UTI, Pyelonephritis, and Antibiotics

Question 1

Common syx seen in cystitis?

Answer 1

suprapubic or abdominal pain

Question 2

common symptoms of urethritis? predisposing factors?

Answer 2

no upper tract symptoms
risk of STI

predisposing factors: frequent intercourse, multiple partners, inconsistent condom use

Question 3

common syx seen in pyelonephritis

Answer 3

fever, back pain, general malaise

Question 4

Common syx seen in vaginitis?

Answer 4

reporting drainage or itching

Question 5

What urine test is helpful/best in detecting urethritis?

Answer 5

Antigen for GC (gonorrhea) + chlamydia; these wont show on standard urine dip, micro or cultures

Question 6

What are some predisposing factors to UTIs in women?

Answer 6

use of spermicids (ex. diaphragm for contraception), frequent sexual intercourse, diabetic women have 2-3 times higher incidences than non-diabetes

Question 7

What is the recurrence rate of UTIs in women?

Answer 7

20-30%

Question 8

Recurrence in post-menopausal females is related to what?

Answer 8

• history of pre-menopausal UTIs
• anatomic factors affecting bladder emptying (cystoceles, urinary incontinence, residual urine)
• tissue effect of estrogen depletion (significant!)

why this occurs: tissues thin and this leaves them fragile and friable, increasing risk of infection

Question 9

What are the predisposing factors to UTIs in men?

Answer 9

prostatic hypertrophy

non-circumscribed (bc ecoli more likely to colonize glans + prepuce)

Question 10

A patient presents with a high fever and no urinary symptoms. A urine sample is obtained and shows bacteria on microscopic evluation. What is this and how would you treat them? Asymptomatic bacteriuria (ABU). What are your next steps to check and should you treat them?

Answer 10

Asymptomatic bacteriuria (ABU)

No treatment unless have other complications such as are diabetic or pregnant

Question 11

Why is it important to treat Asymptomatic bacteriuria in a pregnant patient?

Answer 11

Can result in symptomatic pyelonephritis and more likely to develop sepsis

Question 12

What is considered an uncomplicated UTI patient?

Answer 12

Non-pregnant female, no anatomic abnormalities, no instrumentation of the urinary tract

Question 13

UTI is much more common in females until when?

Answer 13

mid-life

Question 14

What is considered a complicated UTI patient?

Answer 14

ANY pregnant female since its 2 patients and can lead to premature labor or low birth weight babies

Question 15

What is the single most important thing in a complicated UTI case?

Answer 15

HISTORY!!!

Question 16

Causes of a complicated UTI (several things):

Answer 16

• anatomic variant (eg. polycystic kidney dz, one kidney)
• foreign body in urinary tract (stones, urinary catheters, nephrostomy tubes/ureteral stent)
• extrinsic compression of ureter/bladder (tumors, profound constipation, other anomalies)
• immune suppression conditions (diabetes, drug-induced, HIV/AIDS)

Question 17

What are some differentials that may cause dysuria in females?

Answer 17

• Urethritis (gonorrhea, chlamydia, herpes)
• Cystitis (freqency, urgency nocturia, hesitancy, hematuria)
• Interstitial Cystitis (“painful bladder syndrome”)
• Vaginitis (candida, trichomonas)
• Cervicitis (chlamydia, neisseria)
• non-infectious vaginal or vulvar irritation

Question 18

What is Interstitial Cystitis? What are some possible contriubiting factors?

Answer 18

“Painful bladder syndrome”

• chronic; unknown etiology
• possible contributing factors: chronic bladder infection, inflammatory factors, unusual pain sensitivity, functional comorbidities

Question 19

What are some differentials that may cause dysuria in males?

Answer 19

Urethritis (gonorrhea, chlamydia), cystitis, prostatitis, pyelonephritis (DIFF compared to female**)

Question 20

Why is a urine culture not the best option in detecting UTIs?

Answer 20

Will not identify GC + chlamydia (need urine antigen for GC + chlamydia if STI suspected)

Question 21

What are some diagnostic tests you COULD use for UTIs?

Answer 21

US (urinalysis) - urine dipstick, microscopic
urine culture (if + urine dip + micro)
urinary antigen for GC + Chlamydia
Ultrasound - if symptoms are progressing or are unusual

Question 22

A 34 y/o male presents with pain “where they sit down” and describes it specifically in the pelvic area. What might he have? What would you prescribe him?

Answer 22

Prostatitis

prolonged antibiotic course necessary for 4-6 weeks (hard to treat)

Question 23

What are the features of prostatitis?

Answer 23

Infectious or non-infectious, with or without hypertrophy, can be chronic in prostatic hypertrophy

-pain in prostatic, pelvic, or perineal area

Question 24

How would a patient with pyelonephritis present?

Answer 24

generally sicker, fever/chills, body aches (back/flank especially), typically ASCENDING from lower tract infection, positive CVA tenderness

Question 25

What kind of specialty test could you use for pyelonephritis

Answer 25

lloyds punch is preferred

Question 26

What are the most common precursors of pyelonephritis?

Answer 26

- same as UTI (since most commonly ascending from lower tract) and most common organism is E. coli - bacteremia develops in 20-30% of cases - can be hematogenous spread to kidney instead of ascending, but very rare (candida, salmonella, staph aureus)

Question 27

Three major subtypes/complications of pyelonephritis:

Answer 27

1. papillary necrosis 2. emphysematous pyelonephritis 3. xanthogranulomatous pyelonephritis

Question 28

What conditions can lead to papillary necrosis?

Answer 28

obstruction, diabetes, sickle cell, analgesic nephropathy

Question 29

What is emphysematous pyelonephritis? who mostly get its?

Answer 29

production of gas in nephric and perinephric area occurs almost exclusively in diabetic patients

Question 30

What characteristics are seen in xanthogranulomatous pyelonephritis?

Answer 30

chronic obstruction, chronic infections, suppurative destruction of renal tissue, can lead abscess formation

Question 31

What does bacteremia mean?

Answer 31

blood cultures are positive for bacteria

Question 32

What is sepsis?

Answer 32

suspected or documented infection and an acute increase in organ failure dysregulated host response to infection

Question 33

What is septic shock?

Answer 33

HYPOTENSION subset of sepsis; progressive organ dysfunction leading to marked increase in mortality serum lactate greater than 2 mmol/L (18 mg/dL)

Question 34

What therapy is needed for septic shock?

Answer 34

vasopressor therapy needed to maintain mean arterial pressure at 65 mmHg or greater

Question 35

Acute ischemia of major organs occurs when?

Answer 35

when there is a defect in effective circulating volume (decreased O2 delivery, impaired removal of cellular waste) Double whammy on kidney: direct tubular damage by endotoxins and inflammatory cytokines

Question 36

What are signs/symptoms of septic shock?

Answer 36

- signs of infection: fever/hypothermia - tachycardia (cardiac response to hypoperfusion + fever) - tachypnea (compensatory resp response) - hypotension (may be unresponsive to fluid resusc and need vasopressors) - circulating cytokines - endothelial injury (decreased tone, increased permeability) - edema (she emphasized) - decreased oxygenation of tissues - build up of lactic acid (emphasized)

Question 37

When would you treat recurrent UTIs with antibiotics?

Answer 37

if UTI is interfering with patients lifestyle; patient-initiated

Question 38

How would you prevent UTIs without antibiotics?

Answer 38

- empty bladder as soon as reasonable after intercourse - wipe front to back after toileting - showers instead of tub baths - lactobacillus probiotics - cranberry products - vitamin c - increased fluid intake!!! (emphasized)

Question 39

A patient presents with the inability to lay still, pinkish urine, severe/excruciating back and abdominal pain, + CVA tendreness, and pain constant with frequent spasms. What is the most likely diagnosis?

Answer 39

Renal lithiasis

Question 40

What could you do to a patient to relieve really bad hydronephrosis?

Answer 40

nephrostomy tube