3151 finals > UTI > Flashcards

UTI Flashcards

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1
Q

Asymptomatic bacteriuria

A

Isolation of sig colony counts of bacteria in urine (bacteriuria)

From person without symptoms of UTI (asymptomatic)

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2
Q

Pt pop to screen for ASB

A

1) Preg women
a. Prevent pyelo, preterm labour, infant of low birth weight
b. screen on one of first visits 12-16wks gestation
i. Treat with AB (AST) 4-7days

2) Pt going for urologic procedure
a. Mucosal, trauma bleeding is expected
b. Prevent bacteremia, urosepsis (blood stream)
c. Screen before procedure (2-3 days)
i. Use active AB as surgical AB prophylaxis (SAP)
ii. Not include placement of urinary catheter

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3
Q

ASB is common (esp in certain pops)

A

Do not screen in
* Elderly persons (in LT care facility F>M)
* Persons with spinal cord injury (catheter use)
* Kidney transplant
*Indwelling catheter use (ST, LT)

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4
Q

Mental status changes for ASB

A

Bacteriuria & delirium independently COMMON in elderly
○ Delirium, falls, confusions =/= sx of UTI
§ May dehydrated
No diff in insomnia, malaise, fatigue, weakness, anorexia (in presence/ absence of ASB)

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5
Q

Urinary tract infection

A

Isolation of sig colony counts of bacteria in urine

From person with urinary symptoms

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6
Q

severity of UTI

A

cystitis

pyelonephritis

UTI w/ bacteremia/ sepsis/ death

-dysregulated host response to infection cause life-threatening organ dysfunction

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7
Q

Epidemiology of UTI by age
0-6mnths

A

M>F

-structural/ functional abnormality of urinary tract

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8
Q

1- adult

A

F>M

  • shorter urethra, more bacteria access to urinary tract
  • M: protection as prostate secretes antimicrobials
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9
Q

elderly . 65yo

A

EQUAL

Comorbidities, urinary retention, muscular atrophy, stroke
Incr catheter use

M: benign prostatic hypertrophy

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10
Q

Ascending pathophysiology of UTI

A

a. Colonic/ fecal flora colonise periurethra area
b. Ascend to bladder & kidney
c. ** F: shorter urethra, use spermicides, diaphragms contraceptives
- E.coli, klebsiella, proteus

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11
Q

descending pathophysiology of UTI

A

a. Organism at distant primary site (heart valve, bone)
b. Bloodstream (bacteremia)
c. Urinary tract
d. UTI
i. Staphylococcus aureus, mycobacterium tuberculosis
ii. Non-gut bact found in urine + bacteremia lab values

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12
Q

3 factors for development of UTI in host

A

1) competency of natural host defence

2) size of inoculumn
- urinary obstruction= growth

3) virulence of microog
- pili , anti-adherence of bladder

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13
Q

natural host defence

A
  • Bacteria in bladder stimulates micturition
    ○ incr diuresis (empty bladder)
    • Urine, prostatic secretion: Antibacterial properties
    • Bladder anti-adherence mechanism: prevent bact attachment
      *Inflammatory resp with polymorphonuclear leukocytes (PMNs): phagocytosis (prevent spread + control)
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14
Q

risk factors for UTI

A
  • F>M
    • Short urethra, risk ASCENDING
  • Sexual intercourse
    • colonise bact at periurethra area
  • Abnormalities of urinary tract
    • Prostatic hypertrophy
    • Kidney stones
    • Urethral strictures (narrow, retention)
    • Vesicoureteral reflux (urine flows back to bladder)
      ○ Lack valves, risk pyelonephritis
  • Neurologic dysfunction (stroke, DM, spinal cord injury)
    • Malfunction of urinary reflex
  • Anti-cholinergic drugs
    • 1st gen antihistamines/ atropine
  • Catheterisation and other mechanical instrumentation
    • Biofilms, harvest growth. Proliferate in devices
    • Incr access of bact into urethra
  • DM
    • Nephropathy.
    • Incr glucose in urine, more bact growth
  • Preg
  • Diaphragms, spermicides
  • Genetic association (fam hist)
  • Previous UTI
    *Risk factors continue to persist, root cause not removed
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15
Q

prevention of UTI

A
  • Drink fluids (6-8 glasses)
    • Fluid restricted? CKD, HF
  • Urinate frequently when first feel urge
    • Not let bact grow in urine, within bladder
  • Urinate shortly after sex
    • Flush away bact that might have entered urethra
  • Wipe from front to back (after bowel movement)
  • Cotton underwear, loose fitting clothes. Air can keep area DRY
    • Moisture trapped, help bact to grow
  • Alter contraceptives in women, diaphragm/ spermicides
    • Lead to UTI, incr bact growth
      • Incr irritation helps bact grow
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16
Q

complicated UTI

A

a. Associated with conditions that incr potential for serious outcomes, risk for therapy failure
i. UTI in men, children, preg women
ii. Presence of complicating factors:
□ Funct/ struc abnormalities of UT
□ Genitourinary instrumentation
□ DM
□ immunocompromised host

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17
Q

pop for complicated UTI

A

Men, women, children with funct, metabolic, anat conditions
Incr risk of treatment failure
Serious outcomes

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18
Q

uncomplicated UTI pop

A

Healthy, ambulatory women
No history suggestive of ABNORMAL urinary tract

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19
Q

culture for complicated UTI?

A

urinalysis, urine culture indicated

-MDR common, less predictable (FQ)

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20
Q

culture for uncomplicated UTI?

A

culture recc for pyelonephritis

Infection suspected on basis of typical symptoms
-urinalysis and urine culture not routinely needed for susp cystitis

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21
Q

subjective sx for uti

A

i. Localised vs systemic pain
May be diff in elderly
- alr don’t exp much urinary symptoms
1) Altered mental status
2) Drowsy, less alert
3) Change in eating habits
4) General GI symptoms

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22
Q

cystitis sx

A

dysuria, urgency, freq, nocturia
suprapubic pain, heaviness, flank pain
gross hematuria

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23
Q

pyelonephritis sx

A

SYSTEMIC (fever, rigors, headache, maliase)
NV
flank pain, costovertebral tenderness (renal punch)
ab pain

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24
Q

objective sx based on

A

1) UFEME (urine formed elements and microscopic examination)
- WBC, RBC, MICROOG, WBC CAST

2) chemical analysis
- nitrite
- leukocyte esterase

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25
UFEME
-WBC ◊ >10 WBCs/mm3 = PYURIA -Presence of inflammation - May or may not be due to infection * Symptomatic pt (pyuria ~~ sig bacteriuria) * Absence of pyuria = UNLIKELY UTI - RBC ◊ Presence microscopic >5/ HPF or gross = HEMATURIA ◊ Freq occur in UTI, but non-specific - Mensus? Transmem in catheterisation, kidney stones, malignancy - MICROORG ◊ Identify bact, yeast using gram stain - WBC CASTS ◊ Mass of cells and proteins that form in renal tubules (kidney) ◊ Indicate UPPER UTI/ disease
26
chemical analysis
-NITRITE ◊ +ve: presence of GRAM NEG bact (> 10*5 bacteria/mL) *Can reduce nitrate --> nitrite ◊ False -ve: presence of GRAM POS, p. aeruginosa, low urinary pH, freq void/ dilute urine) -LEUK ESTERASE (LE) ◊ +ve test: esterase activity of leukocytes in urine ◊Sig pyuria (>10 WBCs/mm3)
27
URINE Culture (AST) for who and not for who
□ Not for uncomplicated cystitis - Just treat with empiric □ FOR: need find out what bact causing infection <-- complicated UTI 1) Preg 2) Recurrent UTI (relapse within 2wks/ freq) 3) Pyelonephritis 4) Catheter-associated Uti 5) MEN with UTI
28
Urine collection via 3 methods
Midstream clean catch (no contaminants) Catheterization Suprapubic bladder aspiration (NEEDLE)
29
uncomplicated bact
Gut enterobact// common coloniser of urinary tract 1) E coli 2) Staphylococcus saprophyticus 3) Enterococcus faecalis, klebsiella pneumoniae, proteus spp
30
Complicated UTI or HAI UTI pathogen
1) E coli (50%) 2) Enterococci 3) klebsiella pneumoniae, proteus spp, enterobacter spp - P. Aeruginosa
31
HAI risk factors when pt recent/ freq exposure to healthcare settings:
Hosp in last 90 days current hosp >2 days residence in nursing home recent AB use
32
other possible pathogens for UTI
- s.aureus (bacteremia, maybe other primary site infections) - yeast, candida (contaminant, consider other sites of infection)
33
CA UTI Abx choice
empiric treatment based on susceptibilities Aim 70% sensitivity for comm (pt well enough, no need high cover = higher selection P.)
34
HAI UTI abx choice
a. Dependent on hosp (empiric ---> streamline to culture directed) E.coli, Enterobacteriaceae
35
Cystitis in women 1st line Abx
PO - empiric 1) Co-trimoxazole 800/160 BD (3days) 2) Nitrofurantoin 50mg QDS, 5days a. Only for cystitis, no pyelo 3) Fosfomycin 3g single dose a. Only for cystitis. MOA: inhibit cell wall b. (no pyelo: unable to get to kidney tissue, weak bioavail)
36
Complicated cystitis tx
PO - empiric but longer duration (7-14d) 1) Co-trimoxazole 800/160 BD 2) Nitrofurantoin 50mg QDS, 3) Fosfomycin: PO 3g every other day (EOD) x 3 doses
37
cystitis alternative drugs
* Beta-lactams (5-7 days) * Cefuroxime 250mg BD * Amox-clav 625 mg BD * Cephalexin 250-500mg QID * Fluoroquinolones (3 days) * Ciprofloxacin 250mg BD * Levofloxacin 250mg daily **ADR!
38
CA pyelonephritis PO
1) FQ -- good can give shorter duration = good conc, but resistance a. Ciprofloxacin 500mg BD x 7days b. Levofloxacin 750mg daily 5days 2) Cotrimoxazole 160/800mg BD x 10-14 days
39
CA-pyelonephritis severe ill (IV) need culture before start IV for step down
1) Ciprofloxacin 400mg BD 2) Cefazolin 1g q8hr 3) Amox-clac 1.2g q8h (add on) Gentamicin 5mg/kg a. To cover ESBL, Kleb (found in CA) a. Esp if risk bacteremia
40
beta allergy for CA-pyelo
* Beta lactam x 10-14 days (PO) * Cefuroxime 250mg BD * Amox-clauv 625 mg TDS * Cephalexin 500mg QDS Need high dose
41
CA-UTI in MEN = NO concern for prostatitis culture needed
complicated UTI in women PO - empiric but longer duration (7-14d) 1) Co-trimoxazole 800/160 BD 2) Nitrofurantoin 50mg QDS, 3) Fosfomycin: PO 3g every other day (EOD) x 3 doses
42
Abx for those with Concern for prostatitis// pyelonephritis in men culture needed
* PO ciprofloxacin 500mg BD * Po co-trimoxazole 160/800mg BD 10-14 days if at risk 6wks (longer duration) if CONFIRMED
43
HAI- pyelonephritis IV
* Cefepime 2g q12h ○ +/- amikacin 15mg/kg/d (cover psuedo/ other ESBL resistant) * Imipenem 500mg q6h * Meropenem 1g 8h
44
HAI - pyelo risk factors Broad spectrum empiric ---> (change to culture directed) Pseudo, other resistant (ESBL)
- UTI > 48h post admission - pt hosp in last 6mnths - pt underwent urological procedure in last 6mnths - pt has Indwelling catheter
45
Catheter-associated UTI -- iv
IV * Imipenem 500mg q6H * Meropenem 1g q8h * Cefepime 2g q12h +/- amikacin 15mg/kg (1 dose) Duration for 7days
46
catheter-associated UTI -- PO
PO/ IV * Levofloxacin 750mg x 5d (MILD CA-UTI) * Co-trimoxazole 960mg BD 3days ○ Women <65yrs with CA-UTI ○ Without upper urinary tract symptoms after indwell catheter removed
47
catheter-associated UTI duration
Duration for 7days (deferverse - no fever in 72hrs, resolve symptoms) Duration 10-14 days (delayed resp)
48
Catheter-Associated UTI diagnosis
* Presence of symptoms or signs compatible with UTI * With NO OTHER identified source of infection * 10^3 cfu/mL of >1 bacterial species in single catheter urine specimen in pt with ○ indwelling urethral ○ Indwelling suprapubic ○ Intermittent catheterisation ○ Midstream voided urine specimen from pt catheter removed within previous 48h - NOT FROM urine bag, from old catheter (biofilm)
49
risk factor of catheter-associated UTI
* Risk factors: ○ Duration of catherisation § 1 day = 5% § 2 day = 10% ○ Colonisation of drainage bag, catheter, periurethral segment ○ DM ○ Female ○ Renal function impairment ○ Poor quality of catheter care, including insertion
50
Causative org of catheter-associated UTI depending on duration of use of catheter
* ST <7days: 85% MONOORG (prevailing from environ) ○ E.coli, pseudo, kleb * LT >28days: 95% POLY (2-3 org)
51
when tx for catheter-associated UTI
* Not recommended to treat ASB a. (except prior to traumatic urological procedures) * Remove catheter a. If indwelling > 2wks at onset of CA-UTI b. Replace to hasten resolution, reduce risk of CA-bacteriuria// CA-UTI * AB only for symptomatic infection a. Symptoms: b. OBSERVE > immediate AB (Pt stable, low grade fever) c. Need culture (urine + blood) before given AB i. Start empiric Abx first ---> culture based
52
sx to treat catheter-associated UTI
i. new onset/ worsen fever ii. Rigors iii. Altered mental status, malaise, lethargy (but elderly sooo) iv. Flank pain v. Costovertebral angle tenderness vi. Acute hematuria vii. Pelvic discomfort
53
prevention of catheter-associated UTI
* Avoid catheter use * Use for minimal duration (trial off) ○ Reinsert only if retention * LT indwell catheter change before blockage occur * Close system insertion (reduce contamination) * Ensure aseptic insertion technique
54
Not recc TOP, PROPHYLAXIS, CHRONIC SUPPRESSIVE
Chronic suppressive therapy not needed Not recc TOP, PROPHYLAXIS, CHRONIC SUPPRESSIVE * Prophylaxis * ONLY IF Pt high risk sepsis, constant UTI
55
Preg UTI duration for ASB/ cys/ pyelo
4-7 days for asymptomatic bacteriuria or cystitis 14days for pyelonephritis
56
preg UTI chocie of therapy
* Beta-lactams * 1st line for preg * clindamycin safe * ery, azi (macrolide) used in preg * Choice of drug based on cultures * Can be Fosfomycin ○ 3 day dose given, not 1 day ○ PO 3g every other day (EOD) x 3 doses
57
what to avoid in preg
* Ciprofloxacin ○ Fetal cartilage damage ○ Arthropathies in animal ○ child< 18yrs old * Co-trimoxazole ○ 1st & 3rd trimester (0-13 wks/ 29-40th wk) ○ Folate antagonist TMP cause neural tube defect ○ Kernicterus (comp bind bilirubin and sulfonamides to plasma albumin) ○ Foetus G6PD def * Nitrofurantoin ○ 38-42 wks ○ Fetus G6PD def * Aminoglycosides (caution) ○ 8th cranial nerve toxicity in fetus (ana, streptomycin) New AG safe *tetracycline (stain grey), glycycline, linezolid
58
adjunct therapy for UTI
* NSAID ○ Pain, fever * Rehydration ○ Vomit * Urinary symptoms ○ Phenazopyridine 100-200mg TDS § Analgesic effect for urinary tract, symptomatic relief § CI: G6PD def § ADR: NV, orange-red discolour urine/ stool ○ Urine alkalinsation § Relief discomfort in mild UTI
59
Non-antimicrobial options (UTI prevention)
* Cranberry ○ Inhibit adherence E.coli to urinary tract epithelial cells ○ Decr incidence of UTI (clinical studies but have limitations) * Intravag estrogen cream ○ Remain controversial ○ Decr incidence of UTI in post-menopausal women ○ Restore vag flora, prevent colonisation of E.coli * Lactobacillus probiotics ○ Restore normal vag flora § BUT !! Protective effect against E.coli colonisation Intravag lactobacillus reduced recurrence uncomplicated cystitis
60
monitor UTI
1) Resolution of signs and sx 1. Improve in 24-72hrs after effective AB a. Fail to respond 2-3 days b. Persistent +ve blood/ urine culture i. Maybe (bacterial resistance, obstruction, renal abscess, other disease?) 2) Bacteriological clearance 1. Repeat culture not required for pt who responded 2. Culture to document Clearance: preg women 3) Absence of ADR & allergies
61
why moxifloxacin not used for UTI
Moxifloxacin not recommended due to it's poor concentration in the kidneys drug excreted unchanged in the urine (~20%)
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