UTI

Question 1

What is considered an upper UTI?

Answer 1

Kidney and Ureters

Question 2

What is considered a lower UTI

Answer 2

Prostate

Bladder

Urethra

Question 3

What is another name for a lower UTI and what are the symptoms?

Answer 3

Simple

Urinary frequency
Urinary urgency 
Dysuria
Suprapubic tenderness
Gross Haematuria

Question 4

What is another name for upper UTI and what are the symptoms?

Answer 4

Complicated

Often cystitis Sx (not always) with addition of:
Systemic symptoms
Fever, rigors, lethargy
Loin pain/ paravertebral tenderness

Question 5

What are the common uropathogens causing UTIs

Answer 5

Enterobacteriaceae
Escherichia coli  (75-95% cystitis)
P-fimbriated 
Klebsiella spp.
Proteus spp.
Staphylococci saprophyticus- young women

Recent antimicrobials, hospitalisation and urinary catheters
Pseudomonas spp, Enterococcus spp, and Staphylococci spp.

Question 6

What tests are required for UTI diagnosis?

Answer 6

Urinalysis

urine culture

Question 7

How does urinalysis work?

Answer 7

Detect
Leukocyte esterase released by leukocytes indicating pyuria
Nitrites- produced by some Enterobacteriaceae by breaking down nitrates

Can modestly improve diagnosis but cannot adequately rule out infection.

Question 8

When do you not use urinalysis?

Answer 8

Asymptomatic, elderly or catheterised patients

Question 9

Function of urine culture?

Answer 9

Confirm the presence of bacteriuria and to provide antibiotic susceptibility.
Mid stream urine routine
Out-with pregnant women only perform culture of urine on symptomatic patients.
≥ 100 000 cfu/ml of a single strain of bacteria confirms bacteriuria, however recent studies have suggested ≥1000 cfu/ml of E. coli can represent infection in symptomatic patients1.
Mixed cultures usually indicate contamination.

Question 10

Why are woman at more risk for cystitis than men?

Answer 10

Anatomy- shorter distance from anus to urethra compared to men

Question 11

Risk factors for cystitis in adult woman

Answer 11

Sexual activity 
Recent UTI
Diabetes mellitus 
Urinary tract abnormalities
Post-menopause

Question 12

Clinical symptoms in acute cystitis in women?

Answer 12

Dysuria
Urinary frequency
Urinary urgency
 Suprapubic pain 
 Haematuria (sometimes)

Question 13

When should you look for an alternative diagnosis for acute cystitis in women?

Answer 13

Explore alternative diagnosis if vaginal discharge/itch present

Question 14

What investigations for AC in women under 65 years?

Answer 14

In women with 3 or more symptoms of cystitis
Treat empirically. No further investigations required.

Urinalysis:
use to guide treatment decisions mild or 2 symptoms or less or atypical symptoms.
Be wary of using urinalysis in elderly patients

MSU:
Risk of multidrug resistant pathogens, to guide treatment in patients who do not respond to first line antibiotics.

Question 15

Epidemiology of AC in men?

Answer 15

Much less common in men between 16-50 years due to anatomical differences.
Elderly males: risk increases = elderly women, in part due to outflow obstruction

Question 16

AC in men?

Answer 16

Urinary frequency, dysuria, urgency, suprapubic pain, haematuria

Question 17

What should you always evaluate for in AC in men?

Answer 17

Systemic upset/costovertebral tenderness upper urinary tract infection.
Prostatitis- pelvic/perineal pain, obstructive symptoms (dribbling and hesitancy).
Chronic prostatitis-recurrent infections.
STIs and urethritis in all sexually active men.

Question 18

Diagnosis of AC in men?

Answer 18

Diagnosis of UTI: There is no evidence to suggest the best method for diagnosing UTI in men.

All men with suspected UTI should be regarded as complicated.

Send urine for culture in all suspected cases.

All men with recurrent UTIs should be referred for Urological investigation.

Question 19

Antibiotics treatment of acute cystitis?

Answer 19

Empirical treatment: Nitrofurantoin or Trimethoprim

Women: 3 days
Men: 7 days

Nitrofurantoin: Avoid in renal failure (eGFR <45 ml/min) due to concerns regarding toxicity.

Second line therapy: in treatment failure use antibiotic susceptibility from urine cultures to guide therapy.

Question 20

How to confirm asymptomatic bacteriuria?

Answer 20

Laboratory confirmed bacteriuria:
2 x specimens with at least 100 000 cfu/ml of a pure culture for women, only 1 required for men.
Common especially in elderly patients-
DO NOT TREAT
there is no benefit in terms of morbidity/mortality from treating UNLESS Pregnant or in Renal Transplant.

Question 21

Define recurrent UTI

Answer 21

3 or more laboratory confirmed UTIs within a year

Question 22

What should you assess for with recurrent UTI

Answer 22

Constipation 
Uterine prolapse
Atrophic vaginitis 
Diabetes
Prostatitis 
Relating to sexual intercourse
Sexually transmitted diseases

Question 23

Investigations for recurrent UTI in women?

Answer 23

Investigations: Check renal function, urinary tract USS

Question 24

How to treat recurrent UTI in women?

Answer 24

Non-antibiotic approaches:

Consider cranberry supplements in women- evidence is lacking but some may benefit from this.

Antibiotic approaches:

Post-intercourse antibiotic e.g. trimethoprim single dose
Standby antibiotics- 3 day course dependant on known susceptibilities
Prophylactic antibiotics- 3- 6 months course, stop and assess. Specialist input only. Trimethoprim preferred.
Promotes resistance. Evidence for benefit is not strong.

Question 25

Define acute pyelonephritis

Answer 25

Infection causing inflammation of the kidneys

Question 26

Most common cause of upper UTI

Answer 26

E. coli

Question 27

Clinical presentation of acute pyelonephritis

Answer 27

Cystitis symptoms of dysuria, urinary frequency, suprapubic pain and haematuria PLUS Systemic illness – fever, rigors, marked fatigue. Loin pain/costovertebral tenderness- often unilateral Fever and flank pain think pyelonephritis. Sepsis and no localizing symptoms think pyelonephritis in differential Pelvic/perineal pain in men- ? prostatitis Discharge/itch- ?pelvic inflammatory disease

Question 27

Clinical presentation of acute pyelonephritis

Answer 27

Cystitis symptoms of dysuria, urinary frequency, suprapubic pain and haematuria PLUS Systemic illness – fever, rigors, marked fatigue. Loin pain/costovertebral tenderness- often unilateral Fever and flank pain think pyelonephritis. Sepsis and no localizing symptoms think pyelonephritis in differential Pelvic/perineal pain in men- ? prostatitis Discharge/itch- ?pelvic inflammatory disease

Question 28

Examination of acute pyelonephritis

Answer 28

Fever SIRS and SEPSIS 6 Costovertebral tenderness. Suprapubic tenderness. Caution if significant abdominal tenderness/guarding consider reasons for acute surgical abdomen.

Question 29

Investigations for pyelonephritis

Answer 29

All patients: Urine culture. Urinalysis- absence of pyuria may indicate alternative diagnosis if atypical presentation. Inpatients: Blood cultures, FBC, UECs, LFTs, CRP, (lactate if sepsis).

Question 30

Indications of sever pyelonephritis

Answer 30

Severely unwell, Persisting clinical symptoms (48-72 hours) Urinary tract obstruction or Acute Kidney Injury Recurrence of symptoms. Renal tract ultrasound or Computed tomography

Question 31

Who is at risk of a complicated urinary tract infection and how should they be managed?

Answer 31

Patients with urinary stones, history of urological surgery e.g. ureteric stents are at increased risk of both upper urinary tract infections and complications. Perform imaging Seek prompt urological input for obstructive related upper urinary tract infections. Surgical management aimed at relieving the obstruction

Question 32

When should pyelonephritic patients be admited?

Answer 32

If septic, at higher risk of complications (e.g. diabetic), unable to take oral medication or concerns re urinary tract obstruction.

Question 33

Antibiotics therapy for pyelonephritis

Answer 33

IV amoxicillin 1g TDS and IV gentamicin (NHS Lothian calculator) Oral options include: cotrimoxazole, co-amoxiclav and ciprofloxacin. Do not use nitrofurantoin. Review with culture results 7 to 14 days in acute pyelonephritis. Do not continue gentamicin >72 hours without specialist input. All male patients with upper urinary tract infections should be referred for urological investigation.

Question 34

Signs and symptoms of catheterised UTIs

Answer 34

``` New fever, rigors, delirium. Flank pain Pelvic discomfort Acute haematuria In patients whom catheter has been removed- dysuria, urgency, suprapubic pain ```

Question 35

Investigations for UTI catheterized patients

Answer 35

Do not perform urine dipstick on catheterised patients. Send urine for culture. Send bloods and blood cultures. Do not treat asymptomatic bacteriuria. Catheters become colonised very rapidly after insertion, 80% of urinary catheters are colonized at 1 month.

Question 36

UTI antibiotic management in catheterised patients

Answer 36

IV gentamicin dose as per NHS Lothian calculator. Change urinary catheter, consider the need for ongoing catheterisation. Monitor daily decision for ongoing antibiotic therapy 7 day course of antibiotic therapy for males and females with symptomatic catheter associated UTI with prompt resolution of symptoms. Do not continue gentamicin for longer than 72 hours without specialist input Review with urine culture results and refine antibiotic choice.

Question 37

Why is diagnosing UTIs in elderly patients more difficult

Answer 37

Non-specific symptoms- delirium, abdominal pain, loss of diabetic control. High rates of bacteriuria

Question 38

How to assess UTI for elderly patients

Answer 38

Urinary tract infection based upon full clinical assessment. Urine dipstick is not routinely recommended in this age group due to difficulties with interpretation. Extra care with antibiotic prescribing due to increased risk of adverse effects and Clostridiodes difficile infection.