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3151 > UTI > Flashcards

UTI Flashcards

1
Q

When is screening and treatment of ASB indicated and why?

A
  1. pregnant women
    - prevent pyelonephritis, preterm labour, infant low birth weight
  2. patients undergoing urologic procedure where mucosal trauma/bleeding is expected (surgical antimicrobial prophylaxis)
    - prevent bacteremia and urosepsis
    - does not include placement/removal of catheter
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2
Q

What is the definition of ASB?

A

Asymptomatic bacteriuria (ASB): isolation of significant colony counts of bacteria in the urine of patient without symptoms of UTI

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3
Q

What is the definition of UTI?

A

Urinary Tract Infection (UTI): isolation of significant colony counts of bacteria in the urine of a patient with symptoms of UTI

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4
Q

Name the risk factors for UTI

A

Females > males, sexual intercourse, use of spermicides/diaphragms as contraceptives, abnormalities of the urinary tract (e.g. prostatic hypertrophy, kidney stones, urethral strictures, vesicoureteral reflux), neurologic dysfunctions (e.g. stroke, DM, spinal cord injuries), catheterization, anti-cholinergic drugs, DM, immunocompromised, pregnancy, genetic association (women with first degree relatives), previous UTI

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5
Q

Name the criteria for uncomplicated UTI?

A

UTI in healthy, pre-menopausal, non-pregnant women who do not have history suggestive of an abnormal urinary tract.

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6
Q

Name those that can be considered to have complicated UTI?

A

Complicated UTI (maybe complicated cystitis or complicated pyelonephritis)
Men
Children
Elderly
Pregnant women
Women (pre-menopausal), but with recurrent (relapse within 2 weeks) or frequent UTI
Women (pre-menopausal), but with risk factors, e.g. DM, immunocompromised, functional and structural abnormalities in the urinary tract, genitourinary instrumentation
Nosocomial/healthcare-associated UTI
CA-UTI

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7
Q

Describe the clinical presentation (signs and symptoms) of lower urinary tract infection?

A

dysuria, increased frequency, increased urgency, nocturia, suprapubic pain/heaviness, gross hematuria

elderly with recurrent UTI may present with non-specific symptoms such as: anorexia/loss of appetite, altered mental status, drowsiness, decreased alertness, mild gastrointestinal symptoms

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8
Q

Describe the clinical presentation (signs and symptoms + labs) of upper urinary tract infection?

A

fevers, rigors, malaise, headache, tachypnea, tachycardia, nausea, vomiting, abdominal pain, flank pain, positive renal punch (costovertebral pain; indicates a swollen and tender kidney)

labs for general systemic infection/inflammation:
elevated WBC, pro-calcitonin, C-reactive protein

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9
Q

Name the types of urine tests done to diagnose for UTI?

A

UFEME (microscopic urinalysis)
Urine dipstick test (chemical test)
Urine culture

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10
Q

Describe the findings from UFEME (microscopic analysis; Urine Formed Elements and Microscopic Examination) that indicate positive for UTI?

A

WBC > 10 cells/mm^3 (pyuria; in a symptomatic patient, absence of pyuria = unlikely UTI), RBC > 5 cells/HPF or gross (hematuria; frequently occurs in UTI, but have other causesu), presence of bacteria/yeast cells identified, presence of WBC casts (presence of WBC casts indicates upper urinary tract infection)

note: presence of squamous epithelial cells indicate contaminated sample

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11
Q

Describe the findings from urine culture (microscopic analysis) that indicate positive for UTI?

A

Positive urine culture

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12
Q

Describe the findings from urinary dipstick test (chemical urinalysis) that indicate positive for UTI?

A

Positive for nitrite (indicates presence of gram-negative bacteria that reduces nitrate to nitrite), positive for leukocyte esterase (indicates presence of leukocytes in urine, correlates with pyuria)

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13
Q

Outline the rationale for when to obtain urine cultures for UTI

A

Complicated UTI (may be complicated cystitis or complicated pyelonephritis, doesn’t matter) > need to take culture
Men
Children
Elderly
Pregnant women
Women (pre-menopausal), but with recurrent (relapse within 2 weeks) or frequent UTI
Women (pre-menopausal), but with risk factors, e.g. DM, immunocompromised, functional and structural abnormalities in the urinary tract, genitourinary instrumentation
Nosocomial/healthcare-associated UTI
CA-UTI

Uncomplicated UTI: healthy, pre-menopausal women with no history suggestive of anatomical/functional/structural deficits in the urinary tract
- uncomplicated cystitis > no need to take culture
- uncomplicated pyelonephritis > need to take culture

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14
Q

What is the likely pathogen causing community-acquired UTI?

A

E.coli (>85%)
Staphylococcus saprophyticus,
Enterococcus fecalis
Klebsiella spp.
Proteus spp.

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15
Q

What is the likely pathogen causing healthcare associated UTI (including catheter-associated UTI)? (healthcare-associated UTI will be considered complicated UTI)

A

E. coli (~50%) (incl. ESBL producing)
Enterococcus fecalis
Klebisiella spp. (incl. ESBL producing)
Proteus spp. (incl. ESBL producing)
Enterobacter spp. (incl. Amp-C producing)
Pseudomonas aeruginosa

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16
Q

What does the presence of S. aureus in urine culture suggest?

A

hematogenous infection (commonly due to bacteremia), to screen for other primary infection sites

17
Q

What does the presence of yeast/candida in urine culture suggest?

A

possible contaminant

18
Q

What are the categories for empiric treatment for different types of UTI? (including pregnant women)

A

community-acquired cystitis in women
community-acquired cystitis in men
community-acquired pyelonephritis in women
community-acquired pyelonephritis in men
nosocomial/healthcare-associated UTI
catheter-associated UTI (CA-UTI)

ASB in pregnant women
community-acquired cystitis in pregnant women
community-acquired pyelonephritis in pregnant women
nosocomial/healthcare related UTI in pregnant women

19
Q

Describe the adjunctive therapy for UTI

A

For pain and fever, treat using paracetamol/NSAIDs
For vomiting, provide rehydration
For urinary symptoms, treat using:
Phenazopyridine (Urogesic) PO 100-200mg TDS (provides topical analgesic effect on mucosa; not to be taken in G6PD patients, S/E includes N/V, orange-red discolouration of urine and stool)
and/or
urinary alkalization (relives mild discomfort, but unproven benefit)

20
Q

For microbiological clearance, when is repeat urine culture needed for patients with UTI?

A

In pregnant women to document clearance of infection, and in those who did not respond clinically to abx regimen

21
Q

Describe the general lifestyle modifications for prevention of UTI?

A

Drink lots of fluid to flush out bacteria in the urinary tract (6-8 glasses a day)

urinate frequently whenever you feel the urge

urinate shortly after sex

for women, always wipe from front to back after using the toilet, esp. after a bowel movement

keep the urethral area dry by wearing cotton underwear and loose-fitting clothes that are more airy; avoid tight jeans and nylon underwear which can trap moister

for women, avoid diaphragm or spermicides as contraception

22
Q

Describe the methods for prevention of CA-UTI?

A

avoid unecessary catheter use (always review the need for cattheter)

minimize duration of catheter use

long-term indwelling catheters should be changed before blockage is likely to occur

use of closed system

ensure aseptic insertion technique

23
Q

List the possible supplementary agents that may have benefits in preventing UTI? (remains controversial, need more reliable evidence)

A

cranberry juice, intravaginal estrogen cream, lactobacillus probiotics

24
Q

Define nosocomial/healthcare associated UTI?

A

Nosocomial UTI: onset of UTI >= 48h of admission
Healthcare-associated UTI: patients who have UTI who have recent hospitalization in the past 6 months, recent antibiotic use in the past 6 months, recent invasive urologic procedure in the past 6 months, who has an indwelling catheter

25
Q

Define catheter-associated UTI (CA-UTI)

A

CA-UTI: the presence of signs and symptoms compatible with UTI with no other identified sources of infection, along with siginificant isolates (>10 cfu/mm^3) of >=1 bacterial species, in a single catheter urine specimen, in patients who have an indwelling urethral, indwelling suprapubic, intermittent catheter OR in a midstream voided urine specimen from a patient whose catheter was removed in the last 48h

For catheter-associated UTI, short term catheterisation (<7 days) is associated with single organism infection while long term catheterisation is associated with polymicrobial infection

26
Q

Name the specific risk factors for the development of CA-UTI

A

duration of catheterization, colonization of the drainage bag/periurethral area/catheter, poor quality of catheter care incl. insertion, female, DM, impaired renal function

27
Q

Describe the empiric therapy for community-acquired cystitis in women (uncomplicated, complicated) and men

A

uncomplicated cystitis in women:
first line:
co-trimoxazole PO 800/160mg BD x 3 days
nitrofurantoin PO 50mg QDS x 5 days
fosfomycin PO 3g as a single dose

other alternatives:
cephalexin 250-500mg QDS x 5-7 days
amoxicillin-clavulanate 625mg BD x 5-7 days
ciprofloxacin 250mg BD x 3 days
levofloxacin 250mg OD x 3 days

complicated cystitis in women:
as above, but treat for 7-14 days; fosfomycin 3g EOD x 3 doses

cystitis in men:
as above, but treat for 7-14 days; fosfomycin is not used

28
Q

Describe the empiric therapy for community-acquired pyelonephritis in women and men

A

pyelonephritis in women:
first line:
co-trimoxazole PO 800/160mg BD x 10-14 days

other alternatives:
cephalexin PO 500mg QDS x 10-14 days
amoxicillin-clavulanate PO 625mg TDS x 10-14 days
ciprofloxacin PO 500mg BD x 7 days
levofloxacin PO 750mg OD x 5 days

if patient is severe and need IV:
cefazolin IV 1g q8h
amoxicillin-clavulanate IV 1.2g q8h
ciprofloxacin IV 400mg q12h
and/or gentamicin IV/IM 15mg/kg/day or as a single dose

pyelonephritis in men:
as above, prefer to use co-trimoxazole and ciprofloxacin for PO; treat for 6 weeks if prostatitis is present

29
Q

Describe the empiric therapy for nosocomial/healthcare acquired UTI

A

for less sick patients:
Ciprofloxacin PO 500mg BD x 7-14 days
Levofloxacin PO 750mg OD x 7-14 days

for more sick patients:
Cefepime IV 2g q12h x 7-14 days +/- amikacin IV 15mg/kg/day or as a single dose x 7-14 days
Meropenem IV 1g q8h x 7-14 days
Imipenem-cilastin IV 500mg q6h x 7-14 days

30
Q

Describe the empiric therapy for CA-UTI

A

for less sick patients:
Levofloxacin PO 750mg OD x 7-14 days

for more sick patients:
Cefepime IV 2g q12h x 7-14 days +/- amikacin IV 15mg/kg/day or as a single dose x 7-14 days
Meropenem IV 1g q8h x 7-14 days
Imipenem-cilastin IV 500mg q6h x 7-14 days

*for women =< 65 years old and have CA-UTI cystitis (no signs and symptoms of pyelonephritis) after an indwelling catheter has been removed in the past 48h, to treat as an uncomplicated community-acquired cystitis, hence give co-trimoxazole PO 800/160mg BD x 3 days

31
Q

Describe the options for culture-directed treatment of community-acquired ASB/cystitis/pyelonephritis and nosocomial/healthcare associated UTI in pregnant women

A

First line: beta-lactams
ASB/cystitis:
Cephalexin PO 250-500mg QDS
Amoxicillin-clavulanate PO 625mg BD
Treat for 4 days if ASB and 7 days if cystitis

pyelonephritis:
Cephalexin PO 500mg QDS x 14 days
Amoxicillin-clavulanate PO 625mg TDS x 14 days
Cefazolin IV 1g q8h x 14 days
Amoxicillin-clavulanate IV 1.2g q8h x 14 days

nosocomial/healthcare associated UTI:
Cefepime IV 2g q12h x 7-14 days
Meropenem IV 1g q8h x 7-14 days
Imipenem-cilastin IV 500mg q6h x 7-14 days

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