UTIs

Question 1

Urinary Tract Infections epidemiology

Answer 1

● 8.2 million office visits annually
● 1.7 million emergency department visits annually
● $ 6 billion health care expenditures annually
● Present may differ depending on location of infection
○ Cystitis most common
● Hx/presentation, UA dip, UA micro, and/or culture
are typically sufficient to make the Dx
● 60% of women will report UTI in their lifetime

Question 2

UTIs Etiology – 3 possible ways for bacteria to enter the urinary tract

Answer 2

● Bacteria ascension
○ Regarded as most common cause
○ Primary cause of pyelonephritis (ascension from bladder Mto the kidney)
● Direct extension of bacteria from an adjacent organ
○ Abscess or fistulas
● Hematogenous spread
○ Spread through the blood in immunocompromised

Question 3

Most common presentation of UTIs

Answer 3

Cystitis

Question 4

Causative organisms of UTIs

Answer 4

○ E. coli (86%)
○ Staph saprophyticus (4%)
○ Klebsiella species (3%)
○ Proteus species (3%)
○ Enterobacter species (1.4%)
○ <1% – Citrobacter species,
Enterococcus species, Pseudomonas,
Klebsiella, Proteus, Candida, viruses,
Gonorrhea, Chlamydia, etc.

Question 5

Etiology – Risk Factors by Demographic

Answer 5

● Neonates: Uncircumcised – 85% higher incidence than uncircumcised
● Children: Bowel and bladder dysfunction, vesicoureteral reflux, prior UTI
● 16-35 years old: Intercourse (also us of diaphragm or spermicide)
● 35+ years old Obstruction, GU surgery, bladder prolapse, ureterocele, neurogenic bladder, bowel and bladder dysfunction

Question 6

Etiology – Other Risk Factors of UTIs

Answer 6

● Post Menopausal: Lack of estrogen – tissue integrity and pH
● Obesity
● Diabetes
● Sickle cell trait
● Pregnancy
● Poor hygiene: Towelettes/wipes
● Frequent sitting
● Bubble baths
● Catheters
● Age

Question 7

Urinary Tract Infections Host defense

Answer 7

● Estrogen: Encouraged health tissues, and stimulates lactobacillus (keeps pH down
→ decrease colonization of other uropathogens)
● Low pH of urinary tract
○ Urea
○ Lactobacillus
● Epithelial lining
○ Quick recognition of bacteria
○ Antibody production (kidneys) → decrease bacterial adherence and
cause phagocytosis
○ Cytotoxic cells secrete Mannose → bacteria (e.coli) can’t adhere to
the bladder wall as easily
● Complete void: The overlapping layers in the detrusor muscle allow for complete void
● Frequent voiding: Sensation of urgency when the bladder is full or irritated…an effort
to push out irritant

Question 8

If lower tract protections to UTI fail →

Answer 8

bacteria can ascend the urinary tract
○ Additional host defenses will
activate leukocyte phagocytosis and
antibodies produced in the kidney
○ Inflammation and infection ensues

Question 9

Coinfection of UTIs with _____ and chlamydia was demonstrated in 20% of males and 42 % of females

Answer 9

gonorrhea

Question 10

Urethritis - Etiology

Answer 10

Sexually Transmitted Infection
● Gonococcal Urethritis (GU)
● Nongonococcal Urethritis (NGU)
● Recurrent/persistent Urethritis (NGU)

Question 11

Urethritis Presentation/exam

Answer 11

● Dysuria
● Urethral pruritus
● Urethral discharge +/-
● Fever +/-
● Urinary hesitancy
○ More common with recurrent Dz
● 75% asymptomatic

Question 12

Urethritis Diagnosis

Answer 12

● Exam
○ Urethral irritation
○ Urethral discharge +/-
● Urine amplification (NAAT PCR)
○ First void in the morning is best
○ Only accurate test for Mycoplasma
infections
● Culture of swab/discharge

Question 13

Treatment of Gonococcal and/or Chlamydial Urethritis

Answer 13

○ Gonorrhea – Ceftriaxone 250 mg IM; single dose (99% cure rate)
○ Chlamydia – Azithromycin 1 gm; single dose

Question 14

Treatment of Nongonococcal Urethritis (NGU)

Answer 14

○ Azithromycin 1 gm; single dose
or
○ Doxycycline 100 mg PO BID x 7 days

Question 15

Treatment of Recurrent/persistent Urethritis (NGU)

Answer 15

If already treated with Azithromycin 1 gm single dose →
Moxifloxacin 400 mg QD x 7 days

Question 16

Who else needs to be treated for urethritis

Answer 16

● Partner(s) must be treated
○ Partners within the last 6 months;
unless known negative test

Question 17

Urethritis complications

Answer 17

● Males
○ Urethral strictures → infertility
● Females
○ Cervicitis → Pelvic inflammatory disease

Question 18

Urethritis prevention

Answer 18

● Treat for both G&C
● Educated on safe-sex practices – avoiding high risk behaviors
● Routine STI screening with changing partners
● Check screening recommendation for pregnant females

Question 19

Cystitis epidemiology

Answer 19

● Most common bacterial infection in women
● 60% of women will report UTI in their lifetime
○ 11% report 1 infection annually
○ 50% don’t seek medical attention

Question 20

Cystitis Etiology

Answer 20

● Women > Men
○ Shorter urethra
● Ascending infection from periurethral,
vaginal or fecal flora
○ E. coli (86%), Staph, Klebsiella
● Post coital UTI

Question 21

Uncomplicated Cystitis

Answer 21

An urinary tract infection in a healthy, non-pregnant, pre-menopausal
female patient with anatomically and functionally normal urinary tract

Question 22

Complicated Cystitis

Answer 22

● Urinary tract that has metabolic, functional, or structural abnormalities
○ Factors that increase the risk of bacterial colonization and/or decrease the efficacy of therapy
● May involve upper and lower urinary tract

Question 23

Cystitis Presentation

Answer 23

● Irritative voiding symptoms
○ Urgency
○ Frequency
○ Dysuria
● Suprapubic pain
● Incomplete voiding
● Urinary hesitancy
● Gross hematuria
● Incontinence
● Low back pain
● Afebrile

Question 24

Cystitis exam

Answer 24

● Suprapubic tenderness
(seen 10-20% of cases)
● Males – DRE +/-
● Exam often unremarkable

Question 25

Cystitis Diagnosis

Answer 25

● History and physical ○ New onset of frequency and dysuria (with absence of vaginal discharge) has a PPV for UTI of 90% ○ CBC, BMP, A1c? ● UA: Clean, midstream catch ○ RBC and Leuks means inflammation not infection ● Urine Culture: Always culture complicated UTIs

Question 26

Cystitis imaging

Answer 26

● Imaging – (only done for complicated cystitis) ○ Renal bladder U/S with pre & post void residual ○ Voiding cystourethrogram – children, or post GU/pelvic surgery ○ CT urogram – pyelonephritis, recurrent infections, or anatomic abnormalities suspected ● Cystoscopy

Question 27

Uncomplicated Cystitis Treatment

Answer 27

● Healthy, non-pregnant, pre-menopausal female patient, with normal urinary tract anatomy (AUA 2020 Guidelines) ● Start empiric therapy - Nitrofurantion - Bactrim - Fosfomycin ● Urine Culture +/-

Question 28

Treatment of Complicated Cystitis

Answer 28

● Anything not “uncomplicated cystitis” ● Start empiric therapy - Ciprofloxacin - Levofloxacin - Bactrim - Augmentin ● All complicated UTIs need Urine Culture

Question 29

Special Considerations for Recurrent Cystitis/UTI

Answer 29

● Persistence infection or reinfection with another organism ● Possible causes ○ Obstruction (BPH, stone, stricture, etc), ureteral reflux, fistula, intercourse/hygiene, cystitis cystica

Question 30

Evaluation of Recurrent Cystitis/UTIs

Answer 30

● Urine cultures ● Renal bladder U/S (post void residual), VCUG, IVP ● Cystoscopy

Question 31

Treatment of Recurrent Cystitis/UTI

Answer 31

● Surgically – correct obstruction, reflux, or repair fistula ● Hygiene ○ Proper wiping ○ Empty bladder post intercourse ● Hydrate ● Prophylactic antibiotics ○ Continuous low dose TMP or Nitrofurantoin (QD x 3-6 months)

Question 32

Cystitis - special considerations with pregnancy

Answer 32

● Compression of the UT increases the risk of UTI ● Asymptomatic bacteriuria seen in 5-10% of pregnancies

Question 33

Cystitis- Special Considerations for HIV patients

Answer 33

● When CD4 count falls <200 mm-3 there is an increased risk for bacterial and fungal UTIs (candida and aspergillus) ● TMP-SMZ is often used to prevent Pneumocystis Pneumonia – incidence of UTI in these patients is quite low

Question 34

Cystitis - Special Considerations for T2D

Answer 34

● UTIs are more common, more resistance, and more severe ● 2-5 fold increase in pyelonephritis ● The higher the A1c, the higher the risk of UTI ● Treat with abx pending C&S results ○ Often Fluoroquinolones work well ○ Avoid TMP-SMZ – can cause hypoglycemia

Question 35

Cystitis - Special Considerations for Catheterized Patients

Answer 35

● Cultures will alway be positive, but often not symptomatic ○ Biofilms form within 72 hours of placement ● Do not treat asymptomatic bacteriuria in patients with indwelling catheters ● Preventive measures ○ Silicone catheter ○ Catheter/bladder “rinses” – Iodine or acetic acid solutions ○ Regular catheter changes

Question 36

Cystitis complications

Answer 36

● Appropriate Tx should have a rapid resolution of symptoms ● Non-compliance or failure to respond to therapy ○ Drug resistance ○ Anatomic abnormality ● Pyelonephritis → sepsis → death ● Permanent renal impairment

Question 37

Cystitis Prevention

Answer 37

● Hydration ● Ensure full emptying of the bladder – repeat voids ● Hygiene ○ Urinate after intercourse, wipe front to back, no bubble baths, etc. ● Preventative abx – post coital, intermittent self-start ● Probiotics – Lactobacillus; restore natural flora (promote host defence)

Question 38

Pyelonephritis etiology

Answer 38

● Infection of the kidney parenchyma and renal pelvis ● Mostly caused by gram negative bacteria ● Ascending infection from the bladder up the ureters ○ Staph can spread through a hematogenous spread

Question 39

Pyelonephritis Presentation

Answer 39

● Fever (more often than not) ● CVA tenderness (can be bilateral) ● Nausea/Vomiting ● Anorexia ● Irritative voiding (urgency, frequency, and dysuria)

Question 40

Pyelonephritis DDx

Answer 40

Acute cystitis or lower urinary infection, STI, kidney stones, lumbar injury, PID, lower lobe pneumonia, pancreatitis, appendicitis, diverticulitis

Question 41

Pyelonephritis Diagnosis

Answer 41

● CBC – Elevated WBC ● UA – Pyuria, bacteria (gram neg rods – e. coli) ○ Urine micro – may see WBC cast ● Urine C&S ● Blood Cultures – sepsis 20-30 %

Question 42

Pyelonephritis imaging

Answer 42

Seldom required ● Renal U/S – Looking for hydronephrosis (obstruction), abscesses ○ Ideal in the pediatric patient ● CT – Renal enlargement, inflammation, decreased renal perfusion compressed collecting system, “perinephric fat stranding” ● MRI – Renal vascular evaluation

Question 43

Pyelonephritis treatment (outpatient)

Answer 43

● Determine if the Pt is stable enough be treated outpatient - Fluoroquinolones or Bactrim or Augmentin ● Adjust the treatment according culture results if needed

Question 44

Pyelonephritis treatment (inpatient)

Answer 44

Antibiotics (IV) ● Ampicillin & aminoglycosides (Vanco, Gent) ● Augmentin or 3rd gen cephalosporin ● IV abx are continued for 24 hours after fever breaks, then PO abx are given for 14 days ● Adjust the treatment according culture

Question 45

Pyelonephritis Admitting Criteria

Answer 45

● Unable to retain fluid and/or medication ● Signs/Sx of urosepsis ● Fever >102.2F ● High WBC ● Hypotension ● Stones ● Pregnancy

Question 46

Pyelonephritis Complications

Answer 46

● Missed pyelonephritis could lead to sepsis

Question 47

Pyelonephritis prevention

Answer 47

● UTI prevention