1
Q
What classifies an uncomplicated UTI?
A
An infection which occurs in healthy, immunocompetent, non-pregnant women (can occur in men too) with no significant UTI history or any urological structural abnormalities
Symptoms are mild-moderate
2
Q
What classifies a complicated UTI
A
- Existing structural or functional abnormality of the urinary tract
- UTIs in pregnancy are complicated (require close f/u)
- if infection has spread beyond the bladder (pyelonephritis)
3
Q
What classifies a recurrent UTI
A
UTI that occurs after complete resolution of previous & recent UTI
4
Q
What classifies asymptomatic bacteriuria (ABU)
A
Urine that has bacterial colony count >100,000/mL)
No UTI symptoms
5
Q
What is the most common pathogen that causes a UTI?
What are other possible pathogens?
A
Most common: E. coli
Others:
- Staphylococcus saprophyticus
- Enterococcus
- Klebsiella
- Enterobacter
- Proteus genus
6
Q
What are risk factors for UTI in women
A
- Anatomy
- Fecal/vagina contamination
- ⇣ fluid intake, urinary stasis
- Vag pH > 4.5
- Sexual intercourse (void w/in 10-15 min)
- Spermicide use
- Symptomatic partner
- Pregnancy menopause
- Hyperuricemia
- Neurogenic bladder
- Kidney disease
- Immunosuppression
- Diabetes Mellitus
- Urological abnormalities/instrumentation
7
Q
What are UTI risk factors in men
A
- BPH
- Anal intercourse
- Hyperuricemia
- Neurogenic bladder
- Kidney disease
- Immunosuppression
- Diabetes Mellites
- Urological abnormalities/instrumentation
8
Q
What are UTI risk factors in children
A
- Constipation
- Anatomical abnormalities
- Immunosuppression
- Dysfunctional voiding (muscles that control outflow of urine from the bladder do not completely relax, and bladder never fully empties)
9
Q
What findings from a culture and sensitivity are suggestive of contamination?
A
- multiple bacterial species (except in catheterized pt or other special circumstances)
- small numbers of Klebsiella and E. coli
- large numbers of skin flora (staphylococcus epidermis, diphtheroids, beta-hemolytic streptococci)
- Anaerobic bacteria do not usually cause UTIs
- Candida organisms suggest vaginal contamination
10
Q
What is phenazopyridine (Pyridium) used for? What is patient education and contraindications?
A
- Analgesic agent for severe dysuria
- OTC as AZO
- Pt edu:
- may stain contact lenses if touch lens after touching tablet
- urine will be bright orange/red
- should only be used for 2 days
- Contraindicated - those with renal impairment
11
Q
What is the definition of recurrent UTIs
A
≥ 2 UTIs in 6 months
OR
≥ 3 infections in 1 year
12
Q
What are the risk factors for recurrent UTIs
A
- spermicide use
- new partner in the past year
- genetics
- first UTI before age 15
13
Q
What are ways to decrease risk or recurrence of a UTI
A
- increased fluids to 2-3 liters / day
- avoid spermicides / diaphragms
- postcoital voiding
14
Q
When to consider UTI prophylaxis treatment
A
Chronic or recurrent UTI
15
Q
What are the two possible treatment modalities for UTI prophylaxis treatment? How do you chose medication?
A
- Continuous: low dose daily
- Post-coital: low dose after sexual relations
Therapeutic dose when patient feels symptomatic
Choose therapy based on past C&S results and past response to therapy
16
Q
What are risk factors for uncomplicated UTIs in men
A
- uncircumcised
- insertive anal intercourse
17
Q
What are indications for referral or hospitalization in UTIs
A
- Macroscopic hematuria
- suspected malignancy
- recurrent UTIs or infections that don’t respond to standard therapy
- urinary tract anomalies or obstructions
- acute scrotum (painful swollen scrotum)
- pregnant women with pyelonephritis
- older adults and those with acute severe symptoms (may require IV therapy)
- hx of diabetes mellitus
- hx of sickle cell anemia
- hx of nephrolithiasis
- hx of excessive analgesic use
18
Q
What follow up is required with UTIs
A
- Acute simple cystitis and symptoms resolve on antimicrobials: no F/U urine cultures
- Hematuria on initial presentation: urinalysis several weeks s/p antimicrobial therapy to evaluate for persistent hematuria.
- Continued symptoms after 48 to 72 hours of empiric antimicrobial therapy OR recurrent symptoms within a few weeks of treatment: additional evaluation for other potential conditions that may be causing those symptoms and for factors that might be compromising clinical response.
- Urine culture and empiric treatment with another abx
- Tailor abx to the susceptibility profile of causative organism
- Persistent symptoms with appropriate antimicrobial therapy: urologic assessment and radiographic imaging (CT) evaluate for anatomic abnormalities that would interfere with response to antimicrobial treatment.
19
Q
What are the risk factors for acute pyelonephritis
A
- being female
- elderly
- anatomical abnormalities
- stress incontinence
- recurrent UTIs
- kidney disease
- pregnancy
- persons with diabetes
- those with indwelling urinary catheters
20
Q
What is the most common causative agent of acute pyelonephritis
A
- E. coli
- pathogen sends along urinary tract to kidney
21
Q
What are the indications for hospitalization referral in a patient with acute pyelonephritis?
A
- Inability to maintain oral hydration/take meds
- dehydration
- vomiting
- Fever > 101.2F (39C)
- High WBC
- hypotension
- Sepsis or s/sx suggestive of sepsis
- multiple co-morbidities
- unsure diagnosis
- pregnancy
- most cases occur during 2nd and 3rd trimesters
22
Q
What are the sings and symptoms (10 of them) that suggest the need for imaging study to be done in evaluation of headache?
A
- History of recent head trauma and progressive headache
- New seizure, loss of consciousness, or drop attacks
- Papilledema and / or preretinal hemorrhages
- Abnormal mentation
- Abnormal neurological exam, including gait testing
- acute headache, excluding patients with clear migraines or cluster syndrome, which awakens patient from sleep
- Acute headache with onset after exertional activity (sexual or other)
- Abrupt onset, severe and unlike any previous headache patient has experienced, without clear symptoms of migraines
- New headache in patient > 50
- New pattern (excluding clear migraines or cluster) which develops over 1-4 weeks: severe recurrent, paroxysmal or steadily progressive
23
Q
What are the phases of a migraine attack?
A
Timeline can last from 5-7 days
24
Q
How long does an aura last? How is an aura described?
A
- Last 5 to 60 minutes
- Visual disturbances affecting both eyes
- Numbness of face (tingling)
- Weakness in the extremities
- Hemiparesis
- Speech or language disturbances
25
What is the significance of aura's when it comes to monophasic oral birth control?
* Birth control ok
* visual disturbances
* numbness of face
* Birth control NOT OK
* weakness in the extremities
* hemiparesis
* speech or language disturbances
26
What are the secondary “headaches” seen with advancing age
* Trigeminal Neuralgia (TGN)
* Temporal arteritis - Giant Cell Arteritis (CGA)
* Subdural Hematoma (SDH)
* Herpes Zoster (HZ) and Post-herpetic Neuralgia (PHN)
27
What medications can cause primary headache in older adults?
* SSRI
* SNRI
* vasodilators (nitro, nifedipine)
* OTC and other pain medications
28
What is migraine accompaniments?
* aura like symptoms without the headache (ocular migraine)
* visual or speech disturbances, paresthesias
* Duration 15-30 minutes
29
What is Chronic Traumatic Encephalopathy (CTE)?
Pathologic diagnosis with unknown incidence in athletic populations.
Tauopathy
Inadequate recovery between TBIs
Increased incidence of dimension and parkinsonian like symptoms
30
What are Red Flags in infants suggestive of intracranial structural pathology?
* Full anterior fontanelle
* Open metric and coronal sutures
* Poor growth
* Impaired upward gaze
* Abnormal head growth
* Shrill cry
* Lethargy
* Vomiting
31
What are red flags in children suggestive of Intracranial Structural Pathology?
* Headache described as severe, excruciating of recent onset, unlike any previously experienced headache
* No period of normal functioning between episodes
* Persistent and unilateral Papilledema or abnormal eye movements (or one or both eyes suddenly turn in)
* Ataxia
* Hemiparesis
* Abnormal deep tendon reflexes
* Cranial bruits
* Personality changes
32
What are the preventive meds for migraines in pediatrics
* Cyproheptadine
* Propanolol (avoid in asthma)
* Amitriptyline (avoid with fam hx of prolonged QT)
* Topiramate (only FDA approved preventive med for 12-17) avoid with anorexia
* Valproate (teratogenic - not advised for adolescent girls)
* Vitamins (i.e. riboflavin) - limited inconclusive evidence but usually well-tolerated. Evidence of magnesium low quality
* Butterbur Root Extract “Petadolex”?
33
What are the 3 red flag conditions that can occur in pregnancy that manifest as a headache?
* Cerebral venous thrombosis
* Pituitary apoplexy
* Pre-eclampsia
34
What are the signs and symptoms of cerebral venous thrombosis?
* headache
* focal neurologic deficit
* seizure
* altered mental status
* S/S of increased ICP
35
What are the signs and symptoms of preeclampsia?
* headache
* visual disturbance
* edema
* epigastric pain
* in severe cases
* pulmonary edema
* oligouria
* abnormal LFTs
* severe headache
* blurred vision
* blidness
* altered mental status
* seizure
36
What are the signs and symptoms of pituitary apoplexy?
* severe headache
* sudden onset
* N/V
* may have:
* visual symptoms
* altered mental status
* coma
* May have secondary adrenal insufficiency
* hypotensive
* hyponatremic
37
What are the renal differences in pediatrics?
* Biological variances
* All nephrons are present at brith
* Kidneys and the tubular system mature throughout childhood reaching full maturity during adolescence
* During the first two years of life, kidney function is less efficient
* Bladder
* Bladder capacity increases with age
* 20-50mL at birth
* 700mL in adulthood
38
What are red flags related to the eye
* Severe eye pain or headache - narrow angle glaucoma
* Severe foreign body sensation which prevents patient from keeping eye open
* Photophobia
* Decreased visual acuity - always concerning
* Contact lens use - possible corneal involvement
* Ciliary flush - uveal tract involvement, glaucoma
* Corneal opacity - usually from trauma to the cornea
* Fixed pupil - glaucoma
* Vesicular lesions on the face near the eye, or on the tip of the nose - herpes
* Firm or hard orbit
PC-I
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