UTI/Pyelonephritis Flashcards
(46 cards)
1
Q
Bacteriuruia
A
bacteria in urine
- Significant bacteriuria- >105 bact/ml
- Asymptomatic bacteriuria- >105 bact/ml, no symptoms - then leave well alone
2
Q
Lower urinary tract infection (LUTI) definition
A
bladder ->Cystitis
3
Q
Upper urinary tract infection (LUTI)
A
Acute pyelonephritis, renal abscess, renal calculi
KIDNEYS
4
Q
Uncomplicated UTI
A
Infection in a healthy patient with normal GU tract and neurology (LUTI)
5
Q
Acute pyelonephritis definition
A
Infection of the upper urinary tract involving the kidneys
6
Q
Chronic pyelonephritis definition
A
pathological condition with renal scarring and potenitally loss of renal function. Infection may be a contributory cause but the term does not necessarily imply ongoing infection.
other factors include
- diabetes
- veso-ureteric reflux
- urinary obstruction
7
Q
Pyruria
A
presence of pus cells (neutrophill polymorphs) is in significant quantities of urine. This represents an inflammatory process in urine and is supportive evidence of the presence of a UTI
8
Q
Complicated UTI definition
A
UUTI =/- systemic signs and symptoms
Infection associated with factors that increase chance of acquiring bacteria and decrease efficacy of therapy
9
Q
Site of infection of UTIs are classified into:
A
- Bladder – cystitis
- Prostate – prostatitis – this is the most common site of presentation in the male.
- Renal pelvis - Pyelonephritis
10
Q
Relapse definition
A
Infection with the same organisms
11
Q
Recurrent definition
A
Infection with same or different organism
12
Q
Urosepsis defintion
A
complicated UTI:
- Temp >38ºC
- HR>90/min
- RR>20/min
- WBC >15.0 or<4.0
13
Q
Who gets bacteruria?
A
- Infants, first 3 months, boys > girls
- Preschool, girls > boys
- Adults
- Non- pregnant females,1-3%
- Males, 0.1%
- Other at risk groups
- Hospitalised patients
- Diabetic patients
- Post renal transplant
- Catheterised
14
Q
Management of bacteruria
A
- Treat asymptomatic bacteriuria in
- Preschool children (UTI Abnormalities, pyelonephritis or UTI for life)
- Pregnant patients
- Renal transplant/ otherwise immunocompromised
- Treatment in other asymptomatic patients NOT indicated
15
Q
Pathogenesis of urinary tract infections occurs in three ways, name them?
A
- ascending
- descending/haematogenous
- lymphatic
16
Q
Ascending UTI
A
- Urethral colonisation
- female>male
- Multiplication in bladder
- Ureteric involvement
- Haematogenous
17
Q
Haemotgenous
A
- Blood-born bacteria (infection from other part of the body and seeds into renal tract)
- Involvement of renal parenchyma
- Gram positive bacteria> Gram negative bacteria
18
Q
UTIs are caused by?
A
- >95% caused by single organism
- Multiple organisms in
- Long term catheters
- Recurrent infection
- Structural/ neurological abnormalities
- Multi-drug resistant organisms
- Frequent infections
- Multiple antibiotic courses
- Anatomical/neurological abnormalities
- Prophylactic antibiotic use
19
Q
Clinical features of UTI
A
- Dysuria: Painful urination
- Urgency, Frequency, Nocturia
- Fever
- Suprapubic discomfort
- Haematuria: Blood in the urine
- Cloudy or smelly urine
- Abdominal pain and vomitting in child
- failure to thrive, jaundice in neonates
- incontinence, confusion in the elderly
20
Q
Common organsims
A
Gram negative bacilli
- ecoli
- kebsiella
- proteus
- psuedomonas
Gram positive bacteria
- stretococcus (enterococcuus)
- Staphylococcus
Anaerobes
candida
Mnemonic KEEPS (klebseilla, Enterococcus, Ecoli, Psuedomonas, staphylococcus saphrocyticus)
21
Q
Simple/Uncomplicated UTI
A
- female aged 18-65
- 1st presentation
- no signs of pyelonephritis
- not pregnant
22
Q
Complicated UTI
A
- Pregnant
- elderly
- children
- male
- recurrent
- pyelonephritis
23
Q
UTI in non pregnant women clinical features, investigations and treatment
A
- Dysuria (Pain on passing urine)
- Frequency (passing urine more often than usual)
- Urgency (the feeling that you need to pass urine)
- Suprapubic pain
- Polyuria (Increased volume of urine)
- Haematuria (blood in the urine)
Consider UUTI in patients with fever or back pain
Investigations and treatment
LUTI
- MCU, if cloudy then dipstick
- check previous culuture results
- Treatment
- 3 day course of Nitrofuranticin or trimethoprin
UUTI
- Take culture immediately
- Start antibiotics immediately do not wait culture results
- Treatment
- more aggressive
- 7 day course of ciprofloxacin 7 days or co-amoxiclav 14 days
- change antibiotic once cultures comes back
24
Q
UTI in pregnancy
A
Features
- common
- evidence to suggest that asymptomatic bacteruria in pregnancy is associated with increased risk of pyelonephritis and premature delivery
Investigations
- send urine sample at booking scan and with each presentation (MCU)
- Confirm presence of bacteruria with 2nd urine culture
Treatment
- Symptomatic - culture then 7 day course
- Asymptomatic - guidelines then 7 day course
- Treat for 7-10 days
- always refer to guidelines
- amoxicillin and cefalexin relatively safe
- avoid trimethoprin in 1st trimester
- avoid nitrofurantoin near term
- may need hospital admission for IVs if severe
- can develop pyelonephritis (30%)
25
Recurrent UTI features, investigations and treatment
* \>2 episode/year
* Mostly women
Investigations
* Repeat MSU with each episode
* Urological investigation/ rule out UUTI
Treatment
* Self administered single dose/short course therapy
* Single dose post coital
* Books say prophylactic antibiotics
* Most microbiologists say stop
* cranberry products - cranberry tablets more effective (patients taking warfarin shouldnt continue)
* *
26
Catheter related UTI can be due to:
infection due to:
* disturbance of the flushing system
* colonisation of the urinary catheter
* biofilm production by bacteria
27
Likely organisms in catheter related UTI's
* patients flora
* patient-patient transmission
28
Complications of catheters
* obstruction
* urinary tract stones
* chronic renal inflammation
* renal failure
* long term risk of bladder cancer
29
Treatment of catheter related UTIs
_asymptomatic_
* dont treat
_Symptomatic_
* Start empirical antibiotics
* Remove catheter if needed
* Replace catheter under antibiotic cover
* Historically Gentamicin/ Ciprofloxacin
* Poor Gram positive cover
* Increase in resistant GNB
* Check recent culture results
* May need to use broad spectrum antibiotics
* 7 day course or 10-14 day course if delayed response
30
Prevention of catheter infection
* Catheterise only if necessary
* Remove when no longer needed
* Remove/replace if causing infection
* Catheter care
* Hand hygiene
* Review need for catheter regularly
* “Forgotten catheter”
31
Management of acute pyelonephritis
* Community, Trimethoprim/Ciprofloxacin (NICE)
* Hospital, Ciprofloxacin/broad spectrum abx
* May remain symptomatic for few days
* No response, warrants further investigation
* Uncomplicated pyelonephritis, 14/7 antibiotic
* Complicated pyelonephritis, \> 14/7 therapy
32
Complications of UTI
* perirenal abscess
* renal abscess
33
Peri-renal abscess Risk factors and common organisms
Risk factors
* Urinary calculi
* Diabetes mellitus
* Bacteraemia, haematogenous spread
Common organisms
* Gram negative bacilli, E.coli, Proteus sp.
* Gram positive cocci, Staph aureus, Streptococci
* Candida sp.
34
Peri-renal abscess symptoms, investigations and management
**Signs and symptoms**
* Similar to pyelonephritis
* Localised signs and symptoms
**Investigations**
* Radiologically confirmed
* ¨Pyuria +/- bacterial growth
* ¨Usually positive blood cultures
* LOTS OF WHITE CELL without bacteria growth in urine SUSPECT ABSCESS
**Antibiotic treatment**
* Treat empirically as complicated UTI
* Poor response to antibiotic therapy-as ABx wont reach kidneys
* Surgical management
35
Renal abscess features, treatment and what is emphysematous pyelonephritis?
* Complication of pyelonephritis
* Unilateral
* Similar symptoms to pyelonephritis
_Emphysematous pyelonephritis_
* **life threatening condition caused by Some gas forming e.g. E.coli**
* Urgent urology review
* High mortality rate
**Treatment**
* Treat empirically as complicated UTI
* Poor response to antibiotics
* Gram negative bacilli, likely organisms
36
Management of all UTI, complicated
* FBC, U+Es, CRP
* Urine sample
* Urethral, Suprapubic, Nephrostomy
* Blood culture if pyrexia or hypothermic
* Renal ultrasound
* CT KUB
* Antibiotic therapy14/7 or more
37
Urinary microscop interpretation
* Epithelial cells, contamination
* Bacteria with no WBC, contamination
* Bacteria with WBC and no catheter, infection
* Pyuria with no bacteria
* Previous/recent antibiotic
* Tumour
* Calculi
* Urethritis (check for Chlamydia)
* Tuberculosis
38
Local antibiotic guidleines to treat UTI
**Uncomplicated UTI**
PO Amoxicillin, Trimethoprim, Nitrofurantoin
* (Co-amoxiclav, Ciprofloxacin, Cefalexin) - c differgic but can be used to treat
**Complicated UTI**
* Usually IV therapy, e.g. Amoxicillin +Gentamicin
* Initially combination therapy unless result known
* Different antibiotics have different activities
* Do not omit an antibiotic without finding alternatives
* Drug monitoring may be needed, e.g. Gentamicin
**Empirical cover**
* Gram negative and Gram positive bacteria
39
When to do a laboratory confirmation of UTI
Do not do cultures from patients who are asymptomatic, non pregnant women whether they have a catheter or not.
do in
* women with mild or symptoms whos dipsitck is inconclusive
* UTI in men
* acute pyelonephritis
* pregnant women
* reccurent UTI
* children with suspected UTI
40
Mid stream urine sample (MSU)
Collected from non-cathetirsed patients
* discard the first 10-20 ml as anterior urethra is not sterile
* early morning are more likely to be positive from overnight growth
* collected into sterile vessel
* specimens refridgerated and vessels that contain boric acid to prevent bacterial overgrowth
catheter speciemens should be collected from the catheter sampling pot and not from the collecting bag
41
UTI in adult men investigations and treatment
**Investigations**
* MCU, no microscopy
* UUTI in men with backpain, fever
* more likely to be prostatits - caused by coliforms
**treatment**
* Symptomatic - 7 day course of trimpethoprin or nitrofuratin
* if prostate cause likely then quinolones as can penetrate prostatic fluid
42
Acute bacterial prostatitis features, organisms, investigations, management, complications
**Features**
* Localised infection
* Usually spontaneous
* May follow urethral instrumentation
* Fever, perineal/back pain, UTI, urinary retention
* Diffuse oedema, micro abscesses
**Likely organisms**
* ¨Gram negative bacilli, e.g. E.coli, Proteus sp.
* ¨S.aureus (MSSA, MRSA)
* N.gonorrhoea (less common
**Investigations**
* Urine culture, usually positive
* Blood culture
* Trans-rectal U/S
* CT/MRI
* Obtaining prostatic secretions not advisable
* do not PR extremely sore
**Treatment**
* Check sensitivity result
* Ciprofloxacin (no streptococcus cover)
* D/W microbiology in systemic infections
**Complications**
* Prostatic abscess
* Spontaneous rupture
* Urethra, rectum
* Epididymitis
* Pyelonephritis
43
Chronic bacterial prostatitis features, organisms, investigations, management, complications
Recurring infections in the prostate
**Features**
* Most asymptomatic
* Rarely associated with acute prostatitis
* May follow Chlamydia urethritis
* Perineal discomfort/back pain
* +/- low grade fever
* UTI symptoms
**Organisms**
* Gram negative bacilli, e.g. E.coli, Proteus sp.
* Enterococcus sp.
* S.aureus (MSAA, MRSA)
* Recurrent UTIs
* Diagnosis difficult
**Investigations**
* Quantitative Localised Technique
* Urethral urine
* MSU
* Expressed prostatic secretions (EPS)
* Post massage urine
* Interpretation
* Bacterial count in EPS \> ×10 urethral and MSU
**Treatment**
* Difficult
* Poor antibiotic penetration
44
Epididymitis featues, causes, symptoms
**Features**
* Inflammatory reaction of the epididymis (coiled tube that stored and carries sperm)
* Common
**Aetiology**
* Ascending infection from urethra
* Urethral instrumentation
**Symptoms**
* Pain, fever, swelling, penile discharge
* Symptoms of UTI/urethritis
**Common organisms**
* In sexually active men
* Rule out Chlamydia and N.gonorrhoea (urethritis)
* Non sexually transmitted infections
* GNB, enterococci, staphylococci, viruses, TB in high risks
45
Orchitis features, aetiology. pyogenic, complications
**Features**
* Inflammation of one or both testicles
* Testicular pain and swelling
* Dysuria
* Fever
* Penile discharge
**Aetiology**
* Usually viral - mumps
* Bacterial
**Pyogenic**
* Acutely unwell
* Complication of epididymitis
* Similar bacteria to other GU infections
* Ofloxacin/Doxycycline
* If severe, Intravenous antibiotics
* As per complicated UTI
* Urgent urological review
**Complications**
* Testicular infarction
* Abscess formation
46
Fourniers gangrene
**features**
* Form of necrotising fasciitis
* Affects male genitalia
* Rapid onset, spreading
* Systemic sepsis
* Usually \> 50 yrs old
**Risk factors**
* UTI
* Local sepsis
* Trauma
* Recent Surgery
**Common pathogens**
* Mixed infections, mainly GNB and anaerobes
I**nvestigation**
* Blood cultures
* Urine
* Tissue/pus
* ¨Surgical debridement 1st line management
* Broad spectrum antibiotics initially
* e.g. Pip-tazobactam+ Gentamicin+ Metronidazole+/- Clindamycin
