Womens health Flashcards
What bacteria causes a UTI?
E.coli (most common)
others= Klebsiella species, Proteus species, Pseudomonas aeruginosa, and Enterococcus species
Typical symptoms of a UTI
Dysuria- pain, tingling, burning
Increase in frequency and urgency,
Nocturia,
Changes in urine appearance- cloudy, blood present
Suprapubic discomfort
elderly
delirium, lethargy, reduced ability to carry out activities of daily living and anorexia.
How could an elderly patient present with a UTI
delirium, lethargy, reduced ability to carry out activities of daily living and anorexia.
Symptoms of an Upper UTI/ pylenophritis (in addition to lower)
Loin pain
Fever
Symptoms of an Upper UTI/ pylenophritis (in addition to lower)
Loin pain
Fever
Red flag symptoms of a UTI
haematuria, loin pain, rigors (drastic changes in temperature), nausea, vomiting, and altered mental state — consider the possibility of serious illness such as sepsis.
Sepsis NEWS score parameters
Resp rate - 12 - 20
Temperature- 36.1 and 38.0
Heart rate- 51 to 90
Blood pressure (systolic)- 111- 219
Consciousness- alert or not
Oxygen sats- >96
NEWS thresholds
0-4 = low
RED score of 3= medium
5-6= medium
7 or more= high
When can a dipstick be used to aid diagnosis? and what time of day would be most reliable
pt under 65
no symptoms indicating complicated UTI
morning
Which patient groups would a urine dipstick be unreliable?
> 65
catheterised
pregnancy
What would indicate a positive urine dipstick?
positive for nitrite or leukocyte and red blood cells (RBC) UTI is likely.
What patient groups would require sample to be sent for a urine culture?
over 65
pregnancy
persistent symptoms or not resolving
recurrent UTIs- more than 2 in 6 months or 3 in 1 year
Catheterised
risk factors for Complicated uti
what are the risk factors for a complicated UTI?
Abnormalities of genitourinary tract,
renal impairment,
residence in a long term care facility,
hospitalisation for more than 7 days in the last 6 months,
recent travel to a country with increased resistance or previous resistant UTI.
First line UTI treatment for : Females non-complicated
Nitrofurantoin: 100mg MR BD x3 days
Trimethoprim: 200mg BD x3 days
Second line UTI treatment for : Females non-complicated
- Nitrofurantoin 100mg modified-release twice a day for 3 days (if eGFR ≥45ml/minute and not used as first-choice)- if nitro hasn’t been used as first line
or - Pivmecillinam (a penicillin) 400mg initial dose, then 200mg three times a day for a total of 3 days or
- Fosfomycin 3g single dose sachet.
How to treat recurrent UTIs (no haematuria, not pregnant or catheterised)
post menopausal= vaginal oestrogen
if ineffective
prophylaxis abx:
First choice - Trimethoprim 200mg single dose when exposed to a trigger
or
Nitrofurantoin (if eGFR ≥45ml/ minute) 100mg single dose when exposed to a trigger.
Second choice – Amoxicillin 500mg single dose when exposed to a trigger (off label indication)
or
Cefalexin 500mg single dose when exposed to a trigger.
Red flag symptoms UTI in pregnancy
recurrent lower UTI.
catheter associated UTI.
If culture reveals an atypical bacteria.
underlying structural or functional abnormality or co-morbidity which increases the risk of complications or treatment failure.
suspected underlying malignancy or renal disease.
First line UTI treatment for : Females pregnant
Nitrofurantoin (avoid at term) 100mg modified-release twice a day for 7 days if eGFR ≥45ml/minute.
Second line UTI treatment for : Females pregnant
no improvement in lower UTI symptoms on first-choice taken for at least 48 hours or when first-choice not suitable) consider prescribing:
- Amoxicillin (only if culture results available and susceptible- high resistance rates) 500mg three times a day for 7 days.
- Cefalexin 500mg twice a day for 7 days.
When should trimethoprim be avoided?
pregnancy
People with severe hepatic insufficiency, or severe renal insufficiency.
People with megaloblastic anaemia or other blood dyscrasias.
Premature infants or children aged under 4 months.
interacting medication- e.g. methotrexate
Trimethoprim adverse effects
Blood disorders — leucopenia, megaloblastic anaemia, thrombocytopenia, agranulocyctosis, methaemoglobinaemia.
Gastrointestinal — diarrhoea, nausea, vomiting, glossitis.
Nervous system — aseptic meningitis (frequency unknown), headache.
Skin — Pruritus, and skin rashes
Nitrofurantoin contra-indications
Acute porphyria
G6PD deficiency
<3 months
EGFR <45
trimethoprim interactions
Aciclovir — increased risk of nephrotoxicity.
Amitryptiline, carbamazepine, SSRIs, mefanamic acid, NSAIDS— increased risk of hyponatraemia.
ACE inhibitors and angiotensin-II receptor antagonists AIIRAs, diuretics— there may be an increased risk of hyperkalaemia with the concurrent use of these drugs and trimethoprim. Monitor potassium concentrations.
Azathioprine and mercaptopurine — increased risk of haematological toxicity in people who have had a renal transplant. However, the combination is commonly used in practice. Monitor the full blood count routinely.
Ciclosporin — serum creatinine levels may be increased. Possible increased risk of nephrotoxicity. Increased risk of hyperkalaemia. Monitor renal function closely.
Coumarins (warfarin) — the anticoagulant effect of coumarins may be potentiated. Monitor international normalised ratio (INR) and adjust dose accordingly.
Digoxin — digoxin levels may be increased in the elderly if taken with trimethoprim. Monitor for digoxin adverse effects, and adjust dose accordingly.
Methotrexate (a folate antagonist) — there is an increased risk of haematologic adverse effects. Full blood count should be monitored routinely.
Phenytoin – phenytoin levels may be increased if taken with trimethoprim. Monitor phenytoin levels and adjust dose accordingly.
when should Nitrofurantoin be avoided?
<45mL/min
Nitrofurantoin- pt and carer advice
Urine discolouration
seek medical attention if:
- Pulmonary toxicity (SOB),
- Hepatic toxicity (pale stools, upper quadrant abdo pain, dark urine, jaundice)
- Blood disorders
What electrolytes disturbances can trimethoprim cause
hyperkalaemia
hyponatraemia
Pivmecillinam side effects
anaphylaxis
thrombocytopenia
adrenaline doses (all ages)
Adults and children over 12= 500mcg (0.5mL)
Children 6yo-11yo= 300mcg (0.3mL)
Children 6m- 6yo= 150mcg (0.15mL)
Children under 6m= 100- 150mcg (0.1-0.15mL)
A 25 mm needle is best and is suitable for all ages.
In pre-term or very small infants, a 16 mm needle is suitable for IM injection.
In some adults, a longer length (38 mm) may be needed.
Give the IM injection with the needle at a 90° angle to the skin, which should be stretched not bunched.
Pivmecillinam and amoxicillin interactions
methotrexate
phenindione (vit K)
warfarin
What drug class is fosfomycin?
phosphonic acid antibacterial
What bacteria is fosfomycin active against?
Staphylococcus aureus and Enterobacteriaceae.
fosfomycin cautions
Cardiac insufficiency; elderly (high doses); hyperaldosteronism; hypernatraemia; hypertension; pulmonary oedema
fosfomycin DoA
empty stomach (2-3 hours before or after a meal), to be taken at bedtime
Bacterial vaginosis- symptoms
odourous, thin, grey/white discharge.
NO itching or soreness
Bacterial vaginosis- treatment (pregnant and non pregnant)
metronidazole 400 mg twice a day for 5 to 7 days
metronidazole gel 0.75% once a day for 5 days
or
intravaginal clindamycin cream 2% once a day for 7 days.
Bacterial Vaginosis- recurrent
treat episode- 400mg BD x7 days and refer to GUM clinic
Metronidazole- cautions
severe hepatic impairment
Metronidazole- interactions
alcohol - flushing, increased respiratory rate, increased pulse rate, nausea, headache, and dizziness
Hepatotoxic drugs
warfarin- increases anticoagulant effect
lithium (if pt has renal impairment)
Trichomoniasis symptoms- women
vaginal discharge- frothy and yellow-green, vulval itching, dysuria, or offensive odour
Trichomoniasis symptoms- men
urethral discharge and/or dysuria
Trichomoniasis treatment- not pregnant (male or female)
Prescribe oral metronidazole 400–500 mg twice a day for 5–7 days,
or metronidazole 2 g as a single oral dose,
or tinidazole 2 g as a single oral dose.
Trichomoniasis treatment- pregnant
Prescribe oral metronidazole 400–500 mg twice a day for 5–7 days
Licensing for metronidazole gel
over 18’s
How is gonorrhoea diagnosed
detection of Neisseria gonorrhoea at an infected site, either by nucleic acid amplification tests (NAATs) or by culture.
Drug treatment: Gonorrhoea- uncomplicated anogenital or pharyngeal infection
antimicrobial susceptibility is known - ciprofloxacin 500 mg orally as a single dose.
When antimicrobial susceptibility is not known prior to treatment, prescribe ceftriaxone 1 g intramuscular (IM) injection as a single dose
Drug treatment: Gonorrhoea- uncomplicated anogenital or pharyngeal infection.
Patient with an allergy, needle phobia, or other contraindications
gentamicin 240 mg IM as a single dose plus azithromycin 2 g orally
OR
cefixime 400 mg orally as a single dose plus azithromycin 2 g orally
Drug treatment: Gonorrhoea- uncomplicated anogenital or pharyngeal infection.
Pregnant or breast feeding
prescribe ceftriaxone 1 g IM injection as a single dose.
Or
Azithromycin 2 g as a single oral dose
When should a patient with Gonorrhoea be followed up after treatment?
1 week after treatment
Cetriaxone- cautions
Hypercalciuria, kidney stones
Cetriaxone - interaction
Any calcium containing medicines,
Warfarin
phenindione
Ciprofloxacin- contraindication
Tendon damage- risk increased >60, concomitant use of corticosteroids, Tendonitis= stop immediately
Epilepsy
C.diff- caution laxatives
Ciprofloxacin- cautions
QT prolongation, diabetes (affects blood glucose), exposure to sunlight, G6PD deficiency, Hx epilepsy
Ciprofloxacin- interactions
NSAIDS
DAIRY, IRON and ZINC (warning label)
antacids
Benzydamine
Calcium containing medicines (calcium chloride, gluconate etc)
clozapine
Methotrexate
2 gen antipsychotics
1st and 2nd line treatment for chlamydia
1) doxycycline (200mg (1-2 divided doses) then 100mg maintenance)
2) azithromycin (1g OD, or 500mg x2 days)
Doxycycline- patient and carer advice
protect skin from sunlight
no indigestion remedies or meds containing iron or zinc 2 hours before or after
can stain teeth
Doxycycline- side effetcs
Angioedema; diarrhoea; headache; Henoch-Schönlein purpura; hypersensitivity; nausea; pericarditis; photosensitivity reaction; skin reactions; systemic lupus erythematosus exacerbated; vomiting
Doxycycline- interactions
Calcium containing meds
Iron and Zinc (warning label)
isotretinoin
lithium
sodium valproate
statins
Doxycycline- age restriction
only to be used 12 years and above
- stains teeth
Azithromycin- side effetcs
QT prolongation (macrolide), Appetite decreased, skin reactions; taste altered, myasthenia gravis
Vaginal thrush (OTC)
Referral
2 episodes in 6 months, 3 in 12 months
Under 16 or over 60
Diabetes
Odourous discharge
Pain in the lower back or abdomen
Spotting/bleeding between periods
Failed treatment
