18966790 Urinary Tract Infections and Is

8/8/2019 18966790 Urinary Tract Infections and Is

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UTIs result from the presence ofmicroorganisms in the urine (not relatedto contamination) that has the potentialto invade the urinary tract and adjacenttissues

One of the most common bacterialinfections (~ 8 million patient visits/year)

Localized vs. systematic Prevalence:

Women> men while young

Women= men at age of 65


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Lower Tract infection in lower portion of

UT. Can include bladder (cystitis), urethra

(urethritis), prostate gland (prostatitis),and epididymitis.

Upper Tract infection in upper portionof UT. Can include kidneys

(pyelonephritis) and ureters.


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Anatomy and associated infections of the urinary tract


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Uncomplicated:

Infection present in individuals with normal

UTI anatomy and no alterations in urine flowor voiding mechanisms.

Complicated:Infection resulting from predisposing lesion suchas congenital abnormalities, distortion of UT,stone, indwelling catheter, prostatic hypertrophyand neurogenic deficits. Affect both genderssimilarly, and can involve the upper and lowerUT. Men UTIs are considered complicated.


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Bowel flora Uncomplicated UTIs:

E. coli (85%) most common pathogen

S. saprophyticus ( 5- 15%)

K. pneumoniae, Proteus spp., P. aeruginosa andEnterococcus spp. ( 5-10%)

S. Epidermis

Complicated UTIs: Pathogen with increase resistance to antibiotics E

.coli (50%) andE. faecalis (frequently isolated inhospitalized patients)

Candida spp. Single organism vs. multiple organisms Community acquired vs. hospital acquired


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A. Route of entry:

1. Ascending

2. Hematogenous3. Lymphatic

B. Factors that Impact infection development

1. Size of inoculum

2. Virulence of microorganism

3. Natural host defense


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C. Host Defense Mechanisms: Low urine pH

Extreme osmolality

High (urea)

High (organic acid) Prostatic secretions

Micturition

Anti-adherence mechanism:

x Urinary mucusx Tamm-Horsfall protein

Inflammatory response

Lactobacillus and estrogen levels


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Age

Gender

UT structural abnormalities

Obstruction

x BPH

xUrethral stricturesx Caliculi

x Tumors

Incomplete bladder emptying


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Vesicoureteral reflux

Immunocompromised patients

Instrumentation

Pregnancy

Sexual intercourse/diaphragm use

Menopause


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Lower UTIx Dysuriax Urgency/frequency

x Nocturiax Suprapubic discomfort

Upper UTIx Feverx Chills

x Malaisex N/V

x Flank painx Abdominal pain

x Costovertebral tenderness


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Acute bacterial prostatitisx Perineal, sacral, or suprapubic pain

x Urinary retentionx Dysuria

x Urgency/frequency

x Nocturia

Chronic bacterial prostatitisx Voiding difficulties

x Perineal and suprapubic pain


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Urine collection:x Midstream clean catch

x Catherization

x Supra-pubic bladder aspiration

Urinalysis (dipstick for leukocyte esterase ornitrite)

Urine microscopy

Urine culture

Urine culture

Bacterial susceptibility testing


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PARAMETER UTI MARKERS NORMAL VALUES

APPEARANCE Cloudy Yellow

Ph Alkaline 4.5 8.5

Protein Positive Negative

Nitrite Positive Negative

Leukocyte esterase Positive Negative

RBC Positive Negative

WBC > 10/mm3 0 5/hpf

Bacteria many None


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CHARACTERISTIC FINDING

Symptomatic female > 102 CFU coliforms/mL or > 105

non coliforms/mL

Symptomatic male >103 CFU bacteria/mL

Asymptomatic individual >105 CFU bacteria/mL x 2

specimens

Catheterized individual >102 CFU bacteria/mL

Positive bacterial growth on suprapubic catheterization isa symptomatoc patient is considered UTI


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A. Goals

Treat and prevent systematic infection

Eradicate invading organism

Prevent recurrent infections

Prevent ADR

B. Antimicrobial therapy:

TMP/SMX, fluoroquinolones, nitrofurantoin and beta lactam

agents Susceptibility testing

Patient drug allergies

Patient adherence

Cost of therapy


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C. Duration of therapy:

Conventional:

x7-14 days (women)

x 10 14 days (men)

Short cause

x 3-5 days

x Single dose Recurrent/prohylactic

prostatitis


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1. Prevalence/etiology:x Most common type

x Sexual intercourse

2. Pathogens:x E.coli

x S. saprophyticus

x Klebsiella

x Proteus

3. Clinical presentation:x (+/-) dysuria, frequency, urgency and suprapubic

discomfort


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4. Antibiotics:x TMP/SMX

x Nitrofurantoinx Fluoroquinolones

5. Duration of therapy:x Conventional

x Three to five day

x Single dose (one-day)


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1. PREVALENCE/ETIOLOGY:x Complicated UTI

2. Pathogens:x Gram (-): E.coli, Klebsiella, Proteus

x Gram(+): E.faecalis, S.saprophyticus

x Long term hosp. patients: P.aeruginosa,enterococci and multiple resistantpathohgens

3. Clinical presentation:x (+/-) dysuria, frequency, urgency and

suprapubic discomfort


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x

Fluoroquinolonesx Aminoglycosides +/- Ampicillin

x Aminoglycoside +/- Broad spectrumcephalosporin

x Beta lactamase inhibitors

5. Duration of therapy:x Stop IV therapy after 3 day-treatment and patient

clinical improvement, then start PO therapy x 2weeks


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1. PREVALENCE/ETIOLOGY:x Fecal matter

x Sexual intercourse2. Pathogens

x E.coli

x Staph spp.

x Chlamydia trachomatis

x Gardnerella vaginalis

x Neisseria


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3. Clinical presentation:x (+) dysuria, pyuria and urine culture less than 105

bacteria/mL


x Fluoroquinolones

x Azithromycin or doxycycline for chlamydia

treatment

5. Duration of therapy:x Short cause


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1. Prevalence/etiology:x Most common in children, pregnant women, and

elderly patients

x Relapse and reinfection rates are high2. Pathogens

x E.coli

3. Clinical presentation:x No symptoms

x Urine culture > 105 bacteria/mL x 2 specimens

4. Antibiotics:x Controversial in elderly patientsx Children and pregnant women should be treated


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1. Prevalence/etiology:x Complicated high in elderly patients

x Instrumentation

x Lack of circumcision

x Sexual activity

2. Pathogens:

x May vary when compare to women pathogens3. Clinical presentation:

x Combination of lower and upper UTI symptoms

4. Antibiotics:x Urine culture

x Gram(-) coverage: TMP/SMX and fluoroquinolones

5. Duration of therapy:x Conventional (10-14 days) slightly lobger than female

conventional therapy

x Short cause is contraindicated

x 2 week vs 6 week therapy

x F/U cultures


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1. ETIOLOGY:x Urinary stasis, low defenses against bacteria reflux and

high (urine nutrients)

x Asymptomatic bacteriuria occurs in 4 to 7% ofpregnant patients. Of these, 20% - 40% develop acute

symptomatic pyelonephritis.2. Pathogens:

x E.coli

3. Screening:x Recommended at initial prenatal visit and 28 weeks

gestation

4. Antibiotics:x Amoxicillin,cephalosporins or nitrofurantoin x 7 days

x Do not treat with TCN, sulfonamides, fluoroquinolones

x

F/U culture in 1-2 weeks


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Risk Factors:

Duration of catherization (>30 days =

high risk) Catheter system (closed drainage

preferred)

Inappropriate care

Poor aseptic technique for catheterinsertion

Patient susceptibility


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MOSTLY RE-INFECTIONS (DIFFERENTPATHOGEN) BUT ALSO INCLUDE RELAPSES

(SA

ME

PA

THOGEN)

Relapse cases should be treated longerand follow up cultures are recommended

Classification: 2 infections/6 months, < 3

infections/year and > 3 infections/year Etilogy:

x Sexual intercourse

x Diaphragm and spermicide use


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Postmenopausal women topical estrogen

Antibiotic self-administrationx Postcoltal (low-dose prophylaxis) single dose of

TMP/SMX, nitrofurantoin, cephalexin, orfluoroquinolone

x Continued low-dose (long-term, low-doseprophylaxis)x < 3 infections/year:

x Short cause therapy per episode

x > 3 infections/year:x Treat each episode conventionally first

x Prophylatctic therapy second to prevent symptomaticinfections x 6-12 months)

x TMP/SMX, nitrofurantoin, fluoroquinolone (limit usesecondary to high drug resistance, adverse events, drug-

interactions and cost)


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Hydration

Cranberry juice

Lactobacillus

Topical estrogen

UT analgesics

x Phenazopyridine

Shower instead of bathing


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Avoid using any feminine hygiene sprays

and scented douches

Avoid long intervals between urination After urination, wipe from front to back

Empty your bladder after sexual

intercourse


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Assessment: Past medical history

x A

ge related changes, co-morbidities,pregnancy, UT abnormalities, history of UTI orrecurrent UTIs, medication allergies, urineculture susceptibility interpretation (ifapplicable)

xCurrent list of medications

Personal and social history

x Catheter replacement, home arrangement,shower vs. bathing


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Review of systems (physical exam)x General appearance (skin, hydration)x Vitals

x Signs and symptoms of lower UTI vs. upper UTI

x Metal status changes (key presentation in elderpatients)

Assessment: Urinalysis:x (+/-) pyuria, bacteriuria, leukocyte esterase

Others (for acutely ill patients)x Lab. Urinalysis w/ microscopic examx Urine C&S

x CBC with diff.x Clood chemistry

x Blood culture


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Treatment:

Establish treatment goals based on diagnosis

and presentation Select antibiotic dose and therapy duration:

x Consider renal function, drug interactions,urine C&S, medication compliance and cost

Assess the need to treat fever, pain anddehydration

Educate patient about UTI prevention


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A. Acute

B. Chronic bacterial


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~ 60,000 AMBULATORY CARE VISITS BY

MEN OVER THEAGE OF 18 IN THE

U.S./YEAR Young to middle age men

Symptoms include pain (testicles, penis,

lower abdomen) bladder irritation,

bladder obstruction, blood in semen and

impotence


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CATEGORY 1

Acute bacterial prostatitis

CATEGORY II Chronic bacterial prostatitis

CATEGORY III

Chronic pelvic pain syndrome CATEGORY IV

Asymptomatic inflammation


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Microorganism way of entry

Urethra

Risk factors:

Trauma

Dehydration

Sexual abstinence

Chronic indwelling bladder catheters


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Presentation Spiking fever Chills Malaise Dysuria Pelvic or perineal pain Cloudy urine Obstructive symptoms dribbling hesitancy to anuria

Complications:

Bacterimia and sepsis Sacroiliac infection Epididymis Prostatic abscess Chronic bacterial prostatitis


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Pathogens: Gram (-), specially E.coli and Proteus spp.

Diagnosis: Edematous and tender prostate at digital

exam

Urine gram stain Blood cultures

Leukocytosis

High serum prostate antigen levels


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Non protein bound, lipophilic antibiotics

(ideal but not reqd)

NSAIDs to relieve pain, inflammation,and liquefy prostatic secretions

Parental therapycan be switched to oral

antibiotics alone after the patient has

been afebrile for 24 to 48 hours

Duration of therapy: 4-6 weeks


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Gram (+) pathogens:

Cocci in chains (enterococcal)

x Oral amoxicillin 500 mg q8hx IV ampicillin 2 g q6h

Cocci in clusters (staphylococcus)

x Oral cephalexin 500 mg

Q6h; dicloxacillin 500 mg q6h

x IV cefazolin 1g q8h; nafcillin 2 g q6h;vancomycin 1g q12h (MRSA/PCN allergy)


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Gram (-) pathogens:

Oral TMP/SMX one DS q12h;

fluoroquinolone (ciproflox

acin 500 mg daily) IV aminoglycoside (gentamicin or

tobramycin 5 mg/kg q24h) Plus ciproflaxacinor levofloxacin


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Presentation include dysuria andfrequency, urgency, perineal discomfort,low-grade fever, (+/-) prostate edema, and

recurrent UTI in the absence of bladdercatheterixzation Gram (-) rods are the most common

pathogens except for enterococci,Chlamydiae, and Mycobacterium

tuberculosis Diagnosis can be made by analyzing

specimend obtained following prostaticmassage for leukocytes and bacteria.


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For first and recurrent episodes,

ciprofloxacin 500 mg q12h or

levofloxacin 500 mg daily

For chlamydia infection, azithromycin

500 mg daily vs. 1 g once.


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