UTIs

Most common route of infection

Ascending route

Less common route of infection

Hematogenous, lymphatic routes

Define uncomplicated UTI

Lower urinary symptoms (dyslexia, frequency, and urgency) in otherwise healthy non-pregnant women

define complicated UTI

Pregnant women, men, obstruction, immunosuppression, renal failure, renal transplantation, urinary retention from neurological disease, and individuals with risk factors that predispose to persistent or relapsing infections (catheters or other drainage devices), health care associated with:(

define CA-UTI

Presence of dwelling urinary catheters with signs and symptoms of UTI and mother source of infection - presence of >= 10³ CFU/mL in a single catheter urine specimen or in a midstream urine, despite removal of urinary catheter in the precious 48 hours

Define asymptomatic bacteriuria in women

Two consecutive voided urine specimens with isolation of the same bacteria at >= 10^5 CFU/mL

Define asymptomatic bacteriuria in men

A single, clean catch, voided urine specimen with 1 bacteria isolated 10^5 CFU/mL

Signs and symptoms of lower tract infection (cystitis)

Dysuria, frequency/urgency, hematuria

Signs and symptoms of upper tract infections (pyelonephritis)

Same as cystitis, costovertebral angle (CVA) tenderness “flank pain,” fever, chills, N/V

T/F: in women, overactive bladder and interstitial cystitis present with urgency and bladder discomfort but are not bacterial infections

True

what are the categories of risk factors for UTIs

no known/associated RF, recurrent UTI RF but no severe outcomes, extra-urogenital RF with risk of more severe outcomes, nephropathic disease with risk of more severe outcome, urological RF with risk of more severe outcome which can be resolved during therapy, permanent urinary catheter and non-resolvable urological RF with risks of more severe outcomes

examples of no know/associated risk factors for UTIs

healthy premenopausal women

examples of extra-urogenital risk factors with risk of more severe outcomes

pregnancy, male gender, badly controlled DM, relevant immunosuppression, connective tissue disease, prematurity, new born

examples of recurrent UTI risk factors but no risk of severe outcomes

sexual behavior and contraceptive devices, hormonal deficiency in post-menupause, secretory type of ceterin blood groups, controlled DM

examples of nephropathic diseases with risk of more severe outcomes

relevant renal insufficiency, polycystic nephropathy

examples of urological risk factors with risk of more severe outcomes that can be resolved during therapy

ureteral obstruction, transient short-term urinary tract catheter, asymptomatic bacteriuria, controlled neurogenc bladder dysfunction, uroogical surgery

examples of permanent urinary catheter with non-resolving urological risk factors and more severe outcomes

long-term urinary tract catheter treatment, non-resolvable urinary obstruction, badly controlled neurogenic bladder

lab tests for lower urinary tract cystitis

urinalysis, urine gram stain and culture (clean-catch, midstream - often not done)

lab tests for upper urinary tract pyelonephritis

urinalysis, urine gram stain and culture, CBC, blood culture

disognosis based on urinalysis

clean catch mid-stream specimen, pyuria > 10 WBC/mm3 or > 5-10 WBC/hpf, leukocyte esterase, nitrite, hematuria, WBC casts: possible pyelo, proteinuria (ucu < 2 g), bacteria

diagnosis based urine gram stain and culture

clean catch mid-stream specimen, WBC, gram positive or negative organisms, identify organisms

define bacteriuria

presence of bacteria in urine

define significant bacteriuria (GNR)

traditional > 10⁵ cfu/ml, women > 10² cfu/ml, men > 10³ cfu/ml

define clinical jurinary tract infection (UTI)

significant bacteriuria + pyuria and signs/symptoms of infection

when would you treat asymptomatic bacteriruia

if patient is pregnant, prior to invasive urinary tract procedures, or prior to renal transplantation

T/F: UTIs should only be treated when signs/symptoms of infection are present

true

common uropathogens of uncomplicated UTIs

E.coli, S. saprophyticus, enterococcus spp., K.pneumoniae, P.mirabilis

common uropathogens of complicated UTIs

antibiotic-resistant E.coli, P.aeruginosa, acinetobacter baumannii, enterococcus spp., staphylcococcus spp.

common uropathogens for CA-UTIs

P.mirabilis, morganella morganii, providencia stuartii, C.urealyticum, candida spp.

common uropathogens for recurrent UTIs

P. mirabilis, K.pneumoniase, enterbacter spp., antibiotic resistant E.coli, entercoccus spp., staphylcoccus spp.

nonpharmacologic management of UTIs

forcing fluids, analgesics, urine acidification

T/F: forcing fluids does not improve outcome of antibiotic therapy and therefore should not be done

true

examples of analgiscs for UTIs

phenazopyridine (has little place in routine management), systemic agents for flank pain (acetaminophen), if necessary, take acetaminophen around the clock for fever

T/F: dysuria usually requires treatment with an analgesic

false

example of urine acidification agents

ascorbic acid - difficult to achieve goal and rarely if ever necessary

antibiotic therapy principles for UTIs

choice of agent depends on: sensitivity of suspected pathogen, frequency of infections, timing of infection, patient considerations, cost of equally efficacious agents

antimicrobial therapy for women with acute, uncomplicated cystitis

nitrofurantoin monohydrate/macrocrystals 100 PO BID x 5 days

trimethoprim-sulfamethoxazole 160/800 mg (one DS tab) PO BID x 3 days

fosfomycin trometamol 3 grams PO single dose

quinolones

beta-lactams (amoxicillin or ampicillin SHOULD NOT be used empirically)

spectrum of nitrofurantoin

GNR such as E.coli, klebsiella, but not all (proteus, psuedomonas)

PK of nitrofuratoin

concentrations in urine but not blood, contraindicated if CrCl < 60 ml/min, macrocrystals (Macrobid BID, macrodantin QID)

ADRs of nitrofurantoin

GI, neuropathy, pulmonary toxicity, hepatotoxicity

spectrum of fosfomycin

gram positive (S. aureus, S.epi, S.pneumoiae, E.faecalis), gram negative (E.coli, proteus, kleb, enterobacter, serratia, salmonella typhi)

PK of fosfomycin

half-life = 5.7hours ± 2.8 hours (11-50 hours with CrCl 7-54 ml/min), renal clearance unchanged drug, bioavailability decreases by metoclopramide

ADRs of fosfomycin

mild GI, nausea, neutropenia, local phlebitis (parenteral admin)

outpatient treatment for acute pyelonephritis in women

ciprofloxacin 500 mg po BID x 7 days (with or without initial IV dose)

once daily quinolone

trimethoprim/sulfamethoxazole 160/800 bid x 14 days

oral beta-lactams with an initial IV dose x 10-14 days

uncomplicated pyelonephritis is associated with:

subclinical, recurrent, and during pregnancy

complicated pyelonephritis is associated with:

structural and functional abnormality, urologic manipulation, underlying disease (diabetes, transplants)

symptoms of pyelonephritis

cystitis symptoms + fever, chills, N/V, CVA (costovertebral angle) tenderness - flank pain

what is subclinical pyelonephritis in women

no symptoms of upper tract infection - patient appears to have uncomplicated cystitis, suspect with failure of single or multi-dose regimen

which women are at risk for subclinical pyelonephritis

immunocompromised, hx cystitis, pyelonephritis, underlying pathology (GU)

oral therapy duration for subclinical pyelonephritis

7-14 days (depends on risk factors)

outpatient treatment for acute pyelonephritis in women

ciprofloxacin 500 mg po BID x 7 days (with or without IV dose)

• cipro 400 mg IV x 1

• long-acting beta-lactam such as ceftriaxone

• consolidated 24 hour dose of aminoglycoside

once daily quinolone

trimethoprim/sulfamethoxazole 160/800 bid x 14 days

oral beta-lactams

• 10-14 days

• use an initial IV dose of long-acting parenteral agent, such as ceftriaxone 1 gram or a consolidated 24 hour dose of an aminoglycoside

dosing of quinolones for acute pyelonephritis (outpatiennt)

ciprofloxacin 1000 mg ER x 7 days

levofloxacin 750 mg po x 5 days

facts regarding Bactrim use in outpatient acute pyelonephritis

good if uropathogen is known to be susceptible - if susceptibility is unknown use a long-acting beta lactam or consolidated 24 hour dose of aminoglycoside

define moderate severity acute pyelonephritis

systemic symptoms along with cystitis, most do not require hospitalization, oral therapy if tolerated

define severe acute pyelonephritis

symptoms of upper tract infection + marked systemic response, hospitalization is required, parenteral agents preferred

in-hospital management of acute pyelonephritis in women

quinolone IV

aminoglycoside ± ampicillin

extended spectrum cephalosporin

penicillin ± aminoglycoside

carbapenem

duration of therapy for in-hospital acute pyelonephritis

10-14 days

presentation of UTIs in pregnancy

typical cystitis and pyelonephritis symptoms

T/F: 20-40% of asymptomatic bacteriuria in pregnant women will develop pyelonephritis

true

possible therapy choices for UTIs & asymptomatic bacteriuria in pregnancy

Augmentin x 7 days

cephalexin x 3-7 days

nitrofuratoin x 7 days (avoid if close to delivery)

amoxicillin (only if sensitivity is known) x 7 days

Bactrim (only if sens i s known) x 3 days

• AVOID in last trimester; kernicterus and hyperbilibinemia

antibiotic therapies for pyelonephritis in pregnancy

IV beta-lactams (ceftriaxone, cefazolin) - switch to oral agent when possible total of 14 days

which antibiotics are contraindicated in pregnancy?

quinolones and tetracycline

which antibiotic should be avoided in the last trimester of pregnancy

sulfonamides due to possible hyperbilirubinemia and kernicterus

prevention of pyelonephritis in pregnancy

monitor urine cultures periodically, treat asymptomatic bacteriuria

management of asymptomatic bacteriuria in non-pregnant adults and elderly

antimicrobial therapy is NOT indicated - as long as clinical infection has been ruled out

when to treat asymptomatic bacteriuria in non-pregnant adults and elderly

prior to invasive urinary tract procedures, prior to renal transplant (therapy should begin 12 hours prior to procedure)

define relapse in recurrent UTIs

same organism, occurs within 1-2 weeks of therapy for prior infection, extend treatment duration (up to 6 weeks)

define reinfection for recurrent UTIs

different organisms or serotype, treat for duration outlined in guidelines (3-5 days depending on agent)

management for recurrent UTIs in women

continuous prophylaxis (Bactrim daily or TIW, cephalexin), postcoital prophylaxis topical estrogen in post-menopausal women, lactobacillus use, cranberry juice, home screening kits, intermittent self-treatment with antibiotics

pathogens in male UTIs (prostatitis)

E.coli, proteus, klebsiella, enterobacter, enterococci, S.saphrophyticus

rare presentation of cystitis in males

dysuria, frequency (younger men)

typical presentation of cystitis in males

elderly male with dysuria, frequency, fever, lower abdominal pain (possible bacteremia in some cases)

presentation of pyelonephritis in males

similar to pyelonephritis in women

Signs and symptoms of acute bacterial prostatitis

prostate is usually tender/swollen, pyuria, bacteria, positive urine culture, possible bacteremia

treatment for acute bacterial prostatitis

choice and 7-14 day duration (2-4 weeks??)

treatment for acute bacterial prostatitis

quinolones

Bactrim 160/800 mg po BID

gentamicin/ampicillin if entercoccus

treatment for chronic bacterial prostatitis

quinolones

Bactrim 160/800 mg po BID

suppressive therapy doing for chronic bacterial prostatitis

½ usual dose chronically

therapy duration for chronic bacterial prostatitis

4-6 weeks

what is common with indwelling (foley) and condom (Texas) catheters?

asymptomatic bacteriuria (ANTIBIOTICS NOT INDICATED)

prevention of catheter-related uTIs

avoid prolonged use of Abx, avoid unnecessary Abx, intermittent catheterization

which antibiotics are newer for complicated UTIs and pyelonephritis

meropenem-vaborbactam (Vabomere)

ceftazidime-avibactam (Avycaz)

ceftolozane-tazobactam (Zerbaxa)

pathogens of candiduria

candida albicans, candida glabrata, other candida species (tropicalis, parapsilosis)

prentation of candiduria

asymptomatic, lower tract (cystitis) - dysuria, frequency, urgency, upper tract infection (rare)

when to treat symptomatic candiduria

high risk (neutropenia, infants with low birth weights), undergoing urologic procedure for several days before/after

which candida species are resistant to azoles?

C. glabrata and C. krusei

which candida is sensitive to azoles?

C.albicans

treatment for C.albicans (symptomatic candiduria)

fluconazole 200 mg (3 mg/kg) daily x 2 weeks

treatment for C.glabrata (symptomatic candiduria)

amphotericin B deoxycholate 0.3-0.6 mg/kg/day x 1-7 days

flucytosine 25 mg/kg 4x/day for 7-10 days

treatment for C.krusei (symptomatic candiduria)

ampho B deoxycholate 0.3-0.6 mg/kg/day for 1-7 days