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ID Exam 5 D
Beck: Urinary Tract Infections
| Term | Definition |
|---|---|
| UTIs have many variations. They can be classified as _______ or _____ UTI | Lower (bladder); Upper (kidneys) |
| UTIs can be either uncomplicated or complicated. Uncomplicated is ________ ________ and function. | normal structure |
| Normal structure means there is no neurological damage. you don't have a reflux of urine that goes back into the kidneys. Uncomplicated is only seen in which gender? | Women |
| Complicated, it can be both male and female. Give some examples of UTI infections that can be considered complicated: | Pregnancy, Kidney stones, Catheter-associated, Men |
| Men will never be considered to have a ___________ UTI | UNCOMPLICATED |
| Pathogenesis of UTIs: What are the 2 pathways? | Ascending pathway (most common); Hematogenous pathway |
| Tell me about the Ascending pathway: | most prevalent way people get UTIs. Pathogens travel through the urethra. Women are more prone due to having a shorter urethra compared to men |
| Tell me about Hematogenous pathway: | "Bacteria in the blood and it spreads and lands in the kidneys or bladder. 5% of UTIs are caused by this. |
| Uncomplicated cystitis is: | bladder infection; urinary tract symptoms in otherwise healthy, non-pregnant women |
| Other examples of complicated UTI populations include: | pregnant women, men obstruction, immunosuppresion, renal failure, renal transplantation, urinary retention from neurologic disease, and individuals with risk factors that predispose to presistent or relapsing infection (calculi, indwelling catheters or orther drainage device) *health-care associated |
| CA-UTI is: | presnce of indwelling urinary catheters w s/sx of UTI and NO OTHER SOURCE of infection; -presence of >/= 1000 CFU/mL in a single catheter urine specimen or in a midstream urine, despite removal of urinary catheter in the previous 48h |
| Asymptomatic bacteriuria (bacteria in the urine): Give examples | Women: Two consecutive voided urine specimens with isolation of the same bacteria at >/= 10,000 CFU/mL Men: A single, clean-catch, voided urine specimen with 1 bacteria isolated 10^5 CFU/mL -A single catheterized urine specimen with 1 bacteria isolated >/= 10^2 CFU/mL |
| S/sx of cystitis includes: | Frequency and urgency Dysuria (Pain upon urination) Gross hematuria (urine is red) Suprapubic heaviness (bladder is heavy); *fever is absent in cystitis and is more associated with Pyleonephritis |
| S/sx of Pyleonephritis (Upper UTI): | ⭐️ FLANK PAIN ⭐️; or constovertebral angle (CVA) tenderness; Fever; Malaise; Abdominal pain, nausea, or vomiting |
| Constovertebral angle (CVA) is: | "the mid-back (looking for CVA tenderness and its hitting where the kidneys are" |
| Diagnostic tools to help aid diagnosis and treatment of UTI include: | urine sample, looking at bacteria count, and seeing presence of Pyuria, hematuria, and proteinuria |
| Urine sample as a diagnostic tool for UTI diagnosis will include a clean-catch, catheterization, and suprapubic aspiration. What are these 3? | 1. Clean catch--> pee a little then collect "Mid-stream sample" 2. Catheterization: stick tube to bladder ascetically and let it flow 3. Suprapubic aspiration: needle through skin and suck up urine |
| What is the Bacteria count "cut-off number"? | 10^5 CFU/mL (if this number or more, we're leaning towards UTI) |
| pyuria is defined as? WBC count? hematuria? | WBC present in urine, >10 WBC/mm^3; blood in urine *can be microscopic or gross hematuria |
| Leukocyte Esterases is: takes how long? | screening test used to detect leukocuytes in the urine for possible UTI; 24-48h; its not a perfect test |
| If the Leukocyte esterase comes back (+): | should do urine culture if pt also has symptoms of UTI |
| If the Leukocyte esterase comes back as a false (+): | specimen contaminated by vaginal secretions that contain WBC |
| If the Leukocyte esterase comes back as a false (-): | specimen with high levels of protein or ascorbic acid |
| Aside from the Leukocyte Esterase as use of for diagnosis of UTI, we can also look at what kind of screening test? | Nitrites |
| Nitrite screening test is? | screening test used to detect possible UTI on the principle that most (not all) bacteria produce reductase that can reduce urinary nitrates to nitrites; -comes back (+)? Should do urine culture if pt also has symptoms of UTI |
| Urine culture is the ________ ________ for UTI diagnosis and will provide bacteria and ____________ | GOLD STANDARD; Susceptibilities |
| When considering Empiric treatment we must look at: | -which bug(s) is/are causing the infection? (I.e E. coli) -Severity of the signs and symptoms -Site of infection -Uncomplicated vs compiicated -Does it get to the site of infection -Collateral Damage |
| Number 1 bug we will always be treating for in UTI? | E. coli |
| Collateral damage is related to ______ and its effect on flora. When treating UTI, must consider when choosing abx: "are you hitting other bacteria in our body vs targeting specific bugs and wont affet other bugs in our body" | broadness |
| We streamline therapy when we get ________ back. | cultures; -Pick the most susceptible but narrow agent -Does it get to the site of infection? (Lower vs upper UTI?) -PO vs IV |
| When choosing urine tests to screen or not to screen, what are the 3 populations that we screen/treat regardless of symptoms? | 1. Pregnant women; 2. Pts undergoing urological procedure w/ mucosal trauma (treat PRIOR to procedure) 3. Kidney transplant recipients <1 month from transplant *so if no symptoms but bacteria is growing? WE TREAT no matter what for these populations |
| Who pts or populations do we not screen/treat | 1. functionally impaired older adults that live in the community or in nursing home 2. Older adults with altered mental status 3. Diabetics 4. Kidney transplant recipients >1month ago 5. Solid organ transplant pts 6. Neutropenic pts (ANC <100 cells/mm^3 7. Spinla cord injury pt 8. Pts with indwelling urinary catheter 9. Pts getting uroloogical implantations |
| "older pt with altered mental status" was an example of a pt population that we don't screen/treat, why? | elderly population is more prone to errors (not much immune response, may get fever, may not have high WBC count). 1 sign of infection in brain is "LOOPY," but only b/c your altered (does not mean infection); Be an antimicrobial stewart and don't push abx and instead look at their med list and see if that is the cause of their altered mental status (AMS) |
| Why do we screen/treat pregnant women in UTI? | -Increased risk for Pyleonephritis -Risk to fetus -Treatment is tailored to the susceptibility pattern or the isolated pathogen -Risk v Benefits to both mom and baby -In general B-lactams are considered safe in pregnant women -Duration 4-7 days for most abx chosen |
| What things do we consider when you think about treatment options for pregnant women? | Allergies? which trimester? Risk to growing fetus |
| Cipro should not be used because? | AVOID; teratogenic (tendonitis). does not matter on the trimester, do not use for pregnant pts |
| Nitrofurantoin is a safe option? When? | Safe during 2nd trimester. can be used in the first trimester but only if there are NO other options; Avoid during the end of pregnancy (3rd trimester 34-38 weeks) |
| TMP-SMX use in pregnancy? | -Avoid 3rd trimester due to drug's increase in bilirubin. -During first trimester, mom must take folic acid supplements but use with caution -Safe for 2nd trimester but take folic acid |
| Beta lactams (amox; amox-clav; Cephalexin; Cefpodoxime can be used: | in pregnancy; These are fine unless mom has a b-lactam allergy; These are usually first line |
| Fosfomycin use in pregnancy? | MEH 🫤 (has mixed outcomes to babies) Has an off-label use for UTI (pro--> one time dose) |
| Doxycylcine use in pregnancy? | AVOID. increases birth defects of bone and teeth formation; |
| So when you think pregnant women? UTI? give | Beta lactam |
| If pregnant pt is obese, duration for abx use is? | 7 days |
| What are my Etiologies (pathogens) causing UTIs? | E. Coli Enterococcus spp S. saprophyticus K. pneumoniae Candida |
| Empiric tx recommendations: Ask yourself these questions: | Does the abx i want target the pathogen i am concerned about? What is the pt's history of prior abx use? Does it achieve high enough conc. at the site of infection? What about "collateral damage?" |
| What are my 4 steps when choosing empiric tx options for Uncomplicated cysitits? | 1. What kind of UTI does the pt have? 2. What is the likely pathogen causing the infection? 3. Wait for cultures and susceptibilities to streamline therapy 4. Determine duration of tx |
| First line options for Uncomplicated Cystitis are: | 1. Nitrofurantoin 2. TMP-SMX (*do not use if >20% E. coli resistance rate) ⭐️ 3. Fosfomycin |
| Alternative options for Uncomplicated Cystitis are? | Cipro/Levo/ B-lactam (Amox-clav or 3rd gen cephalosporin) |
| Why is Nitrofurantoin the preferred agent for uncomplicated cystitis? | **low collateral damage and low resistance rate -do not use in pyleonephritis (does not penetrate renal parenchyma) or if you suspect pyleonephritis - recommendations changed from avoid use from <60 to <30 for CrCl |
| What is the new ABSOLUTE CI for the use of Nitrofurantoin? | Creatinine Clearance < 30 mL/min |
| What is the recommended formuation and dose of Nitrofurantoin? | MacroBID (formulation of choice); Duration is for 5 days |
| What is the dose of macrbid in the tx of uncomplicated cystitis? | 100 mg PO BID for 5 days |
| TMP-SMX dose and duration in the tx of uncomplicated cystitis? | 160/800 mg PO BID (double strength) for 3 days |
| TMP-SMX can be used empirically _______ cultures come back assuming that E. coli resistance rate to TMP-SMX is ________ | BEFORE; <20% |
| Cautions to consider when using TMP-SMX for uncomplicated cystitis are? | USe with caution in renal impairment (increases K+); Can use to treat Pyleonephritis but do not start for empiric tx of pyleonephritis due to resistance |
| Fosfomycin Dose and duration in the tx of uncomplicated cystitis? comments? | 3g PO ONCE (just once) Comments: COSTLY (compared to other tx options) -interest in fosfomycin to be used in multi-drug resistant infections but CONFLICTING EVIDENCE on efficacy related to UTI |
| Alternative drug options for uncomplicated cystitis are? | 1. Ciprofloxacin for 3 days; Levofloxacin for 3 days (No MOXI since it does not concentrate in the urine 2. Oral Beta lactams Amox/clav; Cefpodoxime; Cefdinirl Cephalexin for 5-7 days |
| FQs are being less pushed due to ADRs for UTI tx when there are other options available. Can use this empirically before cultures come back, assuming that local resistance to FQ is _______ | < 10% *(FQs can be used to treat pyleonephritis |
| Beta lactams have inferior efficacy compared to: | FQs and TMP-SMX; Consider alternative agents (generally not recommended for empiric tx due to increased rates of resistance |
| Inferior drugs are given _______ | longer |
| What is a drug that is OTC or RX? Max dose and duration? CI? Counseling points? | Urinary analgesic (Phenazopyridine) *not an abx -Max dose: 200 mg PO TID for 2 days -Duration: 1-2 dyas until abx start to help with the symptoms -CI: do not use in renal or hepatic impairment -Counseling Points: can cause bodily fluid to turn reddish/orange; drink with a full glass of water or take with food to decrease GI upset |
| Recurrent UTI that is infrequent (</= 3 in a year) so we treat as: | separate infections |
| Recurrent UTI that is frequent (>3 in a year) we treat: | long-term prophylactic antimicrobial therapy *Treat each but add on prophylaxis |
| What are my non-pharm options for Recurrent UTIs? | -Wiping from front to back -drink plenty of water -Postcoital voiding |
| Controversial non-pharm option for Recurrent UTIs? | Cranberry products (guidelines do not recommend, Evidence is mixed more so for bacteria. *lots of sugar in cranberry products = feeds bacteria |
| Recurrent UTI Pharmacological options are: | -Nitrofurantoin 50-100 mg daily (BID to daily) -TMP-SMX 1/2 of SS daily or 3x per week or 1/2 to 1 SS tablet postcoidal (after sex) -Trimethroprim 100 mg daily (*remember it increases K+) -Levofloxacin 500 mg daily -Topical estrogen (post-menopausal women) |
| Topical estrogen fur Recurrent UTIs is only for: | Post-menopausal women -menopause changes the flora |
| So lets say the pt had a recurrent UTI and you gave them TMP-SMX, when they get another UTI, will you give them the same option? | No, worry about resistance so we switch drug options |
| Main concern that we have with Nitrofurantoin is? | the adverse effect of the drug (concern w/ pulmonary fibrosis_ |
| Acute Pyleonephritis is a ____________ UTI | complicated |
| Cystitis is an _________ UTI | uncomplicated |
| Pt comes in with acute pyleonephritis, if outpatient? | they are mild-moderate and want to give them PO abx |
| PT comes in with acute pyleonephritis, if inpatient? | they are meeting Sepsis criteria; N/V/ dehydration where they can not tolerate PO options; IV tx initially |
| What are my mild-moderate tx options for Acute pyleonephritis? | First line: Cipro orLevo if local resistance rate is </= 10% OR TMP-SMX Alternative: If FQ rate is >/= 10% can still use FQ but will require 1 dose of parenteral agent prior to starting FQ (such as Ceftriaxone IV/IM once OR Ertapenem IV/IM once or Aminoglycosides extended interval dosing IM/IV once) Other alternative: Beta-lactams (Amox-clav; Cefdinir; Cefedroxil or Cefpodoxime |
| Ciprofloxacin for mild-moderate for Acute pyleonephritis: Duration and comments: | Duration: 7 days for 500 mg PO BID or 5 days for 750 mg PO daily. -*If local resistance rate is >/= 10%, give one dose of ceftriaxone 1g IV/IM or ertapenem 1g IV/IM or aminoglycoside IV/IM while pending culture results |
| TMP-SMX is not preferred for mild-moderate acute pyleonephritis due to: | 14 day duration high resistance rate -can give ceftriaxone 1g once while pending culture results/susceptibilities; -use with caution with renal impairment |
| Cefpodoxime/Cefdinir in the use for mild-moderate acute pyleonephritis: | 10-14 days (inferior drug means increased duration) -Oral B-lactams inferior to TMP-SMX due to increased risk of relapse -consider alternative until susceptibilities return -give dose of ceftriaxone 1g prior to starting until susceptibilities come back |
| Amox-Clav in the use for mild-moderate acute pyleonephritis: | 10-14 day duration --Oral B-lactams inferior to TMP-SMX due to increased risk of relapse -consider alternative until susceptibilities return -give dose of ceftriaxone 1g prior to starting until susceptibilities come back |
| What are my Empiric tx options for Severe Acute pyleonephritis? | Initial empiric tx: Ceftriaxone; Pip-Tazo; Cefepime; Cipro/Levo; Carbapenem (save for ESBL or if pt took broad spectrum abx recently) |
| Comments on Initial Empiric tx options for Severe Acute Pyleonephritis: Ceftriaxone: | -no renal dose adjustment necessary; Usually first line in the hospital for UTI tx (if that is what brought them to the hospital) |
| Comments on Initial Empiric tx options for Severe Acute Pyleonephritis: Cipro/Levo: | Do not recommend moxi (does not conc. in urine, will not get to site of infection; if pt is clinically stable--> switch to PO or streamline therapy based on cultures |
| Comments on Initial Empiric tx options for Severe Acute Pyleonephritis: Pip-Tazo: | Pseudomonas risk factors: prior hospitalization in the last 6 months; nursing home resident; has urinary catheter (at the time of admission--> can consider it can consider if pt is septic or going into septic shock; follow up on cultures to de-escalate/streamline therapy |
| Comments on Initial Empiric tx options for Severe Acute Pyleonephritis: Cefepime: | Pseudomonas risk factors: prior hospitalization in the last 6 months; nursing home resident; has urinary catheter (at the time of admission)--> can consider it **Will not cover Enterococcus |
| Cefepime is more narrow than _________ since there is no coverage of Enterococcus in any cephalosporin | Pip-Tazo |
| What is the duration of tx for Severe Acute Pyleonephritis? | 7-14 days depending on clinical improvement -switch to PO equivalence of streamlined therapy when pt is clinically stable -Appropriate IV tx counts towards duration of tx |
| What is another example of complicated UTI? | CA-UTI (Catheter-associated-UTI |
| PT has an _______ catheter, which may put them at risk of a CA-UTI | indwelling |
| Symptoms of CA-UTI include: | Fever Elevated WBC and Urinary signs (but have little predictive value to say you have a CA-UTI) |
| If pt is using indwelling catheter for less than 30 days from insertion, and is asymptomatic bacteria, we | do not give abx and tx option is change Catheter |
| For a symptomatic pt with a catheter, we: | change the catheter and start abx **Duration of abx tx is unknown |
| For men: | its rare to get UTIs due to the length of the urethra, but when they do get a UTI, they are considred COMPLICATED |
| For men with concerns of UTI, we: | obtain urine culture before tx (pathogens are not as predictable as females |
| If we suspect gram (-) in men for UTI, what drug should we consider? | TMP-SMX or FQ |
| Per Guidelines and NAPLEX, duration of abx tx for men is for how many days? | 10-14 days of tx however new evidence says 7 days may be good enough |
| Pt is at a HIGHER risk for acute prostatitis if they have the following risk factors: | BPH Genitourinary infections (Orchitis, Urethritis, UTIs, Epididymitis) -History of STD (i.e gonorrhea) -Prostate manipulation (i.e surgery/BPH) |
| Pt is at risk of infection for acute prostatitis if they have the following risk factors: | High risk sexual behavior Phimosis Immunocompromised Urethral stricture |
| What are the most common pathogens associated with an acute prostatitis infection? | E. coli (>50%) PsA (rare) Klebsiella species (-) Enterococcus species (+) Enterobacter species (-) Proteus species (-) Serratia species (-) |
| S/sx of ACUTE prostatitis are: | Fever; chills; Malaise; Myalgias; Pain (rectal, perineal); Frequency,/Urgency; Dysuria |
| S/sx of CHRONIC prostatitis are: | Voiding issues; Lower back pain; Perineal and suprapubic discomfort |
| When choosing Tx agents for Acute Prostatitis we need agents that can: | penetrate the prostate |
| Tx agents for Acute Prostatitis are: | Preferred: TMP-SMX OR Cipro/Levo OR Cephalosporin OR Beta-lactam + beta lactamase inhibitor |
| Duration of tx for Acute Prostatitis is for? | 2-4 weeks |
| When choosing Tx agents for Chronic Prostatitis we need agents that are able to: | achieve therapeutic concentrations in prostatic fluid |
| Tx agents for Chronic Prostatitis are: | -Trimethoprim -Cipro/Levlo (Best option) |
| Duration of tx for Chronic Prostatitis is for? | 6-12 weeks **longer you've had prostatitis, the longer you need to take drug |
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