Urinary Tract Infections Part 1 Flashcards by amanda kastel

definition of a urinary tract infection

presence of microorganisms in the urinary tract (that can’t be accounted for by contamination)

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what is the most common bacterial infection AND the most common reason for antibiotic exposure

urinary tract infection

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around 60% of females will develop a UTI in their lifetime and ____% will have a recurrence within _____

25% within a year

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true or false

urinary tract infections are always more common in women, regardless of age

false

rates are much higher in women, but up until men reach 65 yrs - at this point their rates are similar to women

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urinary tract infections encompass a wide spectrum of clinical entities

explain this

UTI’s can range from an asymptomatic infection – acute pyelonephritis (kidneys) — sepsis

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what is an upper UTI

pyelonephritis - kidney infection

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what is a lower UTI

could be 3 things –

-cystitis (bladder)
-urethritis (urethra)
-prostatitis (prostate gland)

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2 ways UTIs can be classified

complicated or uncomplicated

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define uncomplicated vs complicated UTI in terms of who they affect

uncomplicated - affects premenopausal women of childbearing age (15-45) who are NORMAL and HEALTHY

complicated – UTI in anyone else (ie - any male)

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differentiate between uncomplicated vs complicated UTI based on what they AFFECT

uncomplicated - there are no structural or functional abnormalities of the urinary tract that affect the normal flow of urine

complicated - result of a predisposing factor like a congenital abnormality/distortion of urinary tract, a stone obstruction, or some neurological deficit that INTERFERES WITH THE FLOW OF URINE

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2 main causes of outpatient UTIs

e. coli (MOST - 75-90% of outpatient cases!!)

second is staph saprophyticus in young women (18-22)

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which bacteria is usually a contaminant in urine samples

staph epidermidis

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2 bacteria that commonly cause UTI IN hospitalized patients

pseudomonas and enterococcus

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2 gram negative bacteria that can cause UTI (not pseudomonas and enterococcus)

klebsiella pneumoniae
proteus

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which bacteria usually causes bacteremia and kidney abscess

staph aureus

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generally differentiate between symptoms of a lower UTI vs upper

lower UTI has more localized symptoms like pain when urinating and urgency

upper UTI has those same symptoms but more constitutional symptoms as well like fever nausea, vomiting, malaise

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TRUE OR FALSE

symptoms alone are not a sufficient way to diagnose a UTI

true. symptoms can be used to differentiate upper and lower, but not to diagnose a UTI itself

must have a good urine specimen AND SYMPTOMS

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“gold standard” to diagnose a UTI

a positive urinalysis with a positive urine culture in a SYMPTOMATIC patient

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what is usually the initial step of diagnosing a UTI?

what is done to confirm diagnosis?

initial step is urinalysis

urine culture is done to confirm, but NOT routinely done in outpatient settings for uncomplicated cystitis because MOST OF THE TIME it’s gonna be e. coli anyway

HOWEVER, urine cultures are done to confirm in pyelonephritis (upper - kidney), when treatment isn’t working, or when the patient has atypical symptoms

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3 methods of urine collection and which is preferred

midstream clean-catch method (preferred)

also catheterization and suprapubic bladder aspiration

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explain the midstream clean-catch method

clean urethral opening and discard initial 20-30mL of urine

collect the midstream void and process immediately OR refrigerate if you can’t do so

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catheterization is done to collect urine in which patients?

what is a potential issue with this method of collecting urine

pts who are uncooperative or unable to pee

issue is that it may introduce bacteria into the bladder – causes 1-2% of bladder infections

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in what patients is suprapubic bladder aspiration done to collect urine?
explain the method

the needle is inserted directly into the bladder to aspirate the urine

its safe and painless and bypasses any contaminating organisms in the urethra

done in bbs, paraplegics (leg paralysis), and very ill patients
-these patients NEED a reliable sample to make clinical decisions

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what does a urine culture do

identifies the organisms and provides the susceptibilities

(THATS IT- EVERYTHING ELSE LIKE BACTERIURIA AND HEMATURIA ARE URINALYSIS)

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define bacteruria

when >100,000 CFU/mL of urine

what is pyuria

WBC in urine >10WBC/mm3

what does "nitrite positive" mean and what detects this

detected in urinalysis some bacteria (like e. coli) are able to reduce nitrates to nitrite --- nitrite positive indicates presence of such bacteria

what value in a urinalyis helps to identify if the patient is hydrated/dehydrated what is reference range??

specific gravity 1.001-1.035

what component of a urinalysis is a marker for white blood cells in the urine (pyuria)

leukocyte esterase

what is a marker for common bacterial pathogens in a urinalysis?

nitrite

name 3 bacteria that DO reduce nitrate to nitrite and 3 bacteria that do NOT

DO - e. coli, klebsiella, proteus DONT - pseudomonas, enterococci, coagulase negative staph

are WBC and RBC found in the dipstick or microscopic portion of a urinalysis

microscopic

bacteria are too numerous to count - is this consistent with a urinary tract infection?

YES

epithelial cells are too numerous to count in microcopic portion of a urinalysis - is this consistent with a urinary tract infection?

NO this most likely indicates a contaminated culture

TRUE OR FALSE urinalysis and urine cultures are only useful when also used in conjunction with symptoms

TRUE bc there are many factors that can affect urinalysis results that are not bc of infection ie - for postmenopausal women it is normal to have inflammation in urinary tract - normal for them to have high WBC and leukocyte esterase

urine collected should be testes or cultured within _______ of collection to avoid _____

within 20 mins of collection to avoid erroneously high bacteria counts if unable to do within 20 mins, referigerate until testes

4 treatment goals for UTIs

-get rid of infecting organism(s) -prevent/treat systemic consequences of the UTI -prevent infection from recurring -decrease the potential for collateral damage when we use broad spectrum antibiotics

as mentioned, 1 of the treatment goals for UTIs is to limit the collateral damage when we use broad spectrum antibiotics name 2 components of this potential collateral damage

- breeds resistance - unwanted colonization and infection with multidrug resistant organisms -impact on gut flora - can cause c diff

3 components of overall management of UTIs

initial evaluation empiric antibiotics follow up

true or false test-of-cure is not recommended for UTIs

true dont resend the urine to confirm infection cleared. if they feel better - it's good enough

e. coli has been increasing its resistance to which class of antibiotics

fluoroquinolones - particularly cipro

true or false the overall resistance rates for e. coli are higher in the US than they are in canada

true

what are some risk factors for a patient having e.coli bacterial resistance? (within the prior 3 months of starting the antibiotic)

have a history of multi-drug resistant organisms recently have used broad spectrum antibiotics healthcare exposures travel to parts of world where MDRO's are prevalent

to optimize empiric therapy in terms of avoiding the issue of resistance, what is necessary?

have to ongoingly monitor the LOCAL prevalence of resistance USING ANTIBIOGRAMS

prior to starting antibiotics, do what 2 things

collect urine for urinalysis and urine culture (if complicated)

3 1st line options for empiric treatment for uncomplicated cystitis

nitrofurantoin bactrim fosfomycin

true or false e. coli is usually very susceptible to nitrofurantoin

true

dose of nitrofurantoin for uncomplicated cystitis

100mg Q12 5 days

dose of bactrim for uncomplicated cystitis

1 tab q12 3 days

dose of fosfomycin for uncomplicated cystitis

3g PO for 1 dose

true or false nitrofurantoin has a lot of resistance issues

FALSE - minimal resistance

in which particular UTI is nitrofurantoin AVOIDED

pyelonephritis

most common ADR of nitrofurantoin which 2 are really only seen wiith long term use

GI intolerance neuropathies and pulmonary toxicity

ADRS of bactrim

rash (sjs) hyperkalemia photosensitivty hematologic (pancytopenia)

which 1st line drug for uncomplicated cystitis is avoided if the local resistance prevalence is greater than 20%??

bactrim

aside from not using bactrim when local resistance prevalence is greater than 20%, when else should bactrim be avoided for UTI

if it was used for UTI in previous 3 months (resistance)

what is the only 1st line for uncomplicated cystitis that CAN be used for pyelonephritis

bactrim fosfomycin and nitrofurantoin can't

ADR fosfomycin is it used often? explain

diarrhea, headache, angioedema (but generally well tolerated) it retains activity against multi drug resistant organisms, so not really given to anyone other than those with a MDRO also expensive

which 1st line for uncomplicated UTI is avoided in creatinine clearance less than 30mL/min

nitrofurantoin

monitoring parameters for nitrofurantoin

serum creatinine and BUN

monitoring parameters for bactrim

serum creatinine, bun, electrolytes (potassium), and watch for rash

what if the 3 first line options for acute uncomplicated cystitis cannot be used?? explain (nitrofurantoin, bactrim, or fosfomycin (if MDRO))

use fluoroquinolones (but bad resistance profile) or beta lactams (but avoid ampicillin or amoxicillin alone - less effective than other agents)

a patient's urinalysis and symptoms are consistent with UNCOMPLICATED CYSTITIS allergy to sulfa. when antibiotic regimen is most appropriate

nitrofurantoin 100mg Q12H 5 days

true or false both macrobid and fosfomycin CANNOT BE USED for pyelonephritis

TRUE

true or false in clinical practice, fluoroquinolones are used for empiric treatment of acute pyelonephritis

FALSE this is recommended in the guidelines, but NOT DONE IN CLINICAL PRACTICE serious side effects. risks outweigh benefits. tendon rupture, hypoglycemia, neuro effects, peripheral neuropathies, QT prolongation ONLY RESERVED FOR THOSE WITH NO OTHER OPTIONS

though quinolones are recommended in the guidelines for outpatient acute pyelonephritis, they are not used what is used in clinical practice instead?

if FQ resistance greater than 10%, ceftriazone 1g IV/IM for one dose OR gentamicin/tobramycin 5mg/kg IV/IM for one dose or bactrim Q12H for 14 days IF THE PATHOGEN IS KNOWN TO BE SUSCEPTIBLE if not, potentially beta lactams, but they're less effective for pyelonephritis. if we use them PO, first must give initial dose of long acting IV antibiotic like ceftriaxone

indications for hospitalization for acute pyelonephritis

sepsis persistent high fever severe pain urinary obstruction

empiric treatment for pyelonephritis in HOSPITALIZED PATIENT

3 options - all IV most often it's ceftriaxone 1g (ext spectrum cephalosporin) BC IT'S NARROWEST OF THE 3 EMPIRIC OPTIONS - OTHER 2 ARE BROAD could be aminoglycoside (genta or tobra 5mg/kg) carbapenem - drug of choice for ESBL (etrapenem 1g)

very important consideration when choosing treatment for pyelonephritis in hospitalized patient AND outpatient pyelonephritis

FOLLOW THE CULTURES AND SUSCEPTIBILITIES (complicated)

Urinary Tract Infections Part 1 Flashcards

(70 cards)