UTI - Learning Package

Question 1

What is cystitis?

Answer 1

Cystitis = inflammation of the bladder which can by due to infection (bacterial cystitis) or other cause

Question 2

What is bacteruria?

Answer 2

Bacteruria = presence of bacteria in urine, note anterior urethra is not sterile and presence of urethral organisms washed out during micturition is not bacteriuria

Question 3

What is pyuria?

Answer 3

Pyuria = presence of pus cells (neutrophil polymorphs) in significant quantities in urine

Question 4

What is sterile pyuria?

Answer 4

Sterile pyuria = urine is negative on culture but significant numbers of pus cells present

Question 5

What is acute pyelonephritis?

Answer 5

Acute pyelonephritis = infection of the upper urinary tract involving the kidneys

Question 6

What is chronic pyelonephritis?

Answer 6

Chronic pyelonephritis = pathological condition with renal scarring and potentially loss of renal function

Question 7

Describe the aetiology of UTI?

Answer 7

Aetiology in men:

• Prostatitis
• Infection of the prostate
• STIs

Aetiology in woman:

• Sex

Question 8

What are some predisposing factors for UTI?

Answer 8

• In females, short urethra and its proximity to rectum
• Trauma to female urethra during coitus and childbirth
• In pregnancy due to stasis of urine allowing bacteria to flourish
• Anatomical abnormalities
  
  • Congenital pelvi-ureteric junction obstruction, vesico-ureteric reflux, duplex kidneys, horseshoe kidney, urethral valves, prostatic enlargement etc
• Renal cysts
• Pre-existing renal parenchymal damage
  
  • Such as from recurrent pyelonephritis
• Stones in urinary tract
• Immunosuppression including diabetes, prolonged steroid therapy, transplant rejection medication
• Instrumentation of urinary tract
• Presence of foreign body in urinary tract including catheter

Question 9

How can UTI be classified?

Answer 9

• Complication
  
  • Those which occur in situations other than young, sexually active woman
• Uncomplicated
  
  • Occur in healthy, sexually active young woman
  • Organisms usually E-coli or skin commensals such as staph saprophyticus
  • Further investigations not required

Question 10

What organisms are usually responsible for uncomplicated UTI?

Answer 10

• Organisms usually E-coli or skin commensals such as staph saprophyticus

Question 11

In what situations should cultures be done to diagnose UTI?

Answer 11

There are many cases when clinical diagnosis of simple, uncomplicated UTI does not require lab confirmation and empirical antibiotics can be used

But, situations where cultures should be done:

• Woman with mild or limited symptoms for whom dipstick testing is inconclusive
• Suspected UTI in men
• Suspected acute pyelonephritis
• Pregnant woman with symptoms and for screening
• After failed antibiotic treatment or persistent symptoms
• Recurrent UTI
  
  • Defined as >2 UTIs within 6 months or >3 in a year
• Children with suspected UTI

Question 12

What is recurrent UTI defined as?

Answer 12

Defined as >2 UTIs within 6 months or >3 in a year

Question 13

How is urine collected for culturing?

Answer 13

Urine collected with mid-stream urine (MSU), should be done early morning

Catheter specimens should be obtained from the catheter sampling port and not from the collection bag

Question 14

What are some common organisms that cause UTI?

Answer 14

• E-coli most common cause
• Staph. Saprophyticus is a common cause in young sexually active woman
• Protease, Klebsiella and Pseudomonas are more often found in hospital patients
  
  • Often associated with catheters

Question 15

Other than culturing, what other investigation can help diagnosis?

Answer 15

Microscopy of unstained urine can also be carried out:

• To determine whether or not there are cells, casts or organism present

Question 16

What are the classical symptoms of urinary tract infection?

Answer 16

• Dysuria
• Frequency of urination
• Suprapubic tenderness
• Urgency
• Polyuria
• Haematuria

Question 17

Describe the general treatment for urinary tract infection?

Answer 17

• Antibiotics
• Drinking lots of fluid
• Alkalinising agents (OTC)

Question 18

Describe the presentation of UTI in woman?

Answer 18

• Dysuria (pain on passing urine)
• Frequency (passing urine more often than usual in small amounts)
• Urgency (feeling that you need to pass urine)
• Suprapubic pain
• Polyuria (increased volume of urine)
• Haematuria (blood in the urine)

Question 19

Describe the treatment for UTI in woman?

Answer 19

• If have 3 of above symptoms or severe symptoms should be treated with antibiotics without further investigation
  
  • 3 day course
• If mild or only 2 symptoms or fever should have mid-stream urine (MSU) collected and dipstick test performed
  
  • UTI unlikely if urine not cloudy

Question 20

What can be detected in dipstick test?

Answer 20

• Nitrate (metabolic product of some bacteria)
• Protein (not normally detectable, sign of inflammation)
• Lecucocytes (leucocyte esterase is an enzyme found in leucocyte ie pus cells, marker of inflammatory response)

Question 21

What is the commonest renal disease?

Answer 21

Acute pyelonephritis

Question 22

Describe epidemiology of acute pyelonephritis?

(how common, age)

Answer 22

• Commonest renal disease
• Usually woman of child bearing age

Question 23

Describe the presentation of acute pyelonephritis?

Answer 23

• Loin pain
• Fever
• Urinary symptoms less pronounced but possible
  
  • Frequency and dysuria
• May be systemically unwell
• Bacteraemia in most severe cases
  
  • Rigors, nausea and vomiting

Question 24

What investigations are done for acute pyelonephritis?

Answer 24

• Urine cultured
• Blood culture if systemically unwell

Question 25

Describe the epidemiology of catheter related infection? (how common)

Answer 25

* Very common, 5% per day

Question 26

Describe the epidemiology for asymptomatic bacteriria? (who)

Answer 26

* Presence of bacteria in urine of asymptomatic woman and older men with prostatic hyperplasia is relatively common

Question 27

What is asymptomatic bacteriruia associated with during pregnancy?

Answer 27

* Associated with increased risk of pyelonephritis and premature delivery * Pregnant woman screened at booking by urine (MSU) culture and treated

Question 28

Describe the aetiology of sterile pyuria?

Answer 28

* Usually renal tuberculosis * Genito-urinary infections such as chlamydia trachomatis * Non-infective pathology in bladder or kidney

Question 29

What investigations should be done for sterile pyuria?

Answer 29

* Collect 3 early morning urine samples for a ZN strain and TB culture

Question 30

Describe the treatment for simple cystitis in woman?

Answer 30

* Oral antibiotics to which organism is sensitive * 3 day course of Trimethoprim or Nitrofurantoin * Cultures taken if no response

Question 31

Describe the treatment for suspected lower UTI in men?

Answer 31

* 14 days of quinolone such as ciprofloxacin to cover possible prostatitis * 7 days of nitrofurantoin or trimethoprim if infection uncomplicated

Question 32

Describe the treatment for acute pyelonephritis?

Answer 32

* 7 days of antibiotics guided by sensitivity testing * Non-pregnant woman with ciprofloxacin

Question 33

Describe the treatment for UTI during pregnancy?

Answer 33

* Nitrofurantoin * Trimethoprim is not recommended during pregnancy

Question 34

Describe the treatment for catheter related UTI?

Answer 34

* Only patients with symptoms treated * Appropriate antibiotics preceded by changing the catheter

Question 35

Describe the treatment for asymptomatic bacteriuria?

Answer 35

* No indication for treatment, other than in pregnancy or when operation procedure involving UTI is planned

Question 36

Describe treatment for recurrent infections?

Answer 36

* Drink lots of fluids * Emptying bladder after sexual intercourse * Further investigations * Gynaecological examination and IVP * Long term antibiotic prophylaxis * 1 tablet or nitrofurantoin or trimethoprim per night