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Infectious Disease > Urinary Tract Infections > Flashcards

Urinary Tract Infections Flashcards

1
Q

Urine Characteristics

A
  • Low pH
  • Extremes in osmolality
  • High urea and organic acid concentration
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2
Q

Flushing Mechanisms

A

Introduction of bacteria stimulates increased diuresis

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3
Q

Anti-Adherence Mechanisms

A

Coated epithelial cells of the bladder

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4
Q

Other Potential Factors

A
  • Presence of lactobacillus in vaginal flora

- Estrogen levels

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5
Q

Classification

Uncomplicated

A

Nonpregnant female
Childbearing age (15-45 yo)
Otherwise healthy
No structural or functional abnormalities

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6
Q

Classification

Complicated

A 
Pregnant females
Males
Children
Diabetics
Anatomical or structural abnormalities
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7
Q

Pylonephritis

A

Is a type of urinary tract infection (UTI) that generally begins in your urethra or bladder and travels to one or both of your kidneys. A kidney infection requires prompt medical attentio.

Infection of renal parenchyma

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8
Q

Signs and Symptoms

Uncomplicated Cystitis in Adults

A 
Dysuria
Polyuria
Urgency
Nocturia
Suprapubic discomfort
Gross hematuria
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9
Q

Signs and Symptoms

Pyelonephritis in Adults

A 
Fever
Nausea and vomiting
Leukocytosis
Dysuria, polyuria, urgency 
Flank pain 
Costovertebral angle (CVA) tenderness
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10
Q

Signs and Symptoms: Special Populations

Elderly

A

Altered mental status
Change in eating habits
GI symptoms

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11
Q

Lower UTI

A

Local symptoms: dysuria, frequency, urgency, suprapubic tenderness, hematuria (+/-)
Systemic symptoms: rarely present

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12
Q

Upper UTI

A

Local symptoms: lower UTI symptoms often NOT present

Systemic symptoms: fever, flank pain, abdominal pain, malaise, vomiting, chills, leukocytosis

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13
Q

Elderly

A

Altered mental status, change in eating habits, gastrointestinal symptoms

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14
Q

diagnosis of UTI

A

***Symptomatic Patients **
±
Positive Urine Culture

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15
Q

Urinalysis: Macroscopic

A

Color, appearance, and odor

Dipstick

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16
Q

Urinalysis: Macroscopic

Dipstick

A

Urine pH
Presence of glucose, blood, bilirubin, or protein
Leukocyte esterase
Detect presence of WBC
Nitrite test
Formed by bacteria that reduce nitrate to nitrite
Only members of the Enterobacteriaceae family

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17
Q

Urinalysis: Microscopic

Bacteriuria

A

≥ 10^5 CFU/mL –> indicative of UTI

≥ 10^2 CFU/mL –> diagnostic in presence of symptoms

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18
Q

Urinalysis: Microscopic

Pyuria

A

> 10 WBC/mm3
Nonspecific to UTI
Signifies presence of inflammation

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19
Q

Microscopic hematuria

A

Nonspecific to UTI

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20
Q

Urine Cultures

A 
Gold standard for diagnosis 
Obtain prior to initiating antibiotics
Identification and quantification
Sensitivities
Alter antibiotic treatment as needed
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21
Q

Gram-Negative

A 
Escherichia coli
	Proteus species
	Klebsiella pneumoniae
	Enterobacter species
	Pseudomonas aeruginosa
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22
Q

Gram-Positive

A

Staphylococci species

Enterococcus species

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23
Q

Uncomplicated

Escherichia coli

A

•Most common: 80-90%

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24
Q

Uncomplicated

Staphylococcus saprophyticus

A
  • Usually seen in young sexually active females

* Less common: 5-15%

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25
Q

Uncomplicated

Klebsiella pneumoniae, Proteus spp., Enterococcus spp., Citrobacter spp.

A

•Less common: 5-10%

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26
Q

Complicated

Escherichia coli

A

•Most common: <50%

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27
Q

Complicated

Enterococcus spp.

A

•Second most frequently isolated organism in hospitalized patients

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28
Q

Complicated
Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella pneumoniae, Proteus spp., Citrobacter spp., Acinetobacter spp.and Morganella spp.

A

•Less common

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29
Q

Causartive agents - Pearls

E. coli

A

Most common – responsible for 80-90% of cases

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30
Q

Causartive agents - Pearls

Proteus species

A

Produce urease – increases pH of urine

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31
Q

Causartive agents - Pearls

E. coli and K. pneumoniae

A

Common ESBL organisms

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32
Q

Causartive agents - Pearls

Pseudomonas aeruginosa

A

Does not reduce nitrate to nitrite

33
Q

Treatment Goals

A

Eradicate infection and prevent recurrence
Prevent or treat systemic consequences
Provide supportive care
Minimize cost, adverse effects, and collateral damage of antimicrobial therapy

34
Q

UTI Treatment Principles

A

Treat ALL symptomatic UTIs

Treatment of asymptomatic bacteriuria is patient specific

35
Q

Treatment Principles

Before initiating treatment, always consider:

A

Age, gender, symptoms, site of infection, possible recurrent infection

Medication allergies

Previous cultures for that patient (if available)

Susceptibility patterns within the region

Drug characteristics

Tolerability and adherence

Pregnancy status

36
Q

Empiric Antimicrobial Selection

Dr. Plasma

A

D Drug-drug interactions
R. Renal & hepatic function

P     Primary source(s) of infection
L     Location of acquisition
A     Antimicrobial history
S     Severity of illness
M    Microbiological history
A     Allergy history
37
Q

Urinary tract infections: females

Asymptomatic Bacteriuria

A

Significant bacteriuria (≥10^5) in the absence of symptoms

38
Q

Urinary tract infections: females

Symptomatic Abacteriuria

A

Symptomatic in the absence of significant bacteriuria (<10^5)

39
Q

Urinary tract infections: females

Cystitis

A

Infection of the bladder

40
Q

Urinary tract infections: females

Pyelonephritis

A

Infection of the kidney

41
Q

Which of the following patients listed below would be classified as having an uncomplicated cystitis infection?

A.) 27 year-old healthy male
B.) 29 year-old non-pregnant healthy female
C.) 40 year-old diabetic male
D.) 90 year-old female with urethral obstruction

A

B.) 29 year-old non-pregnant healthy female

42
Q

Asymptomatic Bacteriuria
Microbiologic criterion generally ≥ 10^5 CFU/mL
Asymptomatic Bacteriuria Treatment in Pregnancy
Acceptable Options

A

Nitrofurantoin
Cephalexin
Amoxicillin-clavulanate

43
Q

Asymptomatic Bacteriuria
Microbiologic criterion generally ≥ 10^5 CFU/mL
Asymptomatic Bacteriuria Treatment in Pregnancy
Use with Caution

A

Trimethoprim/Sulfamethoxazole (TMP/SMX): avoid in 1st and 3rd trimester

44
Q

Asymptomatic Bacteriuria
Microbiologic criterion generally ≥ 10^5 CFU/mL
Asymptomatic Bacteriuria Treatment in Pregnancy
AVOID

A

Tetracyclines

Fluoroquinolones

45
Q

Acute Uncomplicated Cystitis

Nitrofurantoin monohydrate 100 mg PO BID

A

5 days
•Minimal resistance and low risk for collateral damage
•Caution in renal impairment

46
Q

Acute Uncomplicated Cystitis

TMP/SMX 160/800 mg PO BID

A

3 days
•Avoid if local resistance exceeds 20%
•Watch for sulfa allergy

47
Q

Acute Uncomplicated Cystitis

Fosfomycin 3 g PO once

A

1 dose
•Minimal resistance and low risk for collateral damage
•High cost and inferior efficacy

48
Q

Acute Uncomplicated Cystitis
Ciprofloxacin 250 mg PO BID
Levofloxacin 250 mg PO daily

A

3 days
•FDA does not recommend
•Concern for collateral damage

49
Q

AL is 28yonon-pregnant femalepresenting to the clinic with painful and frequent urination.She denies fever, nausea, and vomiting. Her UA is leukocyte esterase and nitrite positive. Local resistance to TMP/SMX is > 20%.
What is the most appropriate treatment regimen for AL?

A.) Nitrofurantoin PO for 5 days
B.) Ciprofloxacin PO for 3 days
C.) Amoxicillin/Clavulanate PO for 7 days
D.) TMP/SMX DS PO BID for 3 days

A

A.) Nitrofurantoin PO for 5 days

50
Q

Pyelonephritis

A

Treatment varies based on severity
Setting: Outpatient vs. Inpatient
Patient considerations
Obtain urine cultures prior to initiating antibiotics
Consider blood cultures if concern for systemic infection

51
Q

Pyelonephritis

Patient considerations

A 
Hydration
Ability to take oral medications
High fever
Definitive diagnosis
Pregnancy status
52
Q

Pyelonephritis: Mild to Moderate

A

Fluoroquinolones: Ciprofloxacin, Levofloxacin
-First-line option

If resistance to fluoroquinolones > 10%, use ceftriaxone 1g or aminoglycoside

Dose & Duration:
Ciprofloxacin 500 mg PO BID x 7 days
Levofloxacin 750 mg PO daily x 5 days

53
Q

Pyelonephritis: Mild to Moderate

Susceptible to Bactrim

A

Trimethoprim/Sulfamethoxazole (TMP/SMX) DS
Preferably used only if known susceptibility
If susceptibility unknown, use ceftriaxone 1 g or aminoglycoside
Dose & Duration:
TMP- SMX DS PO BID x 14 days

54
Q

Pyelonephritis: Severe

A 
Initially requires IV antibiotics
Duration: 10-14 days
May repeat cultures
Transition from IV to PO 
Afebrile for 24-48 hours
Clinical improvement
Decreased WBC count
Functioning GI tract
55
Q

Pyelonephritis: Severe

Extended spectrum cephalosporin

A

Ceftriaxone, cefepime, ceftazidime

56
Q

Pyelonephritis: Severe

Extended spectrum penicillin

A

Piperacillin/tazobactam

Ampicillin/sulbactam – resistance has been reported

57
Q

Pyelonephritis: Severe

Fluoroquinolone

A

Ciprofloxacin, Levofloxacin

Consider resistance if using empirically

58
Q

Pyelonephritis: Severe

Aminoglycoside +/- ampicillin

A

Generally avoided due to side effects

59
Q

Pyelonephritis: Severe

Carbapenem

A

Reserve for people with confirmed multi-drug resistant (MDR) pathogen or those at risk

60
Q

Ciprofloxacin as a surrogate marker for levofloxacin susceptibility

A

Levofloxacin susceptibility can be assumed based off of ciprofloxacin susceptibility for Enterobacteriaceae
-BUT NOT for Pseudomonas aeruginosa!

Also, does not work the other way around
Levofloxacin susceptibility cannot predict ciprofloxacin susceptibility

61
Q

LK is a 44 yo non-pregnant female presenting to theurgent care clinicwith a fever and nausea over the last 2 days. She also complains of dysuria, urinary frequency, and right sided CVA tenderness on exam. Her UA is positive for leukocyte esterases and nitrites. Local resistance patterns to E. coli are as follow: FQ 9%, TMP/SMX 25%.
What is the most appropriate empiric therapy for LK?

A.) Moxifloxacin IV for 7 days
B.) Levofloxacin PO for 5 days
C.) TMP/SMX DS PO for 14 days
D.) Ceftriaxone IV for 9 days

A

B.) Levofloxacin PO for 5 days

62
Q

Recurrent Infections: Reinfection

A

Recurrence of infection by a different organism from preceding infection
Reinfection can be divided into two groups:
Less than three episodes per year
More frequent episodes

Three or more infections per year
Start long-term prophylaxis
Check urine cultures every 1 to 2 months

63
Q

Recurrent Infections: Prophylaxis Treatment

Continuous Low Dose Therapy

A

TMP/SMX SS 0.5 to 1 tablet PO daily

Nitrofurantoin 50-100 mg PO daily

64
Q

Recurrent Infections: Prophylaxis Treatment

Self-Administered Therapy

A

Patient initiates treatment after first signs or symptoms of UTI

65
Q

Recurrent Infections: Prophylaxis Treatment

Post-Coital Therapy

A

TMP/SMX SS 1 tablet PO following sexual activity

66
Q

Risk Factors for Men

Very rare to see UTI in a younger male because of the prostatic fluid being secreted into the urine; allows for a protective mechanism.

A 
Lack of circumcision
- Colonization of bacteria
Urologic catheterization
- In-dwelling catheter
Obstruction
- Prostatic hypertrophy, renal calculi, kidney stones, etc.
Intercourse
- Sex with infected partner or anal intercourse
Age
- Incidence increases with age
Drugs
- Anticholinergics
67
Q

Complicated
Treatment Options: Oral
sulfamethoxazole-trimethoprim (Bactrim)

A

Highly effective against most aerobic enteric bacteria
NO Pseudomonas aeruginosa coverage
High urinary tract tissue and urine concentrations

68
Q

Complicated
Treatment Options: Oral
nitrofurantoin (Macrobid)

A

NOT used in males or pyelonephritis

Contraindicated: CrCl <30mL/min

69
Q

Complicated
Treatment Options: Oral
ciprofloxacin (Cipro)
levofloxacin (Levaquin)

A

Great spectrum of activity with Pseudomonas coverage
Effective for pyelonephritis and prostatitis
Moxifloxacin does not achieve adequate urinary concentrations

70
Q

Complicated
Treatment Options: Oral
1.) amoxicillin/clavulanate (Augmentin)
cefdinir (Omnicef)
cefpodoxime (Vantin)

2.)fosfomycin (Monurol)

A
  1. ) NO Enterococcus coverage

2. )Off-label

71
Q

CAUTI Definition

A

Signs and symptoms consistent with UTI with no other identified source of infection

PLUS

≥10^3 cfu/mL of ≥ 1 bacterial species in a:
Single catheter urine specimen
Midstream voided urine specimen from a patient whose urethral, suprapubic, or condom catheter has been removed within the previous 48 hours

72
Q

CAUTI: Duration of Therapy

Women aged < 65 who develop CAUTI without upper UTI symptoms after catheter removal

A

3 Days

73
Q

CAUTI: Duration of Therapy

Quick resolution of symptoms

A

7 days

If on levofloxacin – 5 days

74
Q

CAUTI: Duration of Therapy

Persistent symptoms or bacteremia

A

10-14 days

75
Q

Prostatitis: Acute
Presentation:

A

fever, chills, malaise, myalgia, localized pain, frequency, urgency, dysuria, nocturia, retention

76
Q

Prostatitis: Acute
Diagnosis:

A

clinical presentation and presence of significant bacteria isolated from midstream specimen

77
Q

Prostatitis: Chronic
Presentation:

A

voiding difficulties, lower back pain, perineal suprapubic discomfort

78
Q

Prostatitis: Chronic
Diagnosis:

A

Quantitative localization cultures which compare bacterial growth in sequential urine and prostatic fluid culture obtained during micturition

79
Q

Prostatitis: Treatment

A

Sulfamethoxazole-trimethoprim

Ciprofloxacin
Levofloxacin

Infectious Disease (56 decks)

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