIDs okay but caution b/c excreted through the kidneys
Antibiotics
Consider single dose IM or IV antibiotic: Ceftriaxone 1g
AND
—Ciprofloxacin 500 mg PO BID x 7d, or
—Levofloxacin 750 mg PO QD x 7d, or
—TMP/SMX 160/800 mg PO BID x 14d or
—Beta-lactams 10-14 days
Complications:
• Renal abscess
• Sepsis
• Renal vein thrombosis
• Emphysematous pyelonephritis
• papillary necrosis • acute renal failure
• Referral: ED and Nephrology consultation
Acute bacterial prostatitis
MC pathogen?
Age onset
What are you thinking is another cause except the main one?
Peak onset 20-40 yo
E. coli (58-88%)
Proteus species (3-6%)
Klebsiella, Enterobacter and
Serratia species (3-11%)
Pseudomonas aeruginosa (3-7%)
Sexually active men typically <35yo consider Neisseria gonorrhoeae and Chlamydia
S/S — see image
—pt can either look unwell (septic/toxic) or present like UTI classic, but remember, UTI not common in males… so think prostatitis
—pt may describe feeling heavy, or hurts when sit down
—rectal pain
—obstructive symptoms: dribbling, incomplete voiding, urinary retention
DRE
—warm, boggy, TTP
Acute bacterial prostatitis
Labs
Management
—STD screening
—get all labs if septic appearing
Treat this empirically
Management
Outpatient
<35 or high risk for STDs
—Ceftriaxone (Rocephin) 500mg/1g IM/IV AND Doxycycline 100mg BID x 7 days — for gonorrhea and chlamydia
—Ciprofloxacin/levofloxacin 500mg BID x
10-14 days OR
—Bactrim DS 1 tab BID x 10-14 days
—Tamsulosin if obstructive symptoms
Complications
• Bacteremia
• Epididymitis
• chronic bacterial prostatitis
• prostatic abscess
• Acute urinary obstruction
• infertility
• metastatic infection (spinal or sacroiliac infection)
• Endocarditis- patients with valvular heart disease or a valvular prosthesis
Chronic bacterial prostatitis
Persistent infection >3 months
Risk factors
—recurrent infections
—BPH
—uncircumcised
Consider PSA in this case
Management
• May require a total of 8-12
• Pt education weeks
• Levofloxacin 750mg daily
• Ciprofloxain 500mg BID
• Bactrim DS BID
• Doxycycline (chlamydia)
Gonococcal Urethritis
Pathogen?
Runs with which pathogen?
Complications?
S/S
Pathophysiology
• Neisseria gonorrhea
• Incubation is 2-7 days
less common than Chlamydia but it often coexists with gonorrhea — highly contagious
Age <25y/o
Multiple STDs
Complications
• Disseminated gonococcus — Gonococcal arthritis
• Pelvic inflammatory disease — Fitz-Hugh Curtis Syndrome⭐️ RUQ pain, adhesions around the liver
• Blindness if mucopurulent conjunctivitis
S/S
—frequency, urgency and dysuria
—copious green yellow discharge
—Urethral meatus will be v red and irritated
—Pharyngitis, conjunctivitis, proctitis
—Vaginal bleeding
—PID : chandelier sign
—Often women asymptomatic
—men symptomatic in 90% of cases, discharge
Gonococcal Urethritis
Main lab to diagnose?
—NAAT (nuclei acid amplification test)
—Gram stain: gram neg diplococci
Treatment
— Ceftriaxone 500mg IV/IM for 1 dose
<150kg/330lbs
—Ceftriaxone 1g IV/IM
>150kg/330lbs
AND
Doxycycline 100mg BID PO x 7 days
OR
Azithromycin 1g for 1 dose in pregnant patients
Treat partner
No sex until both partners treated!!
Nongonococcal Urethritis
Chlamydia trachomatis — MCC STD in US
May be asymptomatic esp if female
Check about males ??
Epididymitis
Gonorrhea/chlamydia if <35 y/o and sexually active
E.Coli if >35 no risk factors for sexually transmitted — levofloxacin
Can be non infectious as well and caused from trauma: bike riding, strenuous exercise, prolonged sitting
MUST RULE OUT TESTICULAR TORSION AND TESTICULAR CANCER
• Onset is gradual
• Location: unilateral scrotal pain
• Duration: constant
• Associated: urethral dc, frequency, urgency, dysuria, painful ejaculation
• Radiates: can refer to lower abdomen and opposite testicle • Timing: after new partner, exercise
• TTP to the posterior testicle
⭐️Cremasteric reflex is present
⭐️ Prehn’s sign is positive
• Normal position of testes
• No masses
⭐️ Color doppler scrotal ultrasound
Infectious UTI source
• Levofloxacin 500mg daily x 10 days
• Bactrim DS BID x 10 days
Orchitis
What is it?
A/w which virus
Which reflex is present
Which sign is +
Inflammation of the testicle
mumps, coxsackie virus, Epstein-Barr virus, varicella, or echovirus
Mumps orchitis:
—typically unilateral involvement (70%) and then contralateral involvement in 1 to 9 days
—confers 4% risk of sterility
Bacterial orchitis
—almost always associated with epididymitis
⭐️ Cremasteric reflex is present
⭐️ +/-Prehn’s sign is positive
Infectious- STD
• Gonorrhea/Chlamydia management
Infectious UTI source
• Levofloxacin 500mg daily x 10 days
• Bactrim DS BID x 10 days
Fournier’s gangrene
Necrotizing fasciitis of the scrotum and penis
Emergent
Risk factors
—Diabetes- #1 comorbidity
—cirrhosis, alcoholism
—obesity
S/S
—Pain out of proportion (79%) and then paradoxically w/o sensation
—Unexplained fever (look at pt naked head to toe to find source of infection
—Tachycardia
—Toxic appearing
—Dishwater wound drainage
—Brawny edema
—crepitus when you palpate the wound = nec.fasc.
Full work up!
Imaging
—bedside ultrasound
—surgical emergency! Don’t wait for CT
—debride w/i 12 hours
—IV abx:
1. Zosyn
2. Vanco
3. Clindamycin (has a toxin suppressant in it as well)
