CP4-5 urinary tract infections

Question 1

What is a UTI?

Answer 1

When the urinary tract is invaded by a pathogenic organism

Question 2

How do you diagnose a UTI?

Answer 2

By what symptoms the patient presents with

Question 3

Why do we use cultures when a patient has a UTI?

Answer 3

To determine the causative organism not to diagnose

Question 4

What are risk factors for a UTI?

Answer 4

Women
Urinary stasis
Urological instrumentation e.g. catheter
Sex
Fistulae
Congenital abnormalities

Question 5

What parts of the urinary tract are classed as sterile?

Answer 5

Bladder, kidneys and ureter

Question 6

What parts of the urinary tract are colonised?

Answer 6

Urethra

Question 7

What flora is found in the urethra?

Answer 7

Perineal flora

Question 8

What bacteria are commonly found in perineal flora?

Answer 8

Coagulase negative staphylococci
Entereobacterales
Enteric gram positive cocci
Anaerobes

Question 9

What bacteria most commonly causes a UTI?

Answer 9

E.coli

Question 10

What are 6 bacteria (other than e.coli) that can cause UTI? (In order of most common to least)

Answer 10

Staph saprophyticus
Proteus mirabilis
Enterococus species
Klebsiella species
Other coliforms
Pseudomonas aeruginosa

Question 11

Why might results of a culture indicating a UTI be inaccurate?

Answer 11

Contamination due to poorly taken samples
Colonisation of catheter
Asymptomatic bacteruria

Question 12

What is asymptomatic bacteriuria?

Question 13

How does a patient with cystitis present?

Answer 13

Dysuria
Urgency and frequency of urination
Super-pubic pain or tenderness
Polyuria, nocturia, haematuria
Mainly in women

Question 14

How might a patient with a catheter associated UTI present?

Answer 14

With a catheter or had one removed in past 48 hours
Fever
Supra-pubic tenderness
+/- dysuria, urgency/frequency of urination
Unexplained systemic symptoms like altered mental state

Question 15

Why does a catheter cause UTIs?

Answer 15

Can be colonised (formation of bacterial biofilm) - does not always indicate infection
Manipulation/removal (particularly traumatic) can cause bacteraemia and local infection.
Antibiotic prophylaxis can be indicated in some patient groups

Question 16

Why can you not use a urine dipstick test when a patient has a catheter?

Answer 16

As catheters aren’t sterile so will always show positive for bacteria

Question 17

How do patients present with pyelonephritis?

Answer 17

Symptoms of lower UTI
Loin/abdominal pain or tenderness
Fever
Symptoms of systemic infection like rigours, nausea, vomiting, diarrhoea, elevated CRP and WBC

Question 18

How do patients with acute bacterial prostatitis present?

Answer 18

Male
Lower UTI symptoms
Tender tense prostate on PR plapatuon
Acute retention
Potentially complications like micro abscesses and abscesses

Question 19

What pathogens are known to cause acute bacterial prostatitis?

Answer 19

E.coli
Less commonly gram positive bacteria like s. Aureus and enterococcus

Question 20

What are risk factors for acute bacterial prostatitis?

Answer 20

Abnormal anatomy e.g. cancer or BPH
Prostatic trauma/manipulation
Transrectal biopsies

Question 21

How do patients with chronic prostatitis present?

Answer 21

Pain in and around genitalia and perineum
Lower UTI symptoms
Enlarged +/- tender prostate upon examination

Question 22

What causes chronic prostatitis?

Answer 22

> 90% due to chronic pelvic pain syndrome if non bacterial
Bacterial = recurrent UTI with same organism or can be caused by chlamydia trachomatis

Question 23

How do patients with urethritis present?

Answer 23

Dysuria
Frequency +/- urgency of urination
Urinary hesitance

Question 24

What is an example of an STI causing urethra, symptoms?

Answer 24

Gonorrhoea

Question 25

What causes thrush? What is a common symptom?

Answer 25

Thrush Irritation and dysuria

Question 26

What is urethral syndrome?

Answer 26

Symptoms of lower UTI without any demonstrable infection aka abacterial cystitis or frequency-dysuria syndrome

Question 27

When is a patient classed as having recurrent UTIs?

Answer 27

>2 infections in 6 month or >3 in a year

Question 28

What are risk factors for UTIs?

Answer 28

Renal or bladder stones Having sex Post menopausal low oestrogen Anatomical abnormalities causing stasis

Question 29

What other diseases should be ruled out of a patient has recurrent UTIs?

Answer 29

Cancer Prostatitis (in men)

Question 30

How will a patient with an infection at their nephrostomy site present?

Answer 30

Fever Pain/tenderness at site Heamaturia or purulent discharge +/- urosepsis

Question 31

What is nephrostomy?

Answer 31

Percutaneous drain straight into the kidney

Question 32

What is an ileal conduit/urostomy?

Answer 32

When a short section of ileum is used to drain the ureters directly to a stoma on the anterior abdominal wall after a cystectomy (removal of the bladder)

Question 33

What are symptoms of an infection or an ileal conduit/ urostomy?

Answer 33

Fever Upper UTI symptoms if ascending infection Redness, swelling and pus if para-stomal skin infection

Question 34

What complications can lead to a perinephric renal abscesses?

Answer 34

Commonly = gram negative bacilli infection Uncommonly = complication of renal stones or diabetes or secondary to obstruction of infected kidneys

Question 35

What causes perinephric renal abscesses?

Answer 35

Usually gram negative bacilli

Question 36

What is an intro-renal abscess? What is it associated with?

Answer 36

An abscess caused by haematogenous spread (unilateral, single or renal cortex) of staph aureus which can be associated with classic acute pyelonephritis of the cortex or medulla.

Question 37

How will patients with urosepsis present?

Answer 37

Fever Rigors Nausea, vomiting and diarrhoea +/- haemodynamic compromise Raised inflammatory markers including CRP and WCC

Question 38

What makes a UTI an anatomical complicated UTI?

Answer 38

A UTI alongside: Structural abnormalities e.g. enlarged prostate Calculi Obstruction Vesico-ureteric reflux

Question 39

What makes a UTI a physiological complicated UTIs?

Answer 39

Pregnancy Immunocompromise Impaired renal failure

Question 40

What makes a UTI a iatrogenic complicated UTI?

Answer 40

Recent instrumentation Indwelling catheter or other prosthetic material (including stents)

Question 41

What tests should be done for a UTI?

Answer 41

Urine culture and susceptibility testing Inflammatory markers - monitor in severe infection Imaging to look for stones, abscess or anatomical abnormalities in upper UTIs

Question 42

When should a dipstick test be used?

Answer 42

As a screen to rule out lower UTIs where diagnosis is clinically dubious in women under 65 Over 3 year olds

Question 43

What samples can be tested in the microbiology labs?

Answer 43

Urine -mid stream -Catheter urine -clean catch for paediatric -Supra-pubic aspirate -nephrostomy or ileal conduit Blood cultures

Question 44

When should blood cultures be taken for a UTI?

Answer 44

If suspect pyelonephritis or severe sepsis Before starting IV antibiotics on any patient

Question 45

What is sterile pyuria?

Answer 45

When pus cells are (raised WCC) in urine and no organism grow with standard lab methods. A repeat sample is advised if symptoms continue.

Question 46

What causes sterile pyuria?

Answer 46

Inhibition of bacterial growth due to antibiotics or the sample is contaminated with antiseptic Fastidious organisms Urinary tract inflammation Urethritis due to STI

Question 47

When should a UTI be further investigated?

Answer 47

If UTI in childhood Pyelonephritis In men Recurrent UTIs Red flags for cancer

Question 48

What non-antimicrobial management is used to treat UTIs?

Answer 48

Increase fluid intake Anti inflammatories like NSAIDs Cranberry juice + extracts potentially Removal of catheter if no longer indicated Drainage of obstruction or abscess if present.

Question 49

What is the criteria and antibiotic has to meet to be used for a UTI?

Answer 49

Gets into urine Minimally toxic Effective against likely organisms Easily administered Cheap

Question 50

What are examples of antibiotics for UTIs?

Answer 50

For lower UTI only: Nitrofurantoin (inadequate for systemic infection) Pivmecillinam Fosformycin (oral formulation) Trimethoprim

Question 51

How do you treat cystitis in women?

Answer 51

Self care including increased fluid +/- ibuprofen 3 days of oral antibiotics (can be delayed prescription to try self care first)

Question 52

How do you treat cystitis in men?

Answer 52

Oral antibiotics for 7 days

Question 53

How do you treat cystitis if patient has a catheter?

Answer 53

7 days of antibiotics

Question 54

How is pyelonephritis treated empirically?

Answer 54

Broad action antibiotics against the likely causative pathogen E.g. cefuroxime, aztreonam, ciprofloxacin and gentamicin

Question 55

How is pyelonephritis treated directly?

Answer 55

With the narrowest spectrum antibiotic possible based on sensitivity results for 7-14 days depending on the antibiotic

Question 56

How long does pyelonephritis need treating for.

Answer 56

7-14 days

Question 57

How is prostatitis treated empirically?

Answer 57

IV pipercillin-tazobactam IV/PO ciprofloxacin

Question 58

How is prostatitis treated directly?

Answer 58

With IV pipercillin-tazobactam or IV/PO ciprofloxacin Or trimethoprim or co-trimoxazole

Question 59

How long is prostatitis treated for?

Answer 59

2-4 weeks uncles chronic bacterial prostatitis which is treated for longer

Question 60

Who is treated for asymptomatic bacteruria?

Answer 60

Pregnant people Infants People who are due to have a urological procedure

Question 61

Who does not require antibiotics for asymptomatic bacteruria?

Answer 61

Elderly patients Catheterised patients

Question 62

What lifestyle modifications are recommended for adults with confirmed recurrent UTIs?

Answer 62

Increased fluid intake Review of contraception Peeing after sex Oestrogen replacement in post-menopausal women