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Infection > Y4 - UTI > Flashcards

Y4 - UTI Flashcards

1
Q

How are UTIs split up?

A

Upper UTI
- pyelonephritis

Lower UTI

  • cystitis
  • urethritis
  • prostatitis
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2
Q

In what population do most UTIs occur?

A

Child bearing females

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3
Q

How does the treatment of upper UTIs differ to lower UTIs?

A

Upper UTIs need antibx that will penetrate the kidneys and also tend to need longer Rx

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4
Q

How are UTIs classified?

A

Complicated

Uncomplicated

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5
Q

What is an uncomplicated UTI?

A

Occurring in an individual who lacks structural or functional abnormalities

(Mostly healthy females of childbearing age)

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6
Q

What are complicated UTIs?

A

Predisposing lesion of UT e.g. congenital abnormality, stone, catheter, prostatic hypertrophy, obstruction or neurological deficit which interferes with the normal flow of urine and urinary tract defences

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7
Q

Define recurrent UTI

A

Multiple symptomatic infections with asymptomatic periods

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8
Q

Define reinfection

A

Infection caused by different organism that isolated previously (most recurrent UTIs)

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9
Q

Define relapse

A

Repeated infections with same initial organism and usually indicate a persistent infectious source

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10
Q

What is asymptomatic bacteriuria?

A

> 10^5 bacteria/ml urine without symptoms

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11
Q

In which group of individuals is asymptomatic bacteriuria most common?

A

Elderly

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12
Q

Define symptomatic abacteriuria?

A

Symptoms of frequency and dysuria in absence of significant bacteriuria

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13
Q

Should you treat asymptomatic bacteriuria?

A

No
Doesn’t reduce frequency of UTIs
It leads to drug resistant bacteria, e.g. C. diff infections

ONLY exception in Rx in pregnancy and if patient undergoing urological procedures

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14
Q

Define significant bacteriuria

A

> 10^5 bacteria/ml CFU of urine in clean catch specimen

NB: a bacterial count of 100 CFU/ml has a high positive predictive value of cystitis in symptomatic women

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15
Q

Less than 10^5 CFU may represent true infection, especially if there are what things?

A

Concurrent antibacterial drug administration
Rapid urine flow
Low urine pH
Upper tract obstruction

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16
Q

Micro-organisms causing UTIs usually originate from where?

A

Bowel flora

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17
Q

What bacteria most commonly cause uncomplicated UTIs?

A

E. coli (85%)
S. sacrophyticus (5-15%)
K. pneumoniae, proteus sp., pseudomonas, enterococcus (5-10%)

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18
Q

True or false:

If staph epidermis is isolated from a urine culture, the patient may be in serious danger

A

False

S. epidermis is usually a contaminant in this situation

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19
Q

What do complicated UTIs occur as a result of?

A

Anatomic, functional, pharmacological factors that predispose to persistent infection, recurrent infection or treatment failure

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20
Q

What bacteria mostly cause complicated UTIs?

A

E. coli (50%)
K. pneumoniae, Proteus spp., Pseudomonas, Enterococcus, Enterobacter spp.

OFTEN more resistant pathogens!

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21
Q

What is the 2nd most common cause of UTIs in hospitalised patients?

A

Enterococcus faecalis

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22
Q

What might staph aureus isolate from a UTI indicate?

A

There is bacteraemia producing metastatic abscesses in the kidney

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23
Q

In what sort of patients are UTIs due to candida spp. most common?

A

Chronically ill and chronically catheterised

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24
Q

In which patients are UTIs due to multiple organisms more common?

A

Those with stones, indwelling catheters or chronic renal abscesses

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25
Q

What factors predispose to UTIs?

A

Obstruction of the urinary tract - prevents flushing of bacteria/urinary stasis in bladder

Conditions resulting in residual urine volumes

Urinary catheter, mechanical instrumentation, pregnancy, use of spermicides and diaphragms

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26
Q

What sort of conditions may result in residual urine volumes increasing risk of UTI?

A

Prostatic hypertrophy, urethral stricture, calculi, tumours, drugs (e.g. anticholingeric agents), neurological malfunctions assoc. with stroke, diabetes and spinal cord injuries

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27
Q

What is the clinical presentation of a lower UTI?

A

Dysuria, frequency, nocturia, urgency, suprapubic heaviness, haematuria in women

NO SYSTEMIC SYMPTOMS

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28
Q

What is the clinical presentation of a upper UTI?

A

Flank pain, costovertebral tenderness, abdominal pain, fever, nausea, vomiting, malaise

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29
Q

What is the clinical presentation of an elderly patient with a UTI?

A

Often no specific urinary symptoms

May have altered mental status, change in eating habits or GI symptoms

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30
Q

What is the clinical presentation of a catheterised patients with a UTI?

A

NO lower tract symptoms just flank pain and fever

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31
Q

What is the clinical presentation of acute bacterial prostatitis?

A

Perineal, sacral or suprapubic pain
Fever, urinary retention
Frequency, urgency, nocturia
Digital palpation via rectum reveals swollen, tender, warm and indurated prostate

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32
Q

What tests can you use for UTI?

A

Dipstick (nitrates)
Leukocyte esterase dipstick test (rapid screening for pyuria) - detects >10WBC/mm3
Urine culture - not in every one

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33
Q

What may cause a false negative dipstick for UTI?

A

Gram +ve pseudomonas that do not reduce nitrates
Low urinary pH
Frequent voiding and dilute urine

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34
Q

What is leukocyte esterase?

A

Found in neutrophils

So can help detect pyuria

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35
Q

Who do we do a urine culture in?

A

Children, men, elderly, pregnancy
Patients with red flags
Younger women with risk of upper tract infection
Infection with bacteria not likely to respond to first line antibiotics

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36
Q

What are the ways of collecting a urine specimen?

A

MSSU
Catheterisation in infants/v. old
Plastic bag collection

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37
Q

Define pyuria

A

WBC > 10WBC/mm3

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38
Q

What does pyuria indicate?

A

Presence of inflammation

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39
Q

What is sterile pyuria associated with?

A

Urinary tuberculosis, chlamydial and fungal infections
Calculi, tumours, SLE, pregnancy
Most commonly undeclared presence of antibiotic in urine sample

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40
Q

What does haematuria indicate?

A

Nothing specifically

But may indicate other disorders, e.g. calculi or tumours

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41
Q

What does proteinuria indicate?

A

May indicate infection

42
Q

What is your approach for treating cystitis?

A

If 3+ symptoms/1 severe symptom in non-pregnant with no discharge, treat empirically

43
Q

How do you investigate UTIs?

A

Dipstick: non-pregnant & <65 & <3 symptoms
MSU: pregnant, men, children, failure to respond to antibx Rx
Blood tests if systemically unwell (FBC, E&E, CRP, blood culture)
Imaging (USS, cystoscopy, urodynamics, CT in men with upper UTI, failure to respond to Rx, recurrent UTI (>2/yr), pyelonephritis, unusual organism, persistent haematuria)

44
Q

How do you Rx UTIs in non-pregnant woman?

A

3+ symptoms of cystitis & no vaginal discharge: 3d course trimethoprim/nitrofurantoin
If this fails –> MSSU culture & Rx according to antibiotic sensitivity
Upper UTI - take urine culture & give broad spectrum antibx

45
Q

What is UTI in pregnancy associated with?

A

Preterm delivery and intrauterine growth restriction

46
Q

How do you Rx men with a lower UTI?

A

7 day course trimethoprim/nitrofurantoin

If symptoms suggest prostatitis (pain in pelvis, genitals, lower back and buttocks) consider 4wk course ciprofloxacin

47
Q

How do you manage pyelonephritis?

A

Culture urine and start on antibiotics immediately
Amoxicillin & gentamicin (renal function) 7-14 days
Hospitalisation and IV antibiotics if patient unable to take PO

48
Q

What are possible complications of pyelonephritis?

A

Perinephric/renal abscesses
Nephrolithiasis with UTI

Monitor CRP and if not improving may want to scan for these

49
Q

What is urosepsis?

A

Sepsis with a source localised to the urinary tract

50
Q

How do you Rx urosepsis?

A

7-10 days amoxicillin & gentamicin

51
Q

How common is catheter associated UTI?

A

100% will get a UTI within 4 weeks

NB urine from catheter always positive on dipstick and C&S

52
Q

When do you diagnose catheter associated UTI?

A

ONLY if fever/other systemic manifestation of infection (e.g. malaise, altered mental status, fall in BP, metabolic acidosis, respiratory alkalosis)

53
Q

How do you manage catheter associated UTI?

A

Catheter should be removed or swapped prior to antibiotic Rx

Antibiotics

54
Q

What is the issue with catheter associated UTI?

A

They tend to form biofilms that cannot be removed by antibiotic treatment
Bacteria produce crystals associated with the biofilm and during catheter removal these crystals can damage the urinary tract mucosa

55
Q

Name two common causes of urethritis

A

Chlamydia trachomatis

Nesseria gonorrhoea

56
Q

How does chlamydia present?

A

Usually asymptomatic in females

Can present with dysuria, discharge or PID

57
Q

How do you investigate suspected chlamydia?

A

Send UA, urine culture (suspect in sterile pyuria)

Pelvic exam, send discharge from cervix/urethra for chlamydia PCR

58
Q

How do you treat chlamydia?

A

1g single dose azithromycin

or 100mg doxycycline BID 7 days

59
Q

How does gonorrhoea tend to present?

A

Dysuria, discharge, PID

60
Q

How do you investigate suspected gonorrhoea?

A

Send UA, urine culture

Pelvic exam, send discharge from grain stain, culture, PCR

61
Q

How do you treat gonorrhoea?

A 
Ceftriaxone 125mg IM
Cipro - 500mg 
Levofloxacin 250mg 
Ofloxacin 400mg 
Spectinomycin 2g IM

Remember to also treat for chlamydia when treating gonorrhoea

62
Q

What are the classic UTI symptoms?

A

Dysuria, frequency of urination, suprapubic tenderness, urgency, polyuria, haematuria

63
Q

Define cystitis

A

Inflammation of bladder

64
Q

Define bacteriuria

A

Bacteria in the urine

NB anterior urethra is not sterile so urethral organisms washed out during urination is NOT bacteriuria

65
Q

Define pyuria

A

Pus cells (neutrophil polymorphs) in significant quantities in the urine

66
Q

Define sterile pyuria

A

Negative urine culture but significant no. of pus cells present

67
Q

Define acute pyelonephritis

A

Infection of upper urinary tract involving the kidneys

68
Q

Define chronic pyelonephritis

A

Renal scarring and potentially loss of renal function
Infection may be contributory cause, but other factors (e.g. diabetes, vesico-ureteric reflux and urinary obstruction) may also contribute

69
Q

Women with mild/only 2 symptoms of cystitis or fewer should have what done?

A

MSU

If urine cloudy test with dipstick

70
Q

What can dipsticks detect in the urine of someone with a UTI?

A

Nitrite (metabolic product produced by some bacteria)
Protein (may be sign of inflammation)
Leucocytes (leucocyte esterase is an enzyme found in leucocytes and is a marker of inflammatory response)

71
Q

Men with a UTI should have what test done?

A

MSU collected and sent to the lab

72
Q

Why does the incidence of UTI in men increase with age?

A

UTIs occur more often due to obstruction caused by prostatic hypertrophy

73
Q

What is prostatitis usually due to in older men?

A

Coliforms

74
Q

What is prostatitis usually due to in younger men?

A

STIs

Chlamydia/gonorrhoea

75
Q

Who does pyelonephritis most commonly affect?

A

Women of childbearing age

76
Q

What tend to be most the profound symptoms of pyelonephritis?

A

Loin pain
Fever
Systemically unwell (e.g. rigors, nausea, vomiting)
May also have frequency, dysuria

77
Q

What group of individuals are screened for asymptomatic bacteriuria?

A

Pregnant woman at booking by MSU culture

Treatment of those with significant bacteriuria takes place in this group as well

78
Q

How do you test for renal tuberculosis?

A

Three early morning urines

ZN stain and TB culture

79
Q

What condition that leads to a lot of UTIs in kids should you always be aware of?

A

Vesico-ureteric reflux

As it can lead to renal scarring

80
Q

How do patients with chronic pyelonephritis tend to present?

A

Vague abdominal discomfort

May also have HTN

81
Q

What radiological changes may you see with someone who has chronic pyelonephritis?

A

Clubbing of calyces with scarring of cortical parenchyma

82
Q

What are the risk factors for UTIs?

A

Female sex (short urethra)
Trauma to female urethra during sex & childbirth
Pregnancy
Anatomical abnormalities
Renal cysts
Pre-existing renal parenchymal damage
Stones in urinary tract (kidney, ureter or bladder)
Immunosupression (incl. DM, steroids)
Instrumentation of urinary tract (e.g. cystoscopy)
Presence of foreign body in urinary tract (e.g. catheter/stent)

83
Q

Why is a short urethra a risk factor for UTI?

A

It is short and also because of its close proximity to the rectum transperitoneal introital colonisation with bacteria from the large bowel occurs

84
Q

Why is there an increased risk of UTI in pregnancy?

A

Stasis of urine allows bacteria to flourish

Progesterone dilates ureters and physical pressure of foetus

85
Q

What sort of anatomical abnormalities put patients at increased risk of UTIs?

A

Congenital pelvic-ureteric junction obstruction, VUR, duplex kidneys, horseshoe kidneys, urethral valves, prostatic enlargement, chronic urinary retention

86
Q

Who do uncomplicated UTIs occur in?

A

Sexually active, health young women

87
Q

Who do complicated UTIs occur in?

A

Everyone else

Children, men, patients with an abnormal renal tract

88
Q

What do complicated UTIs require?

A

Investigation to include an upper renal tract scan (USS/CT) and bladder imaging (cystoscopy/post-void bladder scan)
Urinary flow studies may also be used

89
Q

When should you actually do tests when you suspect a UTI?

A 
Women with mild/limited symptoms if dipstick testing is less conclusive
UTI in men 
Suspected acute pyelonephritis
Pregnant women 
Failure of antibx Rx
Recurrent UTI
Children
90
Q

Define recurrent UTI

A

> 2 UTI in 6m

>3 UTI in 1y

91
Q

Where should catheter samples be taken from?

A

Catheter sampling port

92
Q

How can you collect urine from children?

A

Clean catch is best
Urine collection pads
Catheter sample
Suprapubic aspiration

93
Q

Who is S. sacrophyticus UTI most common in?

A

Sexually active women

94
Q

Why are those with proteus UTI more likely to get stones?

A

Proteus produces urease which splits urea to release ammonia thus making urine alkaline and encouraging stone formation

95
Q

What spp are seen more commonly as the cause of UTIs in hospital patients?

A

Proteus, klebsiella, pseudomonas

96
Q

What can microscopy of urine show?

A

Presence of cells, casts or organisms

97
Q

What is significant pyuria?

A

> 10 WBC/mm3

this is a marker of inflammation

98
Q

How do you treat pyelonephritis?

A

Ciprofloxacin for 7 days

Single episodes in men and recurrent episodes in women require further investigation

99
Q

What antibiotics should be used for UTI in pregnancy?

A

NOT trimethoprim
Nitrofurantoin can be used but not at term (can cause neonatal haemolysis)
Cephalexin can generally be used

100
Q

What advice can you give to someone who is repeatedly getting UTIs?

A

Drink plenty of fluids
Empty bladder after sex
Pay attention to personal hygiene

Long term antibiotic prophylaxis (e.g. 1 tablet of nitrofurantoin or trimethoprim per night for up to 1y may be used to break cycle of recurrent infection)

Infection (22 decks)

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