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81 Cards in this Set
- Front
- Back
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Urinary Tract Infections in the kidney? 2
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Acute pyelonephritis
Renal abscess |
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UTIs in the Prostate?
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Acute and chronic prostatitis
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What is the most common bacterial infections in humans?
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UTIs
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Most common gender and age group to get UTIs?
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Females Age 24-64
20% women have UTI by age 30 50% have at least one UTI per lifetime |
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What is the female: male ratio of UTIs in younger and older patients? Prevalence of men and women UTIs in younger and older patients?
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Younger: 30:1
Females: 1-3%, Males 0.1% Older: 2:1 Females: 20%, Males 10% |
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What is the term for lower tract infection? Sx?
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Cystitis:
Dysuria, Urgency, Frequency |
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What is the term for upper tract infections? Sx?
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Pyelonephritis:
Fever Flank pain +/- dysuria |
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What is meant by "significant bacteriuria"?
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Number of bacteria in voided urine exceeds expectation from contamination
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2 types of recurrent UTIs?
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Relapse: bacteria remains after treatment
Reinfection: new organism introduced |
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What are some things that would constitute complicated UTI?
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Men,
Pregnant women, Hospitalized pts, Children, Diabetics, Structural abnormalities, Indwelling caths or instrumentation, Immunosuppressed, 7 days of sx. |
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6 Host defenses against UTIs?
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Number 1***: Urination,
Normal flora, Urine - harsh environment, Post void, thin film of urine remains, Bladder mucosa: cytokines, IgA, Abs formed |
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2 ways frequent, regular urination is the number one host defense against UTIs?
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Lavages organisms,
Assists in removal of sloughed epithelium |
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2 ways normal flora functions as a host defense?
How might normal flora be problematic? |
Competes w/ pathogens,
Normal may change cyclically. May become pathogenic and cause UTI |
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3 ways urine provides harsh environment?
How might men have an additional defense? |
Low pH: good for some organisms, but bad for most.
High osmolality. High urea. Men: prostatic secretions |
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What do cytokines do as host defense?
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Local inflammatory response
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What is produced by mucosal cells that serve as host defense?
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Organic acids from diet rich in fruits and proteins
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What are conditions in which transient bacteria might not be controlled?
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Change in flow or failure to empty: incomplete void or infrequent void.
High glucose level in urine |
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6 Risk factors for getting UTIs?
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Female,
Advanced age, Systemic illness: DM, Structural or functional disorder: obstruction (congenital, stones) or neurogenic bladder., Recent use of systemic abx, Pregnancy |
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2 physiologic causes of increased risk of UTI in pregnancy?
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Change in pH
Urinary stasis |
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Statistical impact of pregnancy and UTI?
-% bacteruria, -% true UTI -%pyelo -% premature delivery |
Bacteriuria: 4-7%
True UTI: 25% Pyelonephritis: 25-40% Premature delivery: 20-50% |
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Causes of increased risk of UTI with sexual activity?
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30% - bacteria enter bladder.
-sex 3x/wk = 2.6x greater risk -lack of urination after sex increases risk New partner: introduces new bacteria Spermicide: kills lactobacilus |
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What causes genetic predisposition to UTI?
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ABH blood group antigens
-secreted ags bind to attachment sites on bacteria preventing uroepi binding. -non-secretors (20%) - increased risk |
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5 organisms that cause community acquired uti?
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E.coli (80-90% of uncomp),
Staph saprophyticus, Klebsiella spp., Proteus mirabilis, Enterobacter spp. |
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What is the most common hospital acquired infection?
Why? (2) |
Nosocomial UTI.
Related to instrumentation, Long term cath |
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How do indwelling catheters increase UTI risk?
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Biofilm forms and protects from host defense.
-3-5 organisms. -extracellular organism products. -urine components |
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6 Most common hospital acquired UTI organisms?
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E. coli,
Kleb spp. Proteus mirabilis. Staph epidermidis. Enterococcus. Pseudomonas aeruginosa. |
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4 steps that lead to pathogenesis of an organism?
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Colonization of perineum w/ uropath.
Introduction of bacteria to urinary tract. Attachment. Invasion. |
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3 routes of UTI?
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Ascending infections: reflux w/ ineffective vesicoureter sphincter.
Hematogenous spread (rare) - if upper tract, renal cortex abscess. Lymphatic |
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What the most major virulence factor of E. coli?
How? |
Adherence to uroepi cells.
Overcome repulsion due to electric charges. 2 types pili + other adhesion factors (dr adhesions) |
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What is Type 1 (or FimH)?
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Adherence factor of E. coli.
Known as "mannose sensitive" -Mannose impacts in vitro hemagglutination. PMNs phagocytize but survive intracellularly Assoc w/ cystitis |
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What is P fimbriae?
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Adherence factor of E. coli.
P blood group ag. Known as "mannose resistant" -attach to mannosylated glycoproteins -Hemagglutination not seen. No receptors for PMNs Assoc w/ pyelonephritis |
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4 other Virulence factors of E. coli?
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Capsule: K antigen.
LPS endotoxin. Aerobactin. Hemolysin (pore-forming RBC and WBC) |
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How is the capsule K antigen of E. coli a virulence factor?
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Protects against phagocytosis.
Decreases ability of abs and/or complement to bind to bacterial surface. |
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How is LPS endotoxin of E. coli a virulence factor?
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Affects bladder and ureter peristalsis, increases likelihood of reflux.
O ag resists complement |
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How is Aerobactin of E. coli a virulence factor?
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Iron acquisition.
Promotes scavenging of host iron in limited iron environment (inflamm = tighter hold by host). Allows for faster microbial growth. |
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How is hemolysin a virulence factor of E. coli?
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Lyses cells to release nutrients.
Increases inflammation (tissue damage). Decreases host cell chemotaxis. Decreases host cell phagocytosis. |
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What is the 2nd most common UTI pathogen in young, sexually active women?
Why? |
Staph saprophyticus.
Stronger adherence than other staph. -uses lactosamine residue to adhere to uroepi. |
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What are 3 virulence factors of proteus mirabilis?
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Attachment: fimbrae.
Swarming: movement of large #s of bacteria across solid surfaces - related to instrumentation. Urease: breaks down urea. - Ammonia product - urine more alkaline. |
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Attachment structure of Klebsiella?
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Fimbrae
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3 characteristics of Staph aureus in UTIs?
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Perinephric, renal cortex abscess.
Hematogenous spread (bacteremia) More common in pts w/ DM |
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In a clean catch mid stream urine, what does it mean if more than a "few" squamous epis are present?
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Contamination
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7 things on UA consistent w/ cystitis?
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Cloudy,
Alkaline pH, +/- RBC, +/- protein, glucose suggests DM, + nitrate, + leukocyte esterase |
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4 things Pyelonephritis is assoc w/?
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Anatomic or functional abnormalities (vesicoureteral reflux).
Underlying dz (DM). Host suscep (immune def). Urinary tract instrumentation |
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Pyelonephritis and bacteremia?
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Increased
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What additional things would you expect to see on a UA in pyelonephritis compared to cystitis?
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+/- ketones - assoc w/ fever.
Glucose suggests DM - although can be raised in renal inflammation. Casts: granular, WBC casts |
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Traditional approach for diagnosis of UTI?
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Assess for pyruia in unspun clean catch (10 WBCs per microL)
Microscopic of spun (2000 rpm for 5 min) |
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What is the "standard: definition of significant bacteriuria?
Female w/ asymptomatic? Female w/ dysuria & pyuria? Male? |
Standard: 10 to the 5th CFU/mL
Female no sx: 10 to the 5th Female w/ sx: 10 to the 2nd Male: 10 to the 3rd |
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Under what circumstances can you rule IN UTI based on history alone w/ a 90% likelihood?
When should this not be used? |
Rule in IF: dysuria, frequency, no vaginal discharge.
NOT used if: sx not characteristic, complicated infections suspected |
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What does "response to short course therapy" mean?
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Follow up after 3 days.
If asymptomatic: no further intervention. If sx: UA and Urine culture done |
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What are the criteria in the Decision Rule?
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Sx for 1 day,
Dysuria, > trace leukocytes - dipstick, Nitrates (any amt) |
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What are the 2 paths suggested in the Decision Rule?
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-Culture alone for women w/ zero or one criterion w/ treatment based on culture results.
-Empiric treatment w/out culture for women w/ 2 or more criteria. |
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What was a big impact on care the Decision Rule made?
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-Reduced urine cultures.
-Reduced unnnec Abx |
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2 viable options to treat UTI? (drugs of choice)
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-Trimethoprim- Sulfamethoxazole (TMP-SMX)
-Flouroquinolones - Ciprofloxacin |
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What are three flouroquinolones you should avoid giving for UTI?
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Levofloxacin: too broad.
Moxifloxacin - low urine levels Gemifloxacin |
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What is something you should be careful about in prescribing abx for UTI?
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TMP-SMX resistance! - watch regional levels of resistance and avoid if 15-20% are resistant.
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What is a reason one might avoid flouroquinolone use for UTI?
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Described as a "public health priority" abx
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What is a former standard drug that can be used if TMP-SMX is resistant?
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Beta lactams (Amoxicillin)
-less effective eradication (rapid excretion, limited gram neg spectrum). -increased recurrence & adverse effects. Nitrofurantoin -avoided in past due to 7 day course. -recently shown to be effective in 5 days |
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2 standard dosing options for Bactrim?
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Single dose treatment.
3 day course. (93% eradication vs 83% w/ single dose). |
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You should forgo short course treatments and use 7 day IF: (4)
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Prolonged sx before abx.
Diabetics. Diaphragm users. Staph saprophyticus: child bearing age, sexually active women. |
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When would you give a 14 days course of abx for women?
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You wouldn't! 7 day is as effective as 14
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If 3 days sx and UA/ culture shows pyuria but no bacteruria, what should you do?
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Treat for Chlamydia
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If 3 days sx and UA/ culture are both negative, what should you do?
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Observe and give urinary analgesic
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What are the increased risks of UTI in pregnant women?
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High incidence of bacteriuria.
Frequently asymptomatic. Increased risk of pyelonephritis. |
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What are the risks involved in pyelonephritis in the pregnant woman?
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Increases prenatal morbidity and mortality.
-prematurity risk. -low birth weight. |
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What can be done to decrease risk of UTIs in pregnant women causing prenatal problems?
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Screen asymptomatic women.
If UTI, intense follow up! |
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What are 3 safe drugs for pregnant women for UTI?
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Nitrofurantoin,
Amoxicillin, Cephalexin |
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Men have an increased incidence of lower tract UTI after 50. What should you assume in this case?
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Prostate invasion
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Treatment for men w/ lower tract UTI?
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NEVER a short course tx!
10-14 days w/ TMP-SMX or Flouroquinolone |
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How is cranberry juice a preventative measure against recurrence of UTIs?
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Tannins impact adhesins
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Anti-microbial strategies if 3 or more UTIs per year?
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Sexually active: pre- or post- coital prophylaxis.
NOT sexually active: prescription for self med at sx onset |
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Anti-microbial strategies if 4 or more episodes?
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Continue prophylaxis.
Review suscep patterns. Prophylaxis every other night at bedtime for 4-6 months |
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2 goals of pyelonephritis?
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Immediate effective abx treatment.
Eradicate residual tissue infection. (10-14 day total duration) |
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What is the method in which treatment for pyelonephritis is given?
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Historically IV until 24 hrs after afebrile.
Mild dz can use oral meds alone if no n/v, low grade fever (up to 101.5), slight WBC elevation. |
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Under what conditions would you hospitalize w/ pyelonephritis?
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If dx is uncertain.
**Severe illness (high fever, sig pain). Comorbid cond's (preg, DM, renal/ uro disorders, liver or cv dz). Other practical factors (can't orally hydrate or take oral meds, pt not compliant) |
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What oral abx can be given for pyelonephritis?
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Flouroquinolone (Cipro 500mg BID 7 days).
- if gram +: Augmentin. |
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What IV abx can be given for pyelonephritis?
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Ceftriaxone or Cipro.
If Enterococcus suspected: - Gentamycin & Ampicillin |
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Usually pyelonephritis can be dx w/ s&s, but under what conditions should a UTI work up be done? (3)
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Pyelo NOT responding to tx.
Rapid recurrence despite tx. Anatomic site unclear (young children w/ 1st or 2nd episode). |
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What are imaging options that can aid in dx of pyelonephritis?
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IVP.
U/S. CT contrast- enhanced helical CT (CECT) |
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What is the most common nosocomial infection?
What is the leading cause? |
UTI
Bladder cath |
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What is a major adverse impact of catheter related UTI?
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3 fold mortality increase!
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What is Urethral syndrome?
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Same lower tract sx but no bacteriuria.
Pyuria: chlamydia urethritis. Unknown cause: 14% |
