IC13 Urinary Tract Infections

Question 1

Who need to be screened and treated for asymptomatic bacteriuria?

Answer 1

1) Pregnant women
2) Patients undergoing urologic procedure, where mucosal bleeding is expected

Question 2

How does the risk of UTI change from infants to elderly?

Answer 2

0-6 months
Males > Females
More structural and functional abnormalities in males

1yo - Adult
Females > Males
Females have shorter urethra
Males have additional protection of antibacterial substances secreted by prostate

Older than 65
Males = Females
Comorbidities increase risk of UTI

Question 3

What is ascending UTI?

What are the risk factors? (2 pts)

Most common pathogens?

Answer 3

Colon or Fecal bacteria colonise urethra → Ascend to bladder and kidney

Females > Males
Use of spermicide, diaphragm contraceptive

Gut bacteria
Gram (-) enterobacteriales gut bacteria eg. E.coli, Klebs, Proteus

Question 4

What is descending UTI?

Risk factor?

Caused by which pathogen?

Answer 4

Bacteria from distant site (eg. heart valve, bone) travel to bloodstream → bacteremia → urinary tract

Patient may already have endocarditis, osteomyelitis, other infections elsewhere

Non-gut Bacteria
Staph Aureus
Mycobacterium TB

Question 5

Non pharm advice for UTI (6 points, incl after poo and sex, clothing)

Answer 5

Drink more water to flush out bacteria
Urinate frequently, when you feel the urge
Urinate after sex
Wipe from front to back
Wear cotton underwear, loose fitting clothing
Modify contraceptive

Question 6

Who falls under uncomplicated UTI?

Answer 6

In healthy premenopausal, non-pregnant women, no history of abnormal urinary tract

Question 7

What are the diagnosis tests needed for uncomplicated UTI?

Answer 7

no need any urinalysis or culture!!

Question 8

Likely pathogens for Uncomplicated or Community acquired UTI

Answer 8

E. coli (85%)

Staph saprophyticus (5-15%)
Common coloniser

Gut gram (-) (Enterococcus faecalis, Klebs, Proteus)

Question 9

First line treatment for Uncomplicated cystitis

Answer 9

Usually use Cotrimoxazole and nitrofurantoin
doses will be lower than pyelonephritis

PO Co-trimoxazole 800/160mg BD x 3d

PO Nitrofurantoin 50mg QD x 5d
CI in CrCl < 30 ml/min
Not in Pyelonephritis

PO Fosfomycin 3g single dose
Not used in hospitals
Reserved for ESBL producing E.coli
Not for pyelonephritis

Question 10

Alternative treatment for uncomplicated cystitis

Answer 10

PO Beta-lactams (5-7 days)
Cefuroxime 250mg BD
Amox-Clav 625mg BD

Question 11

Benefit of fluoroquinolone in UTI?

Why shouldnt use fluoroquinolones in uncomplicated cystitis? (3 points)

Answer 11

Concentrate well in urinary tract

Many AE
Collateral damage
Ciprofloxacin only oral agent for pseudomonas

Question 12

Patient population with complicated UTI? (4 points)

Answer 12

Men

Children

Pregnant women

Factors that ↑ risk of getting and recurrent UTI, eg. functional, urinary tract abnormalities, genitourinary instruments, DM, immunocompromised

Question 13

Diagnostic test needed for complicated UTI

Answer 13

UFEME
Dipstick
Urine culture

Question 14

Likely pathogen in Complicated or HA-UTI (4 points)

Answer 14

E.coli (50%)
Enterococci
Pseudomonas (HAI)
Drug resistant strains
ESBL producing Ecoli, Proteus, Klebs

Question 15

Treatment for complicated cystitis in women

Answer 15

Same drugs as Uncomplicated Cystitis in women
Cotrimox, Nitrofurantoin

Treat for longer duration 7-14 days

Question 16

treatment for UTI in men, cystitis with no concern for prostatitis

Answer 16

Same as complicated cystitis
7-14 days

Question 17

Treatment for UTI in men, cystitis with concern for prostatitis, pyelonephritis

Answer 17

PO Ciprofloxacin 500mg BD
PO Co-trimoxazole 800/160mg BD
10-14 days

Question 18

How long should prostatitis be treated for?

Answer 18

6 weeks

Question 19

Symptoms of Cystitis

Answer 19

More localised symptoms
Dysuria, urgency, frequency, nocturia, blood in urine (gross hematuria), suprapubic pain

Question 20

Symptoms of Pyelonephritis

Answer 20

More systemic symptoms
Fever, rigors, headache, N/V, malaise, flank pain, renal punch, abdominal pain

Question 21

What are some markers to test for UFEME? (5 points)

Which can confirm presence of UTI?

Answer 21

> 10 WBC /mm3 = Pyuria, inflammation
Must have pyuria to be UTI

Red Blood cells
Hematuria
Occurs frequently, nonspecific
Could be due to menses, trauma

Gram stain
Identify microbes or yeast

WBC casts
Cells or proteins formed in renal tubules
Indicate Upper UTI

Squamous Epithelial
Indicates contamination

Question 22

What is tested in urine dipstick?

Answer 22

Nitrite
Test for gram (-) bacteria
Reduce nitrate to nitrite
Requires 10^5 bacterial per ml
False positive results can occur
Gram (+)
Pseudomonas Aeruginosa
Low urinary pH
Dilute urine
Frequent urination

Leukocyte esterase (LE)
Occurs with significant pyuria

Question 23

First line treatment for Pyelonephritis (3 points)

Answer 23

principle: high dose, for long duration (14 days), except for fluoroquinolones cos can concentrate well in urine (7 days)

PO Fluoroquinolones
Ciprofloxacin 500mg BD x 7d
Levofloxacin 750mg OD x 5d

PO Co-trimoxazole
800/160mg BD X 14d

PO Beta lactam (10-14d)
Cefuroxime 250-500mg BD
Amox-Clav 625mg TDS

Question 24

Treatment for severely ill patient who require hospitalisation with pyelonephritis (cover what)

Answer 24

Use aminoglycosides to cover ESBL producing strains

IV Ciprofloxacin 400mg BD + IV Gentamicin 5mg/kg

others + gentamicin
IV Cefazolin 1g TD
IV Amox-Clav 1.2g TD

Question 25

Risk factor for Nosocomial / Healthcare associated UTI (3 points)

Answer 25

Hospitalised or Invasive urological procedures in the last 6 months
Indwelling catheter
Exposure to antibiotics

Question 26

Possible pathogens in Healthcare Associated-UTI (2 points)

Answer 26

Pseudomonas
ESBL producing E.coli, Klebs

Question 27

What to cover for HA-UTI?

Empiric treatment for HA-UTI (more sick, less sick, duration of therapy)

Answer 27

Pseudomonas, ESBL producing gram (-)

More sick = More broad spectrum
IV Cefepime 2g BD + IV Amikacin 15mg/kg/d
Cefepime cover pseudomonas, Amikacin cover ESBL, resistant pseudomonas
IV Imipenem 500mg QD
IV Meropenem 1g TD

Less sick = Narrow spectrum
PO Levofloxacin 750mg
PO Ciprofloxacin 500mg BD

7-14 days

Question 28

How to obtain urine sample for patients with CA-UTI?

Answer 28

Remove old catheter, so that pathogen found will not be from biofilm but from patient

Question 29

When to give antibiotics for CA-UTI?

Answer 29

Only when patient is symptomatic

Systematic symptoms: New onset or worsening fever, rigors, altered mental status, pelvic discomfort

Question 30

Empiric treatment for CA-UTI

Duration of treatment

Answer 30

similar to HA-UTI for serious patients on IV

7 days for prompt resolution and deferverse in 3 days, 10-14 days for those with delayed response

Question 31

What is the requirement for patient to be on PO Cotrimoxazole with CA-UTI, and no pseudomonas coverage (2 points)

Answer 31

Younger than 65, no upper urinary tract symptoms after catheter removed

Question 32

Antibiotics contraindicated in pregnancy and why (4 points)

Answer 32

Ciprofloxacin
Fetal cartilage damage
Arthropathies

Cotrimoxazole (in 1st and 3rd trimester)
1st trimester: Folate deficiency
3rd trimester: Kernicterus

G6PD deficiency
Nitrofurantoin (at term, 38 week onwards)
Cotrimox

Aminoglycosides

Question 33

What should we give to pregnant patients

Answer 33

beta lactams eg. Cefuroxime, Amoxicillin clavulanate

treat for 7 days for ASB and cystitis, 14 days for pyelonephritis

Question 34

How long should symptoms resolve

Answer 34

1-3 days

Trace blood and urine cultures, streamline according to AST

Repeat culture for pregnant women

Question 35

Diagnosis of Pyuria

Answer 35

> 10 WBC /mm3 during EFEME analysis

Dipstick should show (+) Leukocyte esterase also