UTIs

Question 1

define UTI

Answer 1

• Defined as presence of significant bacteriuria and characteristic signs and symptoms

Question 2

what are the risk factors for UTIs?

Answer 2

iatogenic/ drugs- catheter, antibiotic use, spermacides
behavioral- voiding dysfunction, frequent or recent sex
physiologic- female, pregnant
genetic- familal tendency, vaginal mucus properties

Question 3

what can pyleonephritis lead to?

Answer 3

AKI/sepsis- if it becomes systemic

Question 4

who/ what is classified as an uncomplicated UTI?

Answer 4

• Caused by a usual pathogen in a person with a normal urinary tract and normal kidney
  function
  – Female (not elderly)
  – First presentation
  – No signs of pyelonephritis
  – Not pregnant

Question 5

what classifies as a complicated UTI?

Answer 5

• Pregnant
• Male
• Children
• Elderly
• Pyelonephritis
• Recurrent
• Factors present that predispose to persistent or re-current infection or treatment failure
  – Abnormal urinary tract
  – Virulent organism
  – Impaired host defences
  – Poorly controlled diabetes
  mellitus,
  – Immunosuppressive treatment
  – Impaired renal function.

Question 6

what are the typical symptoms of uncomplicated UTI?

Answer 6

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

Question 7

why would you suspect an upper UTI?

Answer 7

• +/- UTI Symptoms
• Fever
• Flank, loin or lower back pain
• Can lead to renal failure and
  septicaemia
• Empirical antibiotics +/-
  admission to hospital required

Question 8

how do you diagnose a UTI?

Answer 8

• Clinical history and symptoms
• Near patient tests?
  – Appearance of urine – smell? cloudy? blood?
  – Urine microscopy
  – Dipstick tests – leucocyte and nitrite
• Urine culture

Question 9

why are urine dipsticks not used?

Answer 9

Dipsticks become more unreliable with increasing age over 65 years. Up to half of older adults, and most with a urinary catheter, will have bacteria present in the bladder/urine without an infection. This “asymptomatic bacteriuria” is not harmful, and although it causes a positive urine dipstick, antibiotics are not beneficial and may cause harm

Question 10

how do you manage an uncomplicated lower UTI?

Answer 10

• Empirical Antibiotics
  – Nitrofurantoin MR 100mg twice daily for THREE days or 50mg QDS
• First line treatment option
• Contraindicated in significant renal impairment
• Activity affected by urinary pH
  – OR Trimethoprim 200mg twice daily for THREE days

Question 11

what do complicated UTIs need?

Answer 11

• Complicated infection requires 5- 10 day treatment courses to eradicate bacteriuria

Question 12

when do you have to be cautious with nitrofurantoin in renal impairment?

Answer 12

• Caution in renal impairment
  – eGFR less than 45ml/minute/1.73m2
  – Ineffective (inadequate concentration in the urine….site of action)
  – 30-45ml/minute/1.73m2 – only if multi-drug resistant(risk/benefit)
  – Increased risk of peripheral neuropathy

Question 13

what patients are already at risk of peripheral neuropathy?

Answer 13

• DM
• Anaemia
• Folate deficiency
• Electrolyte
  imbalances

Question 14

what are some side effects of nitrofuratoin?

Answer 14

– GI
– Pulmonary – cough, chest pain, dysphonea,
hypoxemia….(<1%) – withdraw + corticosteroid

Question 15

when would you be cautious with trimethoprim in renal impairment?

Answer 15

• Caution in severe renal impairment (accumulation - less of an issue with 3
  day courses)
  – GFR 15-25 ml/min – normal dose for 3 days then half dose
  – GFR <15 ml/min – half normal dose

Question 16

what is trimethoprim contraindicated with?

Answer 16

• CI with blood dyscrasias – antifolate effects

Question 17

what interactions does trimethoprim have?

Answer 17

• Interactions (bigger issue with long-term treatment)
  – Methotrexate (folate antagonist)
  – Azathioprine (increased risk of haematological toxicity)
  – Phenytoin (increased levels)
  – Digoxin (increased levels)
  – Warfarin? (often the case with all Abx)

Question 18

what should be done if patient is resistant to first line antibiotics?

Answer 18

urine culture

Question 19

define pyelonephritis

Answer 19

Infection within the renal pelvis, with or without active infection of the renal parenchyma

Question 20

what are the symptoms of pyelonephritis?

Answer 20

UTI + loin pain and/or fever

Question 21

what are the common pathogens of pyelonephritis?

Answer 21

Common pathogens:
* Escherichia coli
* Klebsiella pneumonia.
* Proteusspecies
* Pseudomonasspecies
* Enterococcus species

Question 22

who would you be extra cautious about with pyelonephritis?

Answer 22

• Pregnancy
• Elderly…care homes
• Lack of improvement following antibiotic therapy (24 hours)….close monitoring
• Immunocompromised
• Renal impairment
• Diabetes

Question 23

what is the management of pyelonephritis?

Answer 23

Primary care
* Co-amoxiclav 625mg TDS 7 days or
* Ciprofloxacin 500mg BD 7 days
* Cautions with above agents???
Secondary Care
* Optionsinclude, gentamicin, tazocin®, meropenem, teicoplanin,
ciprofloxacin

Question 24

what is defined as a relapsed UTI?

Answer 24

• Same strain of organism within 2 weeks of finishing treatment

Question 25

what is defined as a reinfection UTI?

Answer 25

* Different strain of organism, most likely if >2 weeks after treatment

Question 26

how do you manage recurrent UTI?

Answer 26

* Patient initiated self treatment * Post coital prophylaxis - * Non antibiotic treatment – Cranberry products – no longer recommended * Continuous prophylaxis – option, but poor evidence – e.g. trimethoprim100mg ON

Question 27

why are UTIs more uncommon in men?

Answer 27

longer urethra – antibacterial activity of prostatic secretions

Question 28

what should be done in all men with suspected UTI?

Answer 28

urine culture

Question 29

how do you treat a UTI in men?

Answer 29

– Seven day course of trimethoprim or nitrofurantoin recommended (HPA) – Treatment failure should be managed according to urine culture results – Recurrent UTI in men and febrile UTI often associated with prostate involvement * Quinolones indicated due to ability to penetrate prostatic fluid

Question 30

what is bacteriuria in pregnant women associated with?

Answer 30

The presence of bacteriuria (with/ without symptoms) is associated with premature rupture of membranes and pre- term labour

Question 31

what is done to prevent bacteruria in pregnant women?

Answer 31

* Routine screening for asymptomatic bacteriuria by midstream urine culture recommended in early pregnancy (NICE)

Question 32

what can be given for cystitis in pregnancy?

Answer 32

* Paracetamol may be recommended for symptomatic relief * Alkalizing agents and cranberry should be avoided * Urine culture + empirical antibiotic therapy * Fever and loin pain suggests upper UTI – Hospital admission and IV antibiotics recommended

Question 33

how may a UTI present in elderly?

Answer 33

* Chronic genitourinary symptoms may be present and not associated with acute infection – Functional decline, increased confusion and non specific symptoms are often attributed to UTI

Question 34

how do you diagnose UTI in elderly?

Answer 34

* Diagnosis of UTI in an older person requires the presence of new urinary symptoms.

Question 35

what must be done for patients with UTIs with indwelling catheters?

Answer 35

* The catheter must be checked for correct positioning and to ensure it is not blocked. * If the catheter has been in place for more than a week, it may be advisable to change it before starting antibiotic treatment * Urine culture must be taken prior to initiating empirical antibiotics * If symptoms are mild, treatment may be delayed to await results of culture & sensitivities * Seven day courses recommended

Question 36

why are people with diabetes at higher risk of UTIs?

Answer 36

* Increased risk of asymptomatic bacteriuria * Higher risk of recurrent infections * Higher prevalence of atypical pathogens * Bilateral infections are more common * Greater likelihood of antimicrobial resistance * Hospital acquired infections are more common * Fungal urinary tract infection is more common * Increased risk of complications like renal failure and septicaemia

Question 37

are UTIs common in children?

Answer 37

* Occurs in 3-7% girls and 1-2% boys before the age of 6 years * 12-30% experience recurrence within a year * Up to half patients have a structural abnormality of urinary tract * Pyelonephritis can damage growing kidney causing scarring

Question 38

how do infants present with UTIs?

Answer 38

* Fever * Vomiting * Lethargy * Irritability * Offensive urine * Poor feeding / failure to thrive * Jaundice * Febrile convulsion * Septicaemia

Question 39

how do children present with UTIs?

Answer 39

* Dysuria and frequency * Abdominal pain or loin tenderness * Fevers +/- rigors * Lethargy * Anorexia * Vomiting, diarrhoea * Haematuria * Offensive/ cloudy urine * Febrile convulsion * Recurrence of enuresis

Question 40

what investigations should be done for infants and children?

Answer 40

Infants and children presenting with unexplained fever of 38°C or higher should have a urine sample tested within 24 hours (NICE)

Question 41

what indications are there to do a culture?

Answer 41

– Diagnosis of acute pyelonephritis/upper urinary tract infection – High to intermediate risk of serious illness – Under 3 years – Single positive result for leukocyte esterase or nitrite – Recurrent UTI – Infection that does not respond to treatment within 24–48 hours – Clinicalsymptoms and dipstick tests do not correlate

Question 42

what are the risk factors for UTI in children?

Answer 42

* Incomplete bladder emptying – Poor urine flow – Dysfunctional voiding resulting in enlarged bladder – Obstruction by loaded rectum from constipation – Neuropathic bladder * Antenatally-diagnosed renal abnormality * Family history of vesicoureteric reflux (VUR) or renal disease * History suggesting, or confirmed, previous UTI * Evidence of spinal lesion * Poor growth * High blood pressure

Question 43

how do you treat children / infants over 3 months?

Answer 43

* Oral antibiotics recommended for children and infant over 3 months: – Acute pyelonephritis: * 7 days - 10 days * IV antibiotics for 2– 4 days if oral antibiotics cannot be used followed by oral treatment for 10 days total – Low UTI: * 3 days * Re-assess if child remains unwell after 24-48 hours * Choice of antibiotic – Trimethoprim, nitrofurantoin, cephalosporin or amoxicillin

Question 44

how can you prevents UTIs in children?

Answer 44

* High fluid intake to produce a high urine output * Regular voiding * Ensure complete bladder emptying – Double micturition * Prevention or treatment of constipation * Good perineal hygiene * Probiotic?? * Antibiotic prophylaxis – Not recommended after first infection – May be indicated in recurrent UTI – Under 2’s with congenital abnormality – Severe reflux – Trimethoprim