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APT Vignette Discussion Session and Master Cards

APT Vignette Discussion Session and Master Cards. Title: Jenny Smith. Descriptive Information. Title: Pyelonephritis Student level: 4 th year Learning Objectives for this Vignette (focus): Know how to diagnose cystitis and pyelonephritis. Know how to assess the severity of UTI.

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APT Vignette Discussion Session and Master Cards

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  1. APT VignetteDiscussion Session and Master Cards Title: Jenny Smith

  2. Descriptive Information

  3. Title: Pyelonephritis • Student level: 4th year • Learning Objectives for this Vignette (focus): • Know how to diagnose cystitis and pyelonephritis. • Know how to assess the severity of UTI. • Explain the rationale for antibiotic selection and route of administration in UTI. • Explain the difference between the outcomes of antibiotic treatment for cystitis and pyelonephritis. • Be able to describe a pathway of care for patients who are hospitalised with UTI, including their discharge from hospital and follow up. • Know how to use this case for reflective learning about appropriate prescribing.

  4. Core Resources Which of the 12 Outcomes this Vignette Can Cover? This Vignette is primarily designed to help the student achieve outcomes 1, 4 and 7 (Clinical Skills, Patient Management and Appropriate Information Handling Skills): 1. Clinical Skills • Elicit key symptoms and signs of commonest sites of bacterial infection. • Recognise and interpret common symptoms and signs of inflammatory response. • Interpret symptoms and signs; distinguish between bacterial infection, viral infection and other causes of inflammatory response. • Make a diagnosis. • Formulate a management plan. • Record findings. 4. Patient Management • Management strategies for common clinical syndromes, including alternatives to antibiotics. • Deciding on duration of treatment, measures of response to treatment and of successful outcome. • Use and abuse of IV antibiotics. • Sepsis and its management. 7. Appropriate Information Handling Skills • Minimum dataset to be recorded in order to support a decision to prescribe antibiotics. • Local antibiotic policy. • Local guidelines.

  5. B. Case Details

  6. History A 32 year old woman presents to her GP as an emergency with a 48 hour history of increasing severe pain in her back on the right. She has burning pain on passing urine, increased frequency and urgency. In past 24 hours she has had episodes of “burning up” and 2 shivering episodes lasting five minutes. She has vomited twice in the past 24 hours and finds it difficult to keep more than sips of water down.

  7. Clinical Signs • On examination: • Pyrexia, Temp 390C • Pulse 120/minute • Respiratory rate 25/minute • Marked tenderness on right loin • BP 120/80

  8. Investigations • Investigations: • Labstix testing showed proteinuria, microhaematuria and nitrites. • Her white cell count was 13.5 • A urine sample was sent for Gram-stain, culture and sensitivity. • A blood sample was sent for culture and sensitivity.

  9. C. Question Categories

  10. Consider a Working Diagnosis (1) 1.1 What is your working diagnosis? 1.2 What is causing her pain? 1.3 Are there any common features between the case that you have clerked this week and Jenny Smith’s clinical presentation? 1.4 Have you encountered similar patients in your previous clinical attachments?

  11. Consider a Working Diagnosis (2) 1.5 What do you understand of the pathophysiological basis of developing a fever? 1.6 What is the profile of someone who is predisposed to a UTI? 1.7 How would you classify Jenny Smith’s presentation and findings?

  12. Assess Severity (1) 2.1 Why do you think she has been admitted to hospital? 2.2 Why was her pulse increased? 2.3 Why was her respiratory rate increased? 2.4 What is the Systemic Inflammatory response? 2.5 Why does it help you manage the patient?

  13. Assess Severity (2) • 2.6 What is your understanding of following terms? • 2.6.1 Sepsis • 2.6.2 Severe sepsis • 2.6.3 Septic shock • 2.6.4 Bacteraemia

  14. Container Dip Slide Consider Investigations 3.1 What would you expect the labstix to show if this patient had a UTI? 3.2 How do you collect a specimen for culture and microscopy? 3.3 What is “significant bacteriuria”?

  15. Appropriate Prescribing (1) 4.1 Should you prescribe antibiotics for Jenny Smith? 4.2 What bacteria are likely to be causing Jenny Smith’s symptoms and which antibiotics are recommended in the Local University Hospitals Antibiotic Policy? 4.3 Which group of drugs does co-amoxiclav belong to and why is this information important?

  16. Appropriate Prescribing (2) 4.4 What side effects from antibiotics have you observed in your clinical practice? 4.5 What is meant by intrinsic or acquired bacterial resistance (hint: Chapter 16.5 Oxford Text)? 4.6 Why is trimethoprim recommended to treat cystitis but not pyelonephritis?

  17. Appropriate Prescribing (3) 4.7 Why is nitrofurantoin recommended to treat cystitis but not pyelonphritis? 4.8 After 48 hours of treatment her inflammatory markers were improving and she was eating normally. Escherichia coli was isolated from blood and urine cultures and after 48h it was shown to be sensitive to co-amoxiclav. What change would you make to Jenny’s antibiotic treatment?

  18. Patient Management 5.1 What fluids would you prescribe Jenny? 5.2 How will you follow up Jenny Smith’s response to treatment?

  19. D. Best Practice Statement

  20. Summary of Management (1) Review: 32 year old woman presented to her GP with symptoms of sepsis due to acute pyelonephritis. She had a history of vomiting and was finding it difficult to keep more than a few sips of water down so her GP referred her to hospital. On examination she was febrile (Temperature 390C) with tachycardia, tachpnoea and a normal blood pressure. She was not confused. Labstix testing showed proteinuria, microhaematuria and nitrites. Urine Gram stain showed Gram-negative rods. Action on admission: A diagnosis of sepsis due to pyelonephritis was made. Urine and blood specimens were obtained for culture. She was treated with IV saline and IV co-amoxiclav. The signs that supported the diagnosis and the management plan were recorded in the case notes: Impression: symptoms and signs of pyelonephritis, supported by presence of proteinuria, microhaematuria and nitrites. Systemic inflammatory response (T 390C, P 120, RR 25, WBC 13.5) but no signs of severe sepsis and normal BP (120/80). Plan: blood and urine samples for culture. IV co-amoxiclav until culture and sensitivity results available IV saline 500ml four hourly, six hourly T, P, RR and BP recording.

  21. MCQs Summary of Management (2) Progress: After 48 hours of treatment her inflammatory markers were improving and she was eating normally. After 24h Escherichia coli was isolated from blood and urine cultures and after 48h it was shown to be sensitive to trimethoprim. Action on review at 48h: She was switched to oral trimethoprim and discharged from hospital. She was instructed to complete 7 days of antibiotic treatment at home and her GP was asked to send a urine specimen for culture four weeks after the end of treatment.

  22. E. Correct/Appropriate AnswersF. Potential Responses and FeedbackG. References and Resources Master Cards:

  23. 1.1 What is your working diagnosis? Correct Response and Reason: Jenny has sepsis, probably due to pyelonephritis. Jenny has symptoms of infection in both the lower urinary tract (dysuria and frequency) and the upper urinary tract (loin pain), and a lack of vaginal discharge. In addition the presence of clear signs of systemic inflammatory response indicated infection of the upper urinary tract because the bladder has relatively poor blood supply, consequently cystitis does not cause a systemic inflammatory response. Potential Responses and Feedback: • Linked Resources: • http://www.show.scot.nhs.uk/thb/adtc/approved/formular/formular.htm • Local Adult Antibiotic Policy in Hospitals • Local Drug Resistance to Antimicrobials • IDSA • Sepsis Protocol

  24. 1.2 What is causing her pain? Correct Response and Reason: Inflammation of the kidney. Inflammation of the kidney in pyelonephritis commonly causes severe loin pain. If Jenny has persisting pain and inflammatory response despite antibiotic treatment then a perinephric abscess should certainly be considered and diagnosed with a CT scan. Potential Responses and Feedback: • Linked Resources: • Mander & Kucers Antibiotic Information • Oxford Textbook of Medicine • Lectures

  25. 1.3 Are there any common features between the case that you have clerked this week and Jenny Smith’s clinical presentation? Correct Response and Reason: The signs of Systemic Inflammatory Response are common to all infections, bacterial, protozoal or viral. Can you think of other cases with similarities? Potential Responses and Feedback: • Linked Resources: • Record Book • Vignettes

  26. 1.4 Have you encountered similar patients in your previous clinical attachments? Correct Response and Reason: Patients with signs of systemic inflammatory response are likely to be encountered on virtually every clinical attachment in fourth year. Patients with symptoms of cystitis are commonly encountered in primary care, although pyelonephritis is much less common. GPs are likely to see people with symptoms of cystitis every week, whereas they may only see one case of pyelonephritis a year. UTI is a very common reason for admission and UTI is also a common hospital acquired infection, especially in patients who have urinary catheters. Potential Responses and Feedback: • Linked Resources: • Record Book • Vignettes • Logbook • Study Guides

  27. 1.5 What do you understand of the pathophysiological basis of developing a fever? Correct Response and Reason: Fever is part of the body’s systemic inflammatory response. This response is triggered by any infection (e.g. bacterial, protozoal or viral) but is also triggered by tissue injury (e.g. surgery, trauma, myocardial infarction), cancer and auto-immune disease. Cytokines released in response to any of these problems will cause the hypothalamus to allow the body’s temperature to increase. Potential Responses and Feedback: • Linked Resources: • Fever and Sepsis Notes • Fever and Sepsis lectures • IDSA • Sepsis Protocol • http://www.gpnotebook.co.uk

  28. 1.6 What is the profile of someone who is predisposed to a UTI? Correct Response and Reason: UTI is usually the result of failure of local host defences rather than a general immunodeficiency. The key local host defences are the normal bacterial flora of the perineum or vagina, unobstructed flow of urine, and intact urethral valves. Women are much more susceptible to UTI than men because they have a shorter urethra, which makes it easier for bacteria to reach the bladder. Anything that prevents the free flow of urine (e.g. a stone or external obstruction of a ureter) predisposes to UTI. UTI is much commoner in pregnancy and also more likely to result in pyelonephritis due to relaxation of smooth muscle and some obstruction of urinary flow. Indwelling urinary catheters provide bacteria with easy access to the bladder. Also bacteria attached to foreign bodies are coated in a thick, impenetrable layer of slime that makes them inaccessible to the body’s host defences or to antibiotics. Women frequently experience recurrent genitourinary symptoms after a course of antibiotics because of their adverse effects on the normal vaginal flora, which predisposes to superinfection by Candida spp (vaginal thrush) or recurrent UTI. Avoid broad spectrum antibiotics like co-amoxiclav for cystitis. Potential Responses and Feedback: • Linked Resources: • Previous Lecturers • IDSA • Oxford Textbook • http://www.infectionacademy.org • http://www.gpnotebook.co.uk

  29. 1.7 How would you classify Jenny Smith’s presentation and findings? Correct Response and Reason: Sepsis due to pyelonephritis. Potential Responses and Feedback: • Linked Resources: • http://www.infectionacademy.org • Sepsis Protocol • IDSA • http://www.gpnotebook.co.uk

  30. 2.1 Why do you think she has been admitted to hospital? Correct Response and Reason: She has sepsis and could well have bacteraemia. The mortality of community acquired bacteraemia is 10-20%, increasing exponentially with signs of severe sepsis and septic shock. Jenny was vomiting, which would compromise the effectiveness of oral antibiotic treatment. She was admitted to hospital in the expectation that she would require IV antibiotic treatment. Potential Responses and Feedback: • Linked Resources: • http://www.show.scot.nhs.uk/thb/adtc/approved/formular/formular.htm • Local Adult Antibiotic Policy in Hospitals • Local Drug Resistance to Antimicrobials • IDSA • Sepsis Protocol

  31. 2.2 Why was her pulse increased? Correct Response and Reason: Part of the systemic inflammatory response. Potential Responses and Feedback: • Linked Resources: • http://www.show.scot.nhs.uk/thb/adtc/approved/formular/formular.htm • Local Adult Antibiotic Policy in Hospitals • Local Drug Resistance to Antimicrobials • IDSA • Sepsis Protocol

  32. 2.3 Why was her respiratory rate increased? Correct Response and Reason: Part of the systemic inflammatory response. Potential Responses and Feedback: • Linked Resources: • Local Pneumonia Protocol • IDSA • Sepsis Protocol

  33. 2.4 What is the Systemic Inflammatory response? • Correct Response and Reason: • Two or more of: • Temperature >380C or <360C • Heart rate >90 beats /min • Respiratory rate >20 breaths /min or PaCO2 <4.3 kPa • WBC >12,000 cells/mm3 or <4,000 cells /mm3 • Potential Responses and Feedback: • Linked Resources: • Oxford Textbook • Fever and Sepsis Lectures and Notes • IDSA • Sepsis Protocol

  34. 2.5 Why does it help you manage the patient? Correct Response and Reason: Finding two or more signs of inflammatory response confirms that the body is making a generalised response to infection or injury. Conversely, if a patient has a single recording of a temperature >380C with no other evidence of inflammatory response it is more likely to be a manifestation of normal variation in body temperature than a response to infection or injury. The signs of inflammatory response are a key component of the assessment of severity of sepsis (see 2.6). In addition to their use in diagnosis, the signs of inflammatory response can be used to monitor the patient’s response to treatment. Potential Responses and Feedback: • Linked Resources: • Oxford Textbook • Fever and Sepsis Lectures and Notes • IDSA • Sepsis Protocol

  35. 2.6 What is your understanding of following terms? (1) • Correct Response and Reason: • 2.6.1 Sepsis • SIRS plus documented infection • 2.6.2 Severe sepsis • Sepsis associated with hypotension or organ hypoperfusion (metabolic acidosis, oliguria or acute alteration in mental status) • 2.6.3 Septic shock • Sepsis-induced hypotension, despite adequate fluid resuscitation or requiring inotropic or vasopressor agents for cardiovascular support • 2.6.4 Bacteraemia • Presence of bacteria in the blood. The diagnosis of bacteraemia requires interpretation of blood culture results. For example, isolation of Staphylococcus aureus in two sets of blood cultures taken from different sites would be interpreted as significant bacteraemia. In contrast, isolation of Staphylococcus epidermidis from one bottle of two sets of blood cultures in a patient with no implanted intravascular device would be interpreted as a skin contaminant.

  36. 2.6 What is your understanding of following terms? (2) • Linked Resources: • Sepsis Protocol

  37. 3.1 What would you expect the labstix to show if this patient had a UTI? Correct Response and Reason: Nitrites and leukocyte esterase indicate the presence of bacteria and white cells in the urine. Haematuria and proteinuria can be caused by infection, especially if it involves the kidneys. Potential Responses and Feedback: • Linked Resources:

  38. 3.2 How do you collect a specimen for culture and microscopy? Correct Response and Reason for a Hospital where they do not use dip slides for hospital inpatients: A freshly voided mid stream specimen should be placed in a sterile container and transported immediately to the microbiology laboratory. Potential Responses and Feedback: • Linked Resources: • Lectures

  39. 3.2 How do you collect a specimen for culture and microscopy? Correct Response and Reason for a Hospital where they do use dip slides for hospital inpatients: A freshly voided mid stream specimen should be placed in a sterile container and transported immediately to the microbiology laboratory. A dipsilde should be used if there is likely to be delay of four hours or move from sampling to arrival in the microbiology laboratory. Dipslides are used routinely in Tayside in primary and secondary care. Potential Responses and Feedback: • Linked Resources: • Previous Lectures

  40. 3.3 What is “significant bacteriuria”? Correct Response and Reason: >105 of a single species of bacteria per millilitre in a freshly voided sample of urine. The evidence that this is significant comes from studies that showed that it is very unlikely to have this number of bacteria in urine unless the bacteria were growing in the urine in the body. Lower numbers of bacteria could be the result of contamination of the urine sample by bacteria from the perineum. Contamination is also likely to result in mixed growth, hence the insistence on “a single species of bacteria”. Finally contamination could result in >105 bacteria if the urine was allowed to stand at room temperature because bacteria will grow in urine at that temperature. Hence the insistence on “a freshly voided sample of urine” and use of dip slides. Potential Responses and Feedback: • Linked Resources: • Oxford Textbook • Lecture Notes • Microbiology text

  41. 4.1 Should you prescribe antibiotics for Jenny Smith? Correct Response and Reason: Yes, she has sepsis with clear evidence of pyelonephritis based on symptoms, signs and near patient tests. Potential Responses and Feedback: • Linked Resources: • http://www.show.scot.nhs.uk/thb/adtc/approved/formular/formular.htm • Local Adult Antibiotic Policy in Hospitals • Local Drug Resistance to Antimicrobials • IDSA • Sepsis Protocol • http://www.dobugsneeddrugs.org • http://www.who.int/medicines/library/par/ggprescribing/begin.htm • http://www.bnf.org/ • http://www.infectionacademy.org • www.bsac.org.uk/pyxis

  42. 4.2 What bacteria are likely to be causing Jenny Smith’s symptoms and which antibiotics are recommended in the Local University Hospitals Antibiotic Policy? Correct Response and Reason: Escherichia coli but also Proteus spp or Klebsiella spp Ciprofloxacin po or iv co-amoxiclavoriv co-amoxiclav + iv gentamicin for severe sepsis Subsequent treatment in line with culture. Potential Responses and Feedback: • Linked Resources: • Local Adult Antibiotic Policy in Hospitals • IDSA • Oxford Textbook

  43. 4.3 Which group of drugs does Co-amoxiclav belong to and why is this information important? Correct Response and Reason: Co-amoxiclav: penicillin (beta-lactam) Patients who are allergic to one antibiotic are likely to be allergic to other drugs from the same class of antibiotics. It is wise to assume that patients who are allergic to one beta-lactam are also allergic to others (i.e. patients who are allergic to penicillins may also be allergic to cephalosporins). Similarly patients who are allergic to one quinolone are also likely to be allergic to other drugs from the same class. Potential Responses and Feedback: • Linked Resources: • Local Drug Resistance to Antimicrobials • http://www.antibioticresistance.org.uk • http://www.npc.co.uk • IDSA • Local Hospital Prescribing Guide

  44. 4.4 What side effects from antibiotics have you observed in your clinical practice? Correct Response and Reason: The commonest side effects of antibiotics are nausea, vomiting or diarrhoea caused by their effects on the normal bacterial flora of the bowel. More seriously, destruction of the normal flora can result in superinfection, which means that another infection is superimposed. Examples include Clostridium difficile causing antibiotic associated colitis, Candida spp causing thrush and reinfection of the urinary tract by bacteria. Allergy to antibiotics results in hypersensitivity reaction. This can either be immediate or delayed. Immediate hypersensitivity is mediated by histamine and results in an urticarial rash, angioneurotic oedema, bronchospasm or anaphylactic shock. Delayed hypersensitivity is either humoral or cell mediated and results in a variety of reactions including rashes, hepatitis, obstructive jaundice or bone marrow suppression. Potential Responses and Feedback: • Linked Resources: • Record Book - Personal Antibiotic Formulary

  45. 4.5 What is meant by intrinsic or acquired bacterial resistance? • Correct Response and Reason: • There are three key mechanisms of resistance: • Inactivation of antibiotic by enzymes (e.g. penicillinase producing Staphylococcus aureus are resistant to penicillin). • Change in the target site (e.g. methicillin resistant Staph aureus are resistant to all beta-lactam antibiotics because they have changed their target site (the penicillin binding proteins). • Preventing entry or actively removing antibiotic from the cell (e.g. Pseudmonas spp are resistant to most antibiotics because they cannot penetrate the complex cell wall. Moreover some strains have developed resistance to antibiotics by acquirig pumps that actively remove them from the cell. • Bacteria can either have resistance intrinsically (e.g. Pseudomonas was always resistant to penicillin, • even before it was used in therapy) or acquire resistance through mutation or from other bacteria. • Potential Responses and Feedback: • Linked Resources: • Oxford textbook, chapter 16.5, (including figure 1 & table 2) ……

  46. 4.6Why is trimethoprim recommended to treat cystitis but not pyelonephritis? Correct Response and Reason: About 15% of E coli are now resistant to trimethoprim. Nonetheless, trimethoprim is still likely to be effective for cystitis because the bacteria are only present in the urine, which will contain very high concentrations of trimethoprim. Moreover, cystitis is often a self limiting infection and patients with persisting symptoms can be treated with a different antibiotic. In contrast, in pyelonephritis the infection has spread to the kidney and, in Jenny Smith’s case the bloodstream. Resistance to trimethoprim is associated with substantial reduction in the probability of cure (from >90% to 50%) and the consequences of treatment failure include death from sepsis. Potential Responses and Feedback: • Linked Resources: • Oxford Textbook • IDSA • Local Adult Antibiotic Policy in Hospitals • Local Drug Resistance to Antimicrobials • Sepsis Protocol • http://www.show.scot.nhs.uk/thb/adtc/approved/formular/formular.htm • http://www.bnf.org/

  47. 4.7 Why is nitrofurantoin recommended to treat cystitis but not pyelonphritis? Correct Response and Reason: Nitrofurantoin only achieves effective concentrations in urine, consequently it is only recommended for the treatment of cystitis. Potential Responses and Feedback: • Linked Resources: • Oxford Textbook • IDSA • Local Adult Antibiotic Policy in Hospitals • Local Drug Resistance to Antimicrobials • Sepsis Protocol • http://www.show.scot.nhs.uk/thb/adtc/approved/formular/formular.htm • http://www.bnf.org/

  48. 4.8 After 48 hours of treatment her inflammatory markers were improving and • she was eating normally. Escherichia coli was isolated from blood and urine • cultures and after 48h it was shown to be sensitive to co-amoxyclav. The urine • isolate was sensitive to nitrofurantoin. What change would you make to Jenny’s • antibiotic treatment? Correct Response and Reason: Switch to oral trimethoprim and discharge from hospital. Potential Responses and Feedback: • Linked Resources: • IVOST Protocol and Care Path Questions • Local Antibiotic Policy • Local Drug Resistance to Antimicrobials • http://www.antibioticresistance.org.uk • IDSA • www.bsac.org.uk/pyxis

  49. 5.1 What fluids would you prescribe Jenny, by what route and how much? Correct Response and Reason: Intravenous saline (0.9%), 3 litres over the next 24 hours. She is likely to be volume depleted even though her blood pressure is normal. She has been vomiting and is also likely to be vasodilated because of her systemic inflammatory response. Normal saline provides some volume expansion whereas 5% dextrose does not. She need more than just replacement of her normal minimum daily requirement so give 3 litres in the first 24 hours and then re-assess. Monitor her potassium to see if she needs replacement. Potential Responses and Feedback: • Linked Resources: • http://www.show.scot.nhs.uk/thb/adtc/approved/formular/formular.htm • Local Adult Antibiotic Policy in Hospitals • Local Drug Resistance to Antimicrobials • IDSA • Sepsis Protocol • http://www.infectionacademy.org • http://www.antibioticresistance.org.uk • http://www.gpnotebook.co.uk

  50. 5.2 How will you follow up Jenny Smith’s response to treatment? Correct Response and Reason: Initial response to treatment will be monitored from the systemic inflammatory response. Once this has stabilized Jenny can be switched to oral treatment. A follow up urine culture should be done 28 days after treatment to make sure that she does not have persistent bacteriuria, which could predispose to recurrence of her pyelonephritis. Potential Responses and Feedback: • Linked Resources: • http://www.show.scot.nhs.uk/thb/adtc/approved/formular/formular.htm • Local Adult Antibiotic Policy in Hospitals • Local Drug Resistance to Antimicrobials • IDSA • Sepsis Protocol • http://www.infectionacademy.org • http://www.antibioticresistance.org.uk • http://www.gpnotebook.co.uk

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