GU Packet 2

UTIs include what?

Cystitis (infection of the bladder/lower urinary tract)

Pyelonephritis (infection of the kidney/upper urinary tract)

What is cystitis?

Inflammation of the bladder mucosa caused by bacteria infection

What is pyelonephritis?

Infectious disease involving the kidney tissue and renal pelvis

How does E. coli reach the kidney?

Migrate up from the bladder, through the ureters, to the kidney, and then it can go anywhere blood can travel

Quote from Hooton and Gupta?

The pathogenesis of UTI begins with colonization of the vaginal introitus or urethral meatus by uropathogens from the fecal flora, followed by ascension via the urethra into the bladder. Pyelonephritis develops when pathogens ascend to the kidneys via the ureters.

What is the usual cause of cystitis?

Bacteria from perineum passing through the urethra to the bladder

What is the logical explanation of why women are at higher risk for urinary tract infections?

They have a shorter distance from the anus to the urethra

What causes 80-90% of UTIs in adults?

E. coli

Simple, uncomplicated cystitis in women is typically caused from what and from where?

Those that have a bacterial cause of UTI that comes from bacterial that inhabit the colon (80-90% is E. coli)

How do we treat simple, uncomplicated cystitis in women (the type of treatment), and what are the prospects of treating it with this method?

Empiric therapy with a high probability of success

What is empiric therapy?

General medical treatment for most probable cause without confirmation (in the case of cystitis it is treating for E. coli)

What is a growing problem with cystitis?

Increasing rates of resistance of E. coli have been widespread

What have medical personal done to fight the increasing resistance of E. coli?

Monitoring of local prevalence of resistance is necessary for optimization of empiric therapy

What defines complicated cystitis in women?

The microbial spectrum of simple cystitis in patients with recent antimicrobial or healthcare exposures may be broader

Includes other Gram-negative bacilli such as Pseudomonas

Who should we suspect of having multidrug-resistant gram-negative urinary tract infections?

History of any of the following in the prior three months

1. Inpatient stay at health care facility (eg, hospital, nursing home, long-term acute care facility)

2. Use of a fluoroquinolone or trimethoprim-sulfamethoxazole

3. A multidrug-resistant gram-negative urinary isolate

What percent of women have had at least one UTI?

43% of females aged 14-61

How many MD/PA visits for UTIs each year?

7 million

When is the peak incidence for UTIs?

20s and 30s

How much more likely is it for a woman to have a UTI than a man?

40-50% more likely

Frequency of UTIs in males increases with what?

Age

Risk factors of cystitis

1. Female gender

2. Previous UTI

3. DM (Diabetes mellitus - bacteria grow well with glucose, and they are more susceptible to infection)

4. Pregnancy

5. Honeymoon cystitis (frequent and vigorous sexual activity)

6. Use of spermicides (decreases the body’s ability to fight off infection)

7. Fecal incontinence (lots of E. coli close to urethra(

8. Wiping back to front

9. Incomplete bladder emptying

10. Underlying abnormality of the urinary tract (tumor, calculi, strictures)

Why are you more likely to get a UTI if you have DM?

Bacteria grow well with glucose, and they are more susceptible to infection

What kind of abnormalities of the urinary tract increase the chance of UTIs?

Tumors

Calculi

Strictures

What are the symptoms of cystitis?

1. Frequency

2. Dysuria described as burning or pain at urethra

3. Urgency

4. Suprapubic discomfort

5. Absence of vaginal symptoms (eg, vaginal pruritus or discharge)

6. Sensation of incomplete bladder emptying

7. Nocturia

What are the main symptoms of cystitis?

Frequency

Dysuria described as burning or pain at urethra

Absence of vaginal symptoms (eg, vaginal pruritus or discharge)

The probability of cystitis in women is highest when they come in with what?

Greater than 90% in women who have dysuria and frequency without vaginal discharge or irritation

What are the signs of cystitis?

May experience lower abdominal pressure or discomfort to deep palpations

No CVA tenderness

Vital signs - evaluate for temperature (though temperature is usually normal)

What is CVA?

Costolvertebral angle (at lowest rib) and palpate kidney for discomfort

What are 2 special populations for cystitis?

Elderly

Pregnancy

How do elderly patients often present when they have a cystitis?

Subtle and more difficult to tease out symptoms with a grossly positive urine assessment

Older women can have a number of nonspecific urinary symptoms such as what?

Chronic dysuria or urinary incontinence that mimic symptoms of cystitis (though there may be no evidence of UTI)

Among debilitated patients what should we be worried for that may point to cystitis?

Many generalized signs or symptoms including:

Falls

Change in functional status

Change in mental status

What is the take home message for elderly patients when dealing with cystitis?

When in doubt think about UTI, investigate for infection of the urinary system when things don’t add up

When is pregnancy testing appropriate?

In women of childbearing potential when the possibility of pregnancy cannot be reasonably excluded by history alone

Pregnancy fall under what category?

Special populations with unique management consideration

Is there a correlation between pregnancy and UTIs?

Many studies have described a correlation between maternal UTI, particularly asymptomatic bacteriuria, and adverse pregnancy outcomes

Pregnancy testing checks for what by what substance?

Human chorionic gonadotropin (hCG) by urine or blood

What is human chorionic gonadotropin?

A hormone produced by the placenta after implantation

What are the forms of lab testing for cystitis?

Dipstick urinalysis

Microscopic evaluation

Culture

What does a dipstick urinalysis show if positive for cystitis?

Leukocyte esterase (presence of esterase from WBCs)

Nitrite (works for 50% of patients) (Bacterial convert nitrate to nitrite)

What will be shown in a microscopic evaluation for cystitis?

WBCs (pyuria)

RBCs (hematuria)

Bacteria (Bacteriuria)

What would the absence of pyuria in a microscopic evaluation suggest when attempting to diagnose cystitis?

Absence strongly suggests an alternative diagnosis

(Pyuria is present in almost all women with acute cystitis)

What is a culture?

Growth of bacteria on a plate including a culture and sensitivity

Why should we avoid cultures when dealing with cystitis?

Takes 3 days

Expensive

Empiric therapy because organism is often known

When should we use cultures when dealing with cystitis?

Concern about antimicrobial-resistant uropathogens

Children

Males

Elderly

Pyelonephritis

Diabetes

Pregnant

Immunocompromized

Unless patient is pregnant or in a complicated state how should you treat cystitis?

Empirically

What is a culture useful for when dealing with an antimicrobial-resistant uropathogen?

Tells us what antibiotics will work on the bacteria (Can prescribe antibiotic C because none grew around it, but can’t prescribe antibiotic A because bacteria grew all around it)

What is the treatment for an acute lower tract UTI?

Antibiotics

Cranberry juice (Proanthocyanidins help prevent E. coli from sticking)

Increase fluid intake (flushes bacteria and dilutes urine reducing bacteria nutrients)

Why is cranberry juice so good at preventing and treating acute lower tracts UTIs?

Has proanthocyanidins that help prevent E. coli from sticking to tract

What are some preventative measures for acute lower tract UTIs?

Cranberry juice

Fluid intake increase

Behavioral interventions:

• Wipe front to back

• Avoid pantyhose (tight clothing)

• Make a habit of post coital voiding (void after intercourse)

What is the pharmacological treatment for non-complicated cystitis in a non-pregnant patient?

Nitrofurantoin (Furadantin; Macrobid; Macrodantin) 100 mg

• Ṫ tab po BID x 5 days

Trimethoprim-sulfamethoxazole (Bactrim DS) 800/160 mg

• Ṫ DS tab po BID x 3 days

• Sulfonamide

Cefpodoxime 100 mg

• Ṫ tab po BID x 5-7 days

• Cephalosporin

Phenazopyridine (Pyridium) 200 mg - For dysuria only

• Ṫ tab po TID after meals x 2 days used concomitantly with an antibacterial agent

What class of antibiotic is Trimethoprim-sulfamethoxazole (Bactrim DS)?

Sulfonamide

What class of antibiotic is Cefpodoxime?

Cephalosporin (Third Generation)

Write a prescription for non-complicated cystitis in a non-pregnant patient using the generic and brand name of a non-sulfonamide and non-cephalosporin (Third Generation medication)

Nitrofurantoin (Furadantin; Macrobid; Macrodantin) 100mg

Sig: Ṫ tab po BID x 5 days

Disp: 10 (ten) tabs

Write a prescription for non-complicated cystitis in a non-pregnant patient using the generic and brand name of a sulfonamide

Trimethoprim-Sulfamethoxazole (Bactrim DS) 160/800 mg

Sig: Ṫ DS tab po BID x 3 days

Disp: 6 (six) tabs

What does the 160/800 represent in Trimethoprim-sulfamethoxazole prescription?

160 Trimethoprim

800 Sulfamethoxazole

Write a prescription for non-complicated cystitis in a non-pregnant patient using the generic name of a cephalosporin (Third Generation medication)

Cefpodoxime 100 mg

Sig: Ṫ tab po BID x 7 days

Disp: 14 (fourteen) tabs

Can also be x 5 days with 10 (ten) tabs or x 6 days with 12 (twelve) tabs

What is a consideration in antibiotic selection for cystitis?

Risk for infection with drug-resistant organisms is a consideration in antibiotic selection for both simple cystitis and acute complicated UTI

Write a prescription (brand and generic) to treat dysuria for acute cystitis in a non-complicated and non-pregnant patient

Phenazopyridine (Pyridium) 200 mg

Sig: Ṫ tab po TID after meals x 2 days

Disp: 6 (six) tabs

What does concomitantly mean?

At the same time

What are the side effect of Phenazopyridine (Pyridium)

Reddish/orange discoloration of body fluids (can stain cloths and contact lenses)

What are the labeled indications for Phenazopyridine (Pyridium)?

Dysuria

Symptomatic relief of:

1. Pain

2. Burning

3. Urgency

4. Frequency

5. Other discomforts arising from irritation of the lower urinary tract mucosa caused by infection

How do we pharmacologically treat acute cystitis in pregnancy?

Amoxicillin and clavulanate (Augmentin)

Cefpodoxime

What may or may not antibiotics do for patients (besides treating the infection)?

Increases the risk of contraception (pregnancy)

Decrease the effectiveness of oral BCPs by 15% for time plus 30 days

Increases the risk of yeast infection

What do we recommend with antibiotics to avoid yeast infections?

Yogurt

What are red flags of a complicated UTI infection?

1. Male

2. Prepubertal or geriatric age

3. Symptoms longer than 7 days

4. Immunosuppressing condition

5. History of Acute Pyelonephritis within the past year

6. Known anatomical abnormality

7. DM

8. Fever

9. Flank pain

How does one get pyelonephritis?

An ascending infection from lower UTI causes it (This is why we treat UTIs)

What are the complication with pyelonephritis?

Bacteremia

Sepsis

Multiple organ system dysfunctions (happens due to E. coli travelling in filtered blood and traveling to other organs in the body

What is the most common organism for pyelonephritis?

E. coli

What is the most common organisms for pyelonephritis in the hospitalized, immunocompromises, and recent catheterization?

Proteus

Klebsiella

Pseudomonas aeruginosa

What are the symptoms of pyelonephritis?

1. Fever

2. Chills (shaking)

3. Unilateral flank/lumbar pain

4. Frequency

5. Urgency

6. Dysuria

7. Anorexia

8. Nausea/vomiting/diarrhea

What are the signs of pyelonephritis?

Febrile

Tachycardia

CVA (costovertebral angle) tenderness - pronounced

What does febrile mean?

Having or showing symptoms of a fever

What are the risk factors of pyelonephritis?

1. Urinary tract abnormalities

2. Indwelling catheter

3. DM

4. Immunocompromised (such as those on steroids, chemotherapy)

5. Elderly

6. Dysuria > 7 days

7. Very young/elderly

8. History of acute pyelonephritis within the past year

Name some examples of those that are immunocompromised?

Those on steroids

Those that are on chemotherapy

DM patients

HIV/AIDS patients

What labs are given for pyelonephritis?

Urinalysis (UA)

CBC

Blood cultures

Urine culture and sensitivity

What is positive in a urinalysis for pyelonephritis?

Pyuria

Bacteriuria

Hematuria

What is positive in a CBC for pyelonephritis?

Leukocytosis with left shift (Neutrophils due to bacterial infection)

What are all the WBCs?

Neutrophils (left shift present with pyelonephritis)

Eosinophils

Basophils

Lymphocytes

Monocytes

For blood culture what do we do specifically for pyelonephritis?

Take in at least 2 spots (right arm, then left arm) before antibiotics are given

What decides if a patient should be inpatient or outpatient with pyelonephritis?

Outpatient if they are able to maintain hydration status and are medically stable

Inpatient if otherwise

What is the pharmacological treatment for pyelonephritis?

Levofloxacin 750 mg

• Ṫ tab po daily x 5-7 days

• Antibiotic class: Fluoroquinolones

Trimethoprim-sulfamethoxazole (Bactrim DS) 160/800 mg

• Ṫ DS tab po BID x 7-10 days

• Antibiotic class: Sulfonamide

What kind of antibiotic class is Levofloxacin?

Fluoroquinolones

Write a prescription for acute pyelonephritis using fluoroquinolones?

Levofloxacin 750 mg

Sig: Ṫ tab po daily x 7 days

Disp: 7 (seven) tabs

Can also be x 5 days with 5 (five) tabs or x 6 days with 6 (six) tabs)

Write a prescription for acute pyelonephritis using sulfonamides (both brand and generic forms)?

Trimethoprim-sulfamethoxazole (Bactrim DS) 160/800 mg

Sig: 1 DS tab po BID x 10 days

Disp: 20 (twenty) tabs

Can also be x 7 days, x 8 days, and x 9 days with 14 (fourteen) tabs, 16 (sixteen) tabs, and 18 (eighteen) tabs

What are antibiotics and length based on with acute pyelonephritis?

Culture and sensitivity results

What is the prognosis for acute pyelonephritis?

Good if no underlying renal disease and if treatment is prompt/appropriate resulting in no loss of renal function

What does a follow up consist of with acute pyelonephritis?

Follow up culture in 2-4 weeks after the end of antibiotic treatment

What is the SIRS criteria for sepsis?

1. Temperature greater than 100.4 or less than 96.8

2. Heart rate greater than 90 beats per minute - tachycardia

3. Respiratory rate greater than 20 breaths per minute or PaCO₂ less than 32mm Hg

4. White blood cell count greater than 12,000/μL, less than 4,000/μL, or featuring more than 10 immature band forms