Screening and Tx of asymptomatic bacteriuria (ASB) is only indicated for 2 adult populations. Which 2 adult populations are they?
- Pregnant women
- Patients going for urologic procedure in which mucosal trauma/ bleeding is expected
Do we associate mental state changes/ decreased feeling of well-being with ASB?
No.
But possible for pt to have symptomatic bacteriuria AND delirium → give empiric Abx therapy
Name the types of lower UTI (4) and upper UTI (1)
Lower UTI:
- Cystitis
- Urethritis
- Prostatitis
- Epididymis
Upper UTI:
- Pyelonephritis (kidneys)
List some examples of pathogens involved in the ascending and descending (hematogenous) route of infection for UTI
Ascending: E. coli, Proteus, Klebsiella
Descending: Staphylococcus aureus, Mycobacterium Tuberculosis
What are the risk factors for UTI? (11)
- Females > males (1 y/o - adult)
- Sexual intercourse
- Abnormalities of urinary tract (eg prostatic hypertrophy, kidney stones, urethral strictures, vesicoureteral reflux)
- Neurological dysfunctions (eg stroke, diabetes, spinal cord injuries)
- Anticholinergic drugs
- Catheterization and other mechanical instrumentation
- Diabetes
- Pregnancy
- Use of diaphragms and spermicides
- Genetic association (positive family history)
- Previous UTI
Non-pharmacological Tx to prevent UTIs?
- Drink lots of fluid to flush the bacteria (6-8 glasses/day), unless you have a condition that requires fluid restriction
- Urinate frequently
- Urinate shortly after sex
- For women: wipe from front to back after using the toilet
- Wear cotton underwear and loose-fitting clothes so that air can keep the area dry. Avoid tight-fitting jeans and nylon underwear which trap moisture
- Use of diaphragm and spermicide, unlubricated condoms or spermicidal condoms increase irritation and can increase bacterial growth
Define complicated UTI and list out several complicating factors. What type of people get complicated UTI?
Complicated UTI: UTI associated with conditions that ↑ potential for serious outcomes, risk for Tx failure
Eg UTIs in men, children and pregnant women
Complicating factors:
- Functional and structural abnormalities of urinary tract
- Genitourinary instrumentation (eg catheter)
- DM (complicated)
- Immunocompromised
Define uncomplicated UTI. What type of people get complicated UTI?
Usually in healthy premenopausal, non-pregnant women with no history suggestive of abnormal urinary tract
What are the subjective s/sx for lower urinary tract infection (cystitis)? (6)
- Dysuria
- Urgency
- Frequency
- Nocturia
- Suprapubic heaviness or pain
- Gross hematuria
What are the subjective s/sx for upper urinary tract infection (pyelonephritis)?
- Fever
- Rigors
- Headache, n/v
- Malaise
- Flank pain, costovertebral tenderness (renal punch)
- Abdominal pain
What are some s/sx that especially elderly may experience if infected with UTI?
Elderly frequently do not experience specific urinary s/sx but can present with altered mental status, less alert, more drowsy, change in eating habits or GI s/sx
What are the 4 different lab results obtained from UFEME (urinalysis)?
What can you say about WBC?
WBC, RBC (non-specific), microorganisms, WBC casts
WBC > 10 x 10^9 cells/L
Signifies inflammation, but may or may not be due to infection, BUT absence of pyuria = unlikely UTI
In which type of pts do we take pre-treatment urine cultures?
- Pregnant women
- Recurrent UTI (relapse within 2w or frequent)
- Pyelonephritis
- Catheter-associated UTI
- All men with UTI
Pathogens in uncomplicated cystitis in women
- E. coli (> 85%)
- Staphylococcus saprophyticus (5-15%)
- Enterococcus faecalis
- Klebsiella pneumoniae
- Proteus spp.
Pathogens in complicated/ healthcare-associated UTI?
- E. coli (~50%)
- Enterococci
- Proteus spp
- Klebsiella spp
- Enterobacter spp
- P. aeruginosa (consider covering if pt has health-care associated risk factors)
What are some healthcare-associated risk factors? (cover for P. aeruginosa if pt has these risk factors)
When pts have recent/ frequent exposure to healthcare settings.
- Recent hospitalisation (in last 90 days)
- Recent antimicrobial use (in last 90 days; parenteral)
- Recent invasive urological procedures
- Use of long-term urinary catheters
Empiric abx Tx for cystitis in women? (first-line and alternatives?)
First-line:
- PO co-trimoxazole 800/160mg bid x 3d
- PO nitrofurantoin 50mg qid x 5d
- PO fosfomycin 3g single dose
Alternatives:
PO beta-lactams x 5-7d
- PO cefuroxime 250mg bid
- PO amoxicillin-clavulanate 625mg bid
PO fluoroquinolones x 3d
- PO ciprofloxacin 250mg bid
- PO levofloxacin 250mg daily
What is the empiric abx Tx for complicated cystitis in women? (first-line and alternatives?)
Duration of Tx?
(same as previous card)
First-line:
- PO co-trimoxazole 800/160mg bid x 3d
- PO nitrofurantoin 50mg qid x 5d
- PO fosfomycin 3g EOD x 3 doses
Alternatives:
PO beta-lactams x 5-7d
- PO cefuroxime 250mg bid
- PO amoxicillin-clavulanate 625mg bid
PO fluoroquinolones x 3d
- PO ciprofloxacin 250mg bid
- PO levofloxacin 250mg daily
Treat longer duration eg 7-14 days
What can you say about the use of FQs in complicated/ uncomplicated UTI?
Avoid giving FQs as it is the only PO option for P. aeruginosa + debilitating SEs
Pathogens involved in community-acquired pyelonephritis in women?
- E. coli (> 85%)
- Staphylococcus saprophyticus (5-15%)
- Enterococcus faecalis
- Klebsiella pneumoniae
- Proteus spp.
Tx for community-acquired pyelonephritis in women? (PO)
Should we do urine culture and AST?
Yes, while waiting for urine culture and susceptibility results…
If pts can take PO:
PO fluoroquinolones:
- PO ciprofloxacin 500mg bd x 7d
- PO levofloxacin 750mg od x 5d
- PO co-trimoxazole
160/800mg bd x 10-14d
PO beta-lactam x 10-14d:
- PO cefuroxime 250-500mg bid
- PO amoxicillin-clavulanate 625mg tds
Tx for community-acquired pyelonephritis in women? (pts severely ill requiring hospitalisation/ unable to take PO)
For severely ill pts requiring hospitalisation/ unable to take oral drug:
- IV ciprofloxacin 400mg bid
- IV cefazolin 1g q8h
- IV amoxicillin-clavulanate 1.2g q8h
AND/ OR
- IV/ IM gentamicin 5mg/kg
THEN
- Switch to PO when pt improves/ able to take oral
What is the Tx duration for UTI in pregnancy? (ASB/ cystitis and pyelonephritis)
Treat for 4-7 days for asymptomatic bacteriuria or cystitis.
Treat for 14 days for pyelonephritis
Tx for UTI pregnancy?
What must you take note about co-trimoxazole, nitrofurantoin and AGs?
PO beta-lactams x 5-7d:
- PO cefuroxime 250mg bid
- PO amoxicillin-clavulanate 625mg bid
- PO fosfomycin 3g single dose
- PO co-trimoxazole 800/160mg bid x 3d
- PO nitrofurantoin 50mg qid x 5d
Co-trimoxazole: avoid in first and third trimester
Nitrofurantoin: avoided at term; 38-42 weeks
AGs must be used with caution (cranial nerve toxicity in fetus reported with older AGs like kanamycin, streptomycin, but not for newer AGs)
