W9 UTI Flashcards
Causes of Cystitis (for info)
Wiping front to back after bowel motion
Previous infection not clearing
Uncontrolled diabetes
Sexual intercourse
Irritation from chemicals / toiletries
Post-menopausal changes to vaginal lining
Side effect of some medication
Cystitis vs UTI
Can they be used interchangeably?
- Terms ‘cystitis’ and ‘UTI’ often used interchangeably
- ‘Cystitis’ is used to describe a collection of urinary symptoms including dysuria (pain on urinating), frequency and urgency
Same symptoms BUT
Main difference: Cystitis can stem from non-infectious causes. A urinary tract infection, by definition, must involve an infection
What are the Normal Symptoms of UTI? (6)
- Signs of impending attack: itching or pricking sensation in urethra
- More frequent desire to pass urine
- Urgent need to pass urine throughout day and night
- Can only pass few burning, painful drops of urine (dysuria)
- Bladder may not feel completely empty after urinating
- Cloudy and strong-smelling urine: sign of bacterial infection
What are the Symptoms Needing Referral for UTI? (4)
- Haematuria (blood in urine)- may just be severe UTI, but could be kidney stone (blood with pain) or
potentially bladder/kidney cancer (blood but no pain) - Symptoms suggestive of upper UTI- pain in lower back, loin pain and tenderness, systemic symptoms such as fever, nausea and vomiting
- Abnormal vaginal discharge- local fungal or bacterial infection
- Cystitis symptoms & alteration in vaginal discharge & lower abdo pain= ? chlamydia
Cystitis- Who to Refer to GP? (11)
- Children
- Males
- Pregnant females
- Post-menopausal women- could be vaginal atrophy
- Catheterised patients
- Upper UTI symptoms
- Symptoms of systemic infection- fever/nausea/vomiting
- Haematuria or abnormal vaginal discharge
- Symptoms lasting longer than 2 days
- Recurrent cystitis- could be diabetes
- Failed treatment
Cystitis:
Management- Self and OTC
- Majority of cases are self-limiting and will resolve in 3 days
- Only antibiotics will treat, rest offers symptomatic relief and prevention of recurrence
Self-management:
* Avoiding vaginal irritants
* Drink plenty of water
* Empty bladder fully
* Wipe front to back after bowel motion
* Urinate after sexual intercourse
* ? Role of cranberry juice in preventing recurrence
OTC OPTIONS
* Simple analgesia
* Alkalysing agents
* Potassium citrate and sodium citrate
* Antibiotics
* Only if scheme running in local area
* Specific inclusion criteria
* Trimethoprim or Nitrofurantoin
Cystitis- POM Management in Primary Care
What is 1st line?
Duration?
- 1st line: Nitrofurantoin OR Trimethoprim
Duration - Women: 3 days
- Men: 7 days
Nitrofurantoin
- Type of antibiotic (classed as ‘other’ in BNF)
- Dose: 100mg BD of the modified-release preparation
-Immediate release available, at a different dose (mainly used for prophylaxis) - Avoid in renal impairment (if eGFR under 45mL/min/1.73m2)
- Antibacterial effect depends on renal secretion of drug into urinary tract
- Also INC risk of peripheral neuropathy
- Can use in eGFR 30-44 mL/min/1.73m2 if benefit outweighs risk
- Common side effects:
o Colours urine yellow / brown
o GI side effects
Trimethoprim:
Dose?
Common SE?
- Type of antibiotic (classed as ‘other’ in BNF)
- Dose: 200mg BD
- Note: high resistance rates to this drug, so might not work
- As much as 50% of E.coli UTIs in Hywel Dda HB are resistant
- Common side effects:
o Diarrhoea and vomiting
o Electrolyte imbalance (K+)
o Headache
o Skin reactions
- Common side effects:
- AVOID in patients with low folate or on a folate antagonist (e.g. methotrexate, some
antiepileptics and proguanil) (AND PREGNANCY!) - Works by blocking production of active form of folic acid in bacteria can’t synthesise DNA cell
death - It can reduce the levels of folic acid in humans (can affect same enzyme)
Complicated Lower UTIs
What is classed as “complicated”?
- Patient over 65 years
- More likely to be resistant to UTIs
- Any other risk factors for resistance:
- Care home resident
- Recurrent UTI
- Recent hospitalisation
- Unresolving urinary symptoms
- Recent travel to areas of high antimicrobial resistance
- Previous resistant UTI
- Complicated UTI in women
- Renal impairment
- Abnormal urinary tract
- Poorly controlled diabetes
- Immunosuppression
- Technically all UTIs in men are complicated
POM management of complicated UTIs:
What is first-line?
What is second-line?
- Treatment is as per local guidelines and sensitivities of recent mid-stream
urine (MSU) sample results - If no MSU available, treat empirically
- 1st Line: Nitrofurantoin OR Trimethoprim
- Same dose as uncomplicated, but 7 day duration for men and women
- 2nd Line: Pivmecillinam OR Fosfomycin
Pivmecillinam
- Pivmecillinam is a type of penicillin antibiotic
- Not suitable in penicillin-allergic patients
- Dose: 400mg TDS
- NB tablets only available as 200mg
- Duration: 7 days
- Patient must be over 40kg
- Risk of oesophageal ulceration
- Must take with half a glass of water and after a meal while sitting or standing (not
lying flat)to risk - Common side effects:
o Nausea / vomiting / diarrhoea
o Hypersensitivity reactions, including skin rashes
Fosfomycin
Dose?
Directions?
SE?
- Type of antibiotic (classed as ‘other’ in BNF)
- Dose: 3g (one sachet) STAT, then repeat dose 3 days later
- Risk of missing the dose
- Dissolve sachet in water and take immediately on an empty stomach
(2-3 hours before or after meal) - Preferably take before bedtime and after emptying bladder
- Common side effects:
o Abdominal pain
o Nausea / vomiting / diarrhoea
o Headaches
UTI treatment in Elderly:
What should be considered?
- Always treat elderly patients (over 65 years) as ‘complicated’
- Elderly patients get very unwell from UTIs
- Increased risk of falls
- Increase in confusion (incl. hallucinations)
- May be misdiagnosed as something else (always ask for MSU in confused/fallen patients)
- Once treated, confusion and fall risk will usually resolve/return to baseline
How are UTIs treated in Pregnancy?
- Tend to always treat with antibiotics
- Risk to baby- infection can cause early labour and low birth weight
- Classed as a ‘complicated’ infection, so treat for 7 days (instead of 3)
- Need to check that drug is safe in pregnancy
- Must know the gestation (i.e. how far along is pregnancy)
- Choice of abx depends on gestation
- E.g. nitrofurantoin ok in 1st and 2nd trimester, but caution in 3rd trimester(avoid near term) due to risk of neonatal haemolysis
- Check local guidelines for specifics
UTI treatment in Children:
Is age an issue?
What is first-line?
What is second-line?
Duration?
- Children under 3 months: Refer to secondary care
- Children over 3 months: Treat
- 1st Line: Cefalexin OR Nitrofurantoin
- 2nd Line: Trimethoprim OR Amoxicillin
- Duration: 3 days
- Use second line if resistance or if you need a liquid (cheaper)
What is an Indwelling Catheter?
- Catheter = flexible tube inserted through the bladder to remove urine
- Can be temporary or long-term (indwelling)
- Often, you will get stagnant urine in bag / tubing, which will grow bacteria
- Doesn’t mean that patient has a UTI
- ONLY treat if symptomatic
- Treat as a “complicated” infection
Pyelonephritis
- Also referred to as “upper UTI” or “kidney infection”
- Happens when the bacteria that cause cystitis travels from the bladder up
to one or both kidneys - Classic symptoms:
- Fever
- Shivers
- Nausea
- Pain in lower back / side
- Associated with lower UTI symptoms
What is Pyelonephritis?
- Potentially serious infection
- Can damage kidneys
- Infection can also spread to bloodstream (sepsis)
- Must treat with antibiotics
- Might need analgesia too- often painful and uncomfortable
- Can take up to two weeks to feel completely better afterwards
Pyelonephritis Management:
1st line?
2nd line?
- Try to prescribe as per MSU results
- If not available, prescribe empirically
MINOR PRESENTATIONS - 1st Line: Cefalexin
- 1g PO TDS 7 – 10 days
- 2nd Line: Co-trimoxazole OR Ciprofloxacin
- Co-trimoxazole: 960mg PO BD for 7 – 10 days
- Ciprofloxacin: 500mg PO BD for 7 day
Cefalexin:
Drug class?
Dose?
Common SE?
- Type of cephalosporin antibiotic (1ST generation)
- Dose: 500mg TDS
- Note: Some cross-sensitivity in patients with penicillin allergy
- Incidence of up to 10% of penicillin-allergic patients
- Do not give if history of immediate sensitivity; otherwise use with caution
- Common side effects:
o Diarrhoea and vomiting
o Headache
o Abdo pain
o Skin reactions - Safe in pregnancy and breast feeding
Co-trimoxazole:
Class of drugs?
What 2 drugs does it contain?
Dose?
What are the common SE?
- Type of antibiotic (classed as ‘Other’ in BNF)
- Combination of trimethoprim and sulfamethoxazole
- Sometimes referred to as old brand name of ‘Septrin’
- Used due to synergistic effects of both antibiotics
- Dose: 960mg BD PO
- Note: Tight restrictions around its prescribing from the Committee on Safety of Medicines
- Want to encourage use of single agents
- Lower risk of side effects if just using one agent
- Can only use for some indications- complex UTI being one (usually if sensitivities to it only)
- Common side effects:
o See those of constituent drugs
o Mainly gastro side effects
- Common side effects:
- Rare but serious side effects:
o Blood disorders (leucopenia, thrombocytopenia, megoblastic anaemia etc.)
o Skin disorders (Stevens-Johnson syndrome, toxic epidermal necrolysis) - Similar contraindications to constituent drugs (e.g. NO in pregnancy)
Ciprofloxacin
- Type of quinolone antibiotic
- Dose: 500mg BD
- Important safety information:
- Tendon damage
o Can cause irreversible tendon damage and rupture
o Usually occurs within 48h of starting treatment; can happen several months after stopping
o Risk increased in increasing age (over 60s), if using steroids concomitantly, or had tendon issues before
o STOP treatment if: tendinitis or tendon rupture, muscle pain, muscle weakness, joint pain, joint swelling, peripheral neuropathy, and CNS effects, - Convulsions
o Can induce convulsions in patient with/without history of convulsions
o Taking NSAIDs at same time can increase the risk
o Caution in epilepsy - Risk of aortic aneurysm and dissection
o Rare, but avoid in patients with history of these
o Seek immediate medical attention if sudden onset severe abdo, chest or back pain develops - Risk of heart valve regurgitation
o Small increased risk
o Use different agent if patient has heart valve or other at-risk disorders (see BNF) - Common side effects:
o Diarrhoea and vomiting
o QT prolongation
o Headache
o Skin reaction
Gentamicin
- Type of aminoglycoside antibiotic
- Dose: Calculated on a patient-by-patient basis
- Most health boards will have a ‘gentamicin calculator’ to calculate dose based on renal function and BMI. This will ‘band’ the dose
- Usual initial dose: 3-5mg/kg IV OD for max 5-7 days
- Note: Drug has a narrow therapeutic index
- Requires therapeutic drug monitoring to ensure serum levels not toxic
- Check trough level immediately prior to second dose (wait for level before giving dose)
- Safe = level under 1mg/L (OK to continue to give at same dose)
- If level is high: extend dosing interval by another 12-24 hours then check level again
- Common side effects (these are dose-related)
o Renal impairment
o Deafness (can be irreversible)
o Headache
o Skin reactions - AVOID in patients with poor renal function (CrCL <30mL/min)
- Drug is renally excreted
- If can’t remove drug from body, will accumulate = increased risk of ototoxicity and nephrotoxicity
Piperacillin with tazobactam (Tazocin®)
Drug classes?
Dose?
Common SE?
- Type of penicillin antibiotic
- Do not give to patients with penicillin allergy!!
- Piperacillin is the antibiotic whilst tazobactam* prevent bacterial enzymes from breaking down the beta
lactam ring (thus overcoming some resistance) - Type of broad-spectrum antibiotic
- Dose: 4.5g IV TDS
- Reduce in renal impairment
- Common side effects:
o Diarrhoea and vomiting
o Hypersensitivity reactions
o Thrombocytopenia (low platelets)
o Skin reactions - Only use to treat as per local guidelines
- As it’s broad-spectrum, some prescribers will use for any sort of infection
- Poor practice, as increases risk of resistance and rates of C.diff
*Beta-lactamase inhibitor
Meropenem
Type of carbapenem antibiotic
* Some similarities in structure to penicillins (beta-lactam ring), so risk of cross-sensitivity
* AVOID in severe penicillin allergy
* Caution in mild-moderate allergy - ?alternative, or closely monitor for reaction
* Dose: 0.5-1g IV TDS
* Reduce dose in renal impairment
* Common side effects:
o Diarrhoea and nausea and vomiting
o Abdo pain
o Headache
o Skin reactions
* Use is tightly restricted
* Only use for specific indications, usually under consultant micro advice
What is Urosepsis?
- Occurs when bacteria from a UTI move into the bloodstream
- Very serious condition
- As person’s body tries to fight the infection, it can cause heart rate,
fever, chills and confusion, which can lead to organ failure and death - Signs and symptoms
o heart rate and respiratory rate
o Fever and chills
o Little to no urine output (oliguria or anuria)
o Anxiety, impending sense of doom/death
o Dizziness, inability to focus, loss of consciousness
o Organ failure and septic shock (low BP, cyanosis, pale extremities)
o UTI symptoms (recognise these early to prevent progression to sepsis)
Urosepsis- Cause
- E. coli (usually) infects bladder causing UTI
- Multiplies and travels up to kidneys
- Causes pyelonephritis and continues to multiple
- As kidneys are always in direct contact with blood when they filter it, the bacteria
has easy access to the bloodstream - Bacteria then spreads to rest of body via bloodstream
What are the risk factors for developing UTI?
o Female (shorter urethra)
o Faecal incontinence
o Urinary retention / difficulty emptying bladder fully
o Recent urinary tract surgery
o Urinary tract obstruction (stones, BPH or tract scarring)
o Improper catheter insertion
Urosepsis Management
- For diagnosis, should send away blood and urine samples for culturing
- Whilst waiting for the culture results, treat empirically:
- If CrCL over 30mL/min
- Gentamicin OD IV for max of 5 days
- If CrCL under 30mL/min
- Piperacillin-tazobactam (Tazocin®) 4.5g IV TDS
- OR Meropenem IV (for non-severe penicillin allergy)
- OR drug as per micro advice in severe penicillin allergy
What are the barriers to managing UTI’s? (4)
- Resistance
o High rates of UTI resistance due to mismanagement in past
o Push to have urine MSU* to ensure appropriate, targeted treatment - Prophylaxis
o Not a common practice anymore
o Increases risks of resistance
o Is common in children, try to avoid in elderly - Commissioning of services
o UTI service not available in all community pharmacies
o No equity in service provision across Wales - Misdiagnosis (e.g. confusion and falls)
o Treating UTI may resolve these issues
o Quick and easy to rule out UTI
*midstream specimen of urine
-test for infection
What can untreated UTIs lead to? (2)
Pyelonephritis and Urosepsis
What 2 drug classes are the safest in pregnancy treatment of UTI?
Penicillins & Cephalosporins
What are the issues around pregnancy?
Really important to check what stage of pregancy:
Trimethoprim- Avoid in 1st trim, ok in 2nd and 3rd
Nitrofurantoin- Ok in 1st, 2nd trim, avoid in term - Inc risk of haemolysis
