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3151 > ASB/UTI > Flashcards

ASB/UTI Flashcards

1
Q
A
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2
Q

Antibiotics indicated for ASYMPTOMATIC bacteriuria

A

NONE

UNLESS pts show signs of systemic infection & delirium
*in elderly: bacteruria & delirium independently common

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3
Q

Bacteriuria definition

A

presence of significant colonies of bacteria in urine

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4
Q

When to screen for asymptomatic bacteriuria?

A
  1. pregnant women - screen @ one of first visits (12-16wks gestation)
    - prevent pyelonephritis, preterm labor, low infant birth weight
    - IF ASB: treat with active abx BASED ON AST; duration 4-7d
  2. patients undergoing urologic procedure (where mucosal trauma/ bleeding expected)
    - IF ASB: use active abx as SAP
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5
Q

Difference between ASB & UTI

A

UTI: pts are SYMPTOMATIC (have urinary symptoms)

ASB: pts are ASYMPTOMATIC

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6
Q

Prevalence of UTI

A

0-6months: M > F
1y - adult: F > M
Elderly (>65y): equal

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7
Q

Pathogenesis of ascending type of UTI

A

Type of pathogen: Enterobacteriaceae (E.coli/ Klebsiella/ Proteus)
- Colonic/ fecal flora colonise (peri)urethra area -> ascend to bladder & kidney
*HIGHER RISK in females (shorter urethra) // use of spermicides & contraceptives

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8
Q

Pathogenesis for descending (hematogenous) type of UTI

A

*more rare
Type of pathogen: S. aureus, M. tuberculosis

Bacteria from distant site eg. heart valve/bone enters BLOODSTREAM *bacteremia -> urinary tract -> UTI

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9
Q

Factors in determining development of UTI

A
  1. Host defence mechanisms
    - Bacteria in bladder stimulates micturition with increased diuresis -> emptying of bladder
    - Antibacterial properties of urine & prostatic secretion
    - Anti-adherence mechanisms of bladder mucosa (prevent bacterial attachment to bladder)
    - Inflammatory response w polymorphonuclear (PMN) leukocytes -> phagocytosis -> prevent/ control spread
  2. Size of inoculum -> increased risk with obstruction/ urinary retention
  3. virulence/ pathogenicity of microorganism eg. E.coli: presence of pili -> resistant to washout/ removal by antiadherence mechanisms of bladder
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10
Q

Risk factors for development of UTI

A
  • F > M
    *pregnancy, use of spermicides & diaphragms
  • Sexual intercourse
  • Structural abnormalities of urinary tract
  • Neurologic dysfunctions (Stroke, DM, Spinal cord injury)
  • Anti-cholinergic drugs (1st gen antihistamine S/E urinary retention)
  • Catheterisation & other mechanical instrumentation
  • Diabetics
  • Genetic association
  • Previous UTI
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11
Q

Counseling points on preventing UTI

A
  • HYDRATION (flush bacteria) - 6-8 glasses a day (unless fluid restricted)
  • Urinate frequently
  • Urinate shortly after sex
  • (Women) wipe from front to back
  • Wear cotton underwear/ loose clothing to air the area (keep dry)
  • Modify birth control method (X spermcides/ lubricated condoms: increase irritation -> promote bacterial growth)
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12
Q

Types of UTI

A
  1. Complicated vs uncomplicated
    - Uncomplicated: UTI that occurs in healthy premenopausal, non-pregnant women with NO history suggestive of an abnormal urinary tract
    - Complicated: everything else; suggests INCREASED potential for serious outcomes/ risk for therapy failure (needs longer therapy duration)
  2. Upper vs Lower UTI
    - UPPER: pyelonephritis
    *systemic symptoms (fever/ malaise/ headaches/ +ve renal punch/ flank pain/ UFEME: +ve WBC casts
    - LOWER: cystitis
    *urinary symptoms: dysuria, urgency, urinary frequency, nocturia, suprapubic heaviness/ pain, gross hematuria
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13
Q

Clinical presentation for UTI

A

Subjective
- Lower UTI: urinary symptoms (dysuria, urgency, urinary frequency, nocturia, suprapubic heaviness/pain, gross hematuria)
- Upper UTI *kidney infected: systemic symptoms (fever, headache, nausea/vomiting, malaise, flank pain, +ve renal punch, abdominal pain)

Objective
- Urinalysis - UFEME // culture
*urine to be collected via midstream CLEAN-catch/ catheterisation/ aspiration of suprapubic bladder
UFEME:
WBC (> 225 OR 10/mm3) -> PYURIA *not specific for infection; if NO pyuria -> UNLIKELY UTI
RBC (>5) -> hematuria
Microorganisms * Gram stain
WBC casts *specific for UPPER UTI

  • Dipstick
    1. Nitrite - if +ve -> Gram -ve bacteria (reduces nitrate to nitrie) *requires at least 10^5 bacteria/ml
    **false +ve: S. aureus & P. aeruginosa, low urinary pH, frequent voiding, dilute urine
    2. Leukocyte esterase -> indicates presence of WBC in urine (esterase activity of leukocytes) -> significant pyuria (>10 WBC/mm3)
  • Culture:
    *NOT needed if uncomplicated cystitis
    pre-treatment culture for: pregnant women/ recurrent UTI (relapse <2wks/ frequent)/ pyelonephritis/ CA-UTI/ all men w UTI)
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14
Q

Likely pathogen for UTI

A

uncomplicated: E. Coli (>85%); S. saprophyticus (5-15%); Gut enterobactericeae (Enterococcus faecalis, Klebsiella pneumoniae, Proteus spp.)

Complicated/ HA-UTI: E. Coli (~50%), Proteus/ Klebsiella/ Enterobacter / P. aeruginosa

Others: S. aureus (often due to bacteremia -> consider other PRIMARY sites of infection), yeast (candida) *possible contaminant -> consider other sites of infection

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15
Q

Antimicrobial regimen for UNCOMPLICATED vs COMPLICATED CYSTITIS in WOMEN

A

UNCOMPLICATED
- Nitrofurantoin 50mg QID x5d (*CI if CrCl <30ml/min)
- Fosfomycin 3g single dose *reserve for ESBL, not 1st line
- Co-trimoxazole 800/160mg (double strength) BD x 3d

Alternatives: beta-lactams (5-7d)
- cefuroxime 250mg BD
- amoxi-clav 625mg BD
- cephalexin 250-500mg QID

FQ (3d) *avoid if possible
- cipro 250 BD
- levo 250 OD

if COMPLICATED - treat for longer duration (7-14d)
*fosfomycin dose: fosfomycin 3g every other day x3 doses

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16
Q

treatment for community-acquired PYELONEPHRITIS in women

A

1st line: Fluoroquinolones
- PO Cipro 500mg BD x7d
- PO Levo 750 OD x 5d

  • PO co-trimoxazole 800/160mg BD x10-14d

Beta-lactams x10-14d
- Cefuroxime 250-500mg BD
- Amoxi-clav 625mg TDS/ q8h
- Cephalexin QID

*if severely ill/ unable to take oral -> IV
- IV cipro 400mg BD
- IV cefazolin 1g q8h
- IV amoxi-clav 1.2g q8h
AND/OR
- IV/IM gentamicin 5mg/kg (good for GNR, ESBL; concentrates in UT)
*AGs: not v good for bacteriuria (NOT for monotherapy) -> add-on cipro/cefa/amoxi-clav
**if bacteria is ESBL: usually resistant to FQs, cefazolin & amoxi-clav also usually not susceptible

Switch back to oral when pt improves/ able to take PO

17
Q

Treatment for community-acquired UTI in MEN (cystitis, pyelonephritis)

A

*if no concern for prostatitis (no pain)
- treat as per complicated cystitis for women
(longer duration of 7-14d)
- nitro 50mg QID
- co-trim 800/160mg BD
- fosfomycin 3g EOD x3 doses

-beta lactams (cefuroxime 250mg BD/ amoxi-clav 625mg BD/ cephalexin 250-500mg QID)

  • FQs (cipro 250mg BD/ levo 250mg OD)

** IF concern with prostatitis OR PYELONEPHRITIS
- PO cipro 500mg BD
- PO co-trimoxazole 800/160mg BD
Duration: 10-14d BUT if prostatitis confirmed: 6 weeks

18
Q

nosocomial/ HA-UTI occurrence, possible pathogen

A

Onset: after 48h past hospital admission

Pathogen: possibility of more resistant bacteria -> P. aeruginosa, ESBL, Klebsiella
*BROAD-spectrum beta-lactam for empiric therapy

19
Q

Empiric therapy for HA-UTI

A
  • IV cefepime 2g q12h +/- IV amikacin 15mg/kg OD (amikacin to cover for ESBL)
  • IV Imipenem 500mg q6h
  • IV Meropenem 1g q8h

*if able to take oral/ less sick:
- PO cipro 500mg BD
- PO levo 750 OD

Duration: 10-14d

20
Q

Definition of catheter-associated UTI

A

Presence of symptoms/ signs compatible w UTI with NO other identified source of infection/ 10^3 cfu/ml of at least 1 bacterial species in a single catheter urine specimen
*pts with indwelling urethral/ suprapubic/ intermittent catheterisation/ in midstream voided urine specimen from patient w catheter removed within 48h

21
Q

Risk factors for CA-UTI

A
  • duration of catheterisation (<7d/short-term: single organism; >28d/long-term: polymicrobial)
  • diabetes
  • female
  • renal function impairment
  • Colonisation of drainage bag/ catheter/ periurethral segment
  • Poor quality of catheter care, including insertion
22
Q

Clinical presentation/ antibiotic indication for treatment of CA-UTI

A
  • if pt has asymptomatic bacteriuria: treatment NOT recommended (except prior to traumatic urological procedure)
    *consider removal of catheter; if catheter is still indicated -> REPLACE catheter

SYMPTOMATIC infection:
new onset/ worsening of fever/ rigors/ altered mental status/ malaise/ lethargy with NO OTHER IDENTIFIED CAUSE// flank pain/ +ve renal punch/ acute hematuria/ pelvic discomfort
**if patient stable + low-grade fever -> consider observation first
**URINE +/- BLOOD CULTURE MUST BE TAKEN BEFORE ABX GIVEN
[Empiric therapy: as per HA-UTI]
- IV cef 2g q12h +/- IV amikacin 15mg/kg OD
- IV imi 500mg q6h // IV mero 1g q8h
- **PO/IV levo 750mg OD x 5d mild CA-UTI
- **PO co-trim 800/160mg BD x3d *women =/<65 w CA-UTI W/O upper UTI symptoms AFTER indwelling catheter removed
Duration of therapy: 7d (if prompt resolution of symptoms/ fever gone in 72h), ELSE if delayed response 10-14d

chronic suppressive therapy NOT recommended
topical/prophylactic (prevention) abx NOT recommended

23
Q

Management of UTI in pregnant women

A
  • AVOID cipro
  • AVOID co-trimoxazole in 1st & 3rd trimester (risk of kernicterus, concern for fetus being G6PD-deficient)
  • AVOID nitrofuration if (38-42weeks)
  • AGs: USE WITH CAUTION
  • fosfomycin: crosses placenta, use if benefit > risk (BUT dont use if risk of preterm labour)

1st line: beta-lactams
* if ASB/ cystitis -> 4-7d
* if pyelonephritis -> 14d

24
Q

Adjunctive therapy for UTI (pain, fever, vomiting, urinary symptoms)

A

Pain/fever -> paracetamol, NSAIDs
Vomiting -> rehydration
Urinary symptoms:
1. PHENAZOPYRIDINE 100-200mg TDS
azo dye w analgesic effect on UT mucosa -> symptomatic relief
**only take when symptoms are present
** CI: G6PD deficient // ADR: N/V, orange-red discolouration of urine & stool

  1. urine alkalinisation - relief discomfort in mild UTI (not proven)
  2. Cranberry juice - inhibit adherence of E. coli to UT epithelial cells (insuff evidence)
  3. Intravaginal estrogen cream *controversial
    *lowers UTI incidence in postmenopausal women (Restore vaginal flora, prevent E.coli colonisation)
  4. Lactobacillus probiotics: restore normal vaginal flora + protective effect against E.coli colonisation
    *intravaginal lactobacillus LOWERS recurrence of uncomplicated cystitis
25
Q

Monitoring treatment for UTI

A
  1. Resolution of symptoms
    *improvement/ resolution by 24-72h after initiation of effective abx
    **if pt does not respond within 2-3d OR persistently +ve blood/urine culture -> further investigate: bacterial resistance/ possible obstruction/ renal abscess/ other disease process?
  2. Bacteriological clearance
    *repeat culture NOT NEEDED if pts respond to treatment
    ** PREGNANT WOMEN culture needed to document clearance of infection
  3. Absence of ADR & allergies
26
Q

when is pre-treatment culture required for uti?

A

pregnant women
recurrent uti (relapse within 2 weeks/ frequent)
pyelonephritis
CA-UTI
men w UTI

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