Genitourinary infections Flashcards
Who’s more prone to UTIs?
Predominately sexually active females (predominately ages 16-35)
Shorter urethra – hygiene, proximity to fecal bacteria
Esherichia coli predominates
Spermicides
Pregnancy
Vaginal Atrophy
presentation of UTIs
Dysuria, frequency, urgency, strong urine odor, cloudy urine, suprapubic tenderness on physical examination
Absence of vaginal discharge or vaginal pain
underlying risk factors for UTIs
Neurogenic bladder (urinary retention)– MS, spinal cord disorders, etc.
Diabetes
Urinary instrumentation
Structural abnormalities like cystocele
Simple Cystitis
Approach – controversial
- Simple cystitis may be evaluated by presenting symptoms with or without dip stick testing in young females and treated on that basis without a culture
Culture indicated regardless of presentation
- Pregnancy
- Antibiotic resistant organisms suspected
- The patient has multiple drug sensitivities
- The patient has underlying complicating medical conditions
Complicated Cystitis
These are conditions that not only require a culture but a structural evaluation:
Recurrent in Female Males - men rarely present with simple cystitis Urethral malformations Turbulent urine flow (strictures and obstruction) Neurogenic Bladder Nephrolithasis Immunocompromised Renal disease Pregnancy Diabetes Catheterization - Urethral - Suprapubic - Nephrostomy Upper tract disease
Pyelonephritis
Presentation
- Fever and much more toxic appearance, Lloyd’s sign present (percussion)
- Usually an elevated WBC with a left shift
Usually from an ascending bacteria
- Residual urine
- Reflux
Hematogenous/lymphatic spread
- i.e., endocarditis, osteomyelitis, injection drug users
Structural evaluation indicated
- Evaluate anatomically, foreign bodies (nephrolithiasis)
Renal Abscess
- Surgical intervention
Asymptomatic Bacteriuria
What constitutes an infection?
- Dysuria, frequency, urgency, strong urine odor, cloudy urine, suprapubic tenderness on physical examination – a host response is an indication of an infection versus a colonization.
Asymptomatic bacteriuria is usually not treated
- More commonly found in:
Females
Diabetics
Elderly (especially nursing home patients)
Indications for treatment of Asymptomatic Bacteriuria
Pregnancy
- Associated with premature birth and low birth weight
- No vertical transmission of illness
Urinary outflow obstruction
Anticipated urinary instrumentation
Goal of treatment is to prevent upper-tract disease
Urosepsis
Septic (Systemic Inflammatory Response System - tachycardiac, tachypneic, fever or low temperature, leukocytosis) patients may actually have a hypothermic body temperature as the initial symptom
- Usually an elevated WBC with a left shift
- Rigors
30% or more fatality rate
Blood and urine cultures
Imaging – should always be a part of the evaluation in a patient this ill
- Obstructive uropathy or suspected structural integrity alteration, (foreign bodies, tumors, etc.)
Lab Evaluation
CBC, Renal Chemistries
Urine dip stick
- Positive for nitrites and leukocyte esterase is 68-88% sensitive for a urinary tract infection
- Negative for nitrites and leukocyte esterase has a high negative predictive value
Urine culture
- Colony counts
- Antibiotic sensitivity patterns
Imaging
- Ultrasound vs. CT scan
Urology referral/cystoscopy
Treatment of UTIs- abx
Nitrofurantoin – bacteriostatic
TMP/SMX (Trimethoprim/sulfamethoxazole) – bactericidal
Fluoroquinolones – bactericidal (no longer 1st line due to resistance)
β-lactam antibiotics – bactericidal
- Penicillins
- Cephalosporins
- Monobactams
- Carbapenems
Aminoglycosides – variably bacteriostatic vs. bactericidal (concentration dependent)
Duration of treatment
- Simple cystitis – usually 3 days
- Complicated cystitis/pyelonephritis – 10-14 days
prevention of UTIs
Post-coital voiding in sexually active women
Double/triple voiding
Antibiotic prophylaxis
- Pregnancy
- Diabetes? – controversial and usually not recommended
- Recurrent UTI’s
Non-antibiotic prophylaxis
- Topical estriol replacement (vaginally)
- Cranberry
- Methenamine (the bacteria cleave it and create formaldehyde, which kills them)
Resistant organisms
MRSA
VRE
CRE
A 33 y/o male intravenous drug user presents with a fever and left flank pain. He admits to sharing needles. He often trades sex for injection drugs. He has an elevated WBC count, a new loud aortic valve murmur, splinter hemorrhages and a rash on his palms. He is HIV negative. He relates that his father had a heart murmur. He has no genital abnormalities and no recent history of genital lesions. You suspect the most likely etiology of his pyelonephritis to be:
A) Secondary syphilis B) Staphylococcus saprophyticus C) Staphylococcus aureus D) Candida species E) Bacteroides species
this is staph aureus
it is a likely organism in injection drug users, causes the endocarditis, and causes Osler lesions (rash on hands!)
A 64 y/o male who is positive for HIV and on broad spectrum beta-lactam antibiotics for pneumonia complains of burning with urination, urinary frequency and urinary urgency. His urine stream is otherwise normal. A urine dip-stick is strongly positive for leukocyte esterase and the lab reports that he has too numerous to count white blood cells per high powered field on the microscopic examination of the urine. After three days the lab reports there is no growth on the cultures. What is the most likely causative organism of his urinary tract infection?
A) Staphylococcus saprophyticus B) Bacteroides species C) Esherichia coli D) Candida species E) Enterococcus species
candida is a likely colonization in an HIV-positive person
also, he’s already been on broad-spectrum abx
candida also would not grow on culture
