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Urinary Tract Infections. 22 September 2004. Definition. Bacterial (fungal) invasion of the urothelium resulting in an inflammatory response Uncomplicated vs Complicated Complicated UTIs carry a moderate/high risk of causing sepsis, tissue destruction or significant morbidity/mortality

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urinary tract infections

Urinary Tract Infections

22 September 2004

definition
Definition
  • Bacterial (fungal) invasion of the urothelium resulting in an inflammatory response
  • Uncomplicated vs Complicated
  • Complicated UTIs carry a moderate/high risk of causing sepsis, tissue destruction or significant morbidity/mortality
    • Male, elderly, febrile utis, haematuria, diabetes, immunosuppression, pregnancy, obstruction, stones, instrumentation and resistant organisms
    • Structural and functional abnormalities
definitions ii
Definitions II
  • Isolated
  • Unresolved
  • Recurrent
    • Reinfection
    • Persistance
pathogenesis
Pathogenesis
  • Organisms normal bowel flora
  • Facultative Gram neg. anaerobes
    • Coliforms – E-Coli, Proteus
  • Gram neg. aerobic
    • Pseudomonas
  • Gram pos.
    • Staph saprophyticus and ent. faecalis
uti prophylaxis
UTI Prophylaxis
  • Cranberry Juice
    • Contains antiseptic Hippuric acid
  • Trials
    • colonisation with benign strain
    • Immunisation with uropathogens
recurrent uti risk groups
Recurrent UTI Risk Groups
  • Premenopausal – sexually active, spermicide, childhood and maternal
  • Postmenopausal – oestrogen deficiency, incontinence, cystocoele
  • Elderly – cognition, incontinence, catheterisation
bacterial vs host factors
Bacterial vs Host factors
  • Bacterial – adherance factors, haemolysins (e-coli), urease (proteus), swarming (proteus, klebsiella)
  • Host – micturition, bactericidal urine, secreted factors, vaginal epithelium cell receptivity
primary care guidelines for diagnosis
Primary Care Guidelines for Diagnosis
  • Females – MSSU
  • Toddlers/infants – pads from nappies/suprapubic aspiration (paraplegic also)
  • Males – MSSU, VB1(urethral),VB2 (midstream), VB3 (prostate)
  • Refrigerate specimens at 4ºC or use specimen pots containing boric acid
diagnosis ii
Diagnosis II
  • Kass criteria - >105 CFU/ml (70% of those with definite UTI), 30-40% have 103-4 CFU but symptomatic
  • The Urethral Syndrome (50%)
  • Acute uncomplicated UTI
    • Routine culture unnecessary
    • Use dipstick tests to decrease antibiotic use and unnecessary investigations
diagnosis iii
Diagnosis III
  • Lab testing for C+S reserved for
    • Pregnancy screening at first antenatal visit
    • >2 UTIs in men
    • Suspected pyelonephritis
    • Elderly with 2 signs of infection especially dysuria, pyrexia or new incontinence
    • Recurrent UTI
    • Catheterised patients with features of systemic infection
    • Failed antibiotic treatment or persistant symptoms
    • Abnormalities of GU tract
    • Renal impairment
  • Remember C. trachomatis (www.hpa.org.uk)
treatment
Treatment
  • Amoxicillin resistance is common
  • Those >65 do not treat asymptomatic bacteriuria
  • Only treat those with catheter who are systemically unwell
  • 25% of young men with UTIs have abnormal IVU
  • Pregnant women have x2 incidence of asymptomatic bacteriuria, 2% incidence of pyelonephritis
  • Diabetics have x4 risk of pyelonephritis, consider prophylaxis
treatment ii
Treatment II
  • Uncomplicated UTI- no fever or flank pain
    • Use urine dipstick, perform c+s if treatment fails.
    • Trimethoprim 200mg bd for 3 days or
    • Nitrofurantoin 50-100mg qds for 3 days or
    • Second line: depending on sensitivity of organism isolated, use amoxicillin, cefalexin, co-amoxiclav, quinolone, or pivmecillinam
treatment iii
Treatment III
  • UTI in pregnancy and men
    • Suggest MSU for susceptibility testing
    • Short-term use of trimethoprim or nitrofurantoin in pregnancy is unlikely to cause problems to the foetus
      • Nitrofurantoin 50-100qds or
      • Trimethoprim 200mg bd or
      • Cefalexin 500mg bd or amoxicillin 250mg tds
      • All of above for 7 days
  • NB texbook of urology suggest first line for pregnancy are gentamicin! and cefalexin
treatment iv
Treatment IV
  • Children
  • Recurrent UTI in women (>3 pa)
    • Post coital prophylaxis is as effective as prophylaxis taken nightly
      • Nitrofurantoin 50mg or
      • Trimethoprim 100mg
    • Stat post coital or od at night
treatment v
Treatment V
  • Acute pyelonephritis
    • Recent RCT showed 7 days of ciprofloxacin as good as 14 days of co-trimoxazole
    • NO response within 48 hours, consider referral
      • Ciprofloxacin 500mg bd for 7 days or
      • Co-amoxiclav 500/125mg tds for 14 days
      • If sensitive, trimethoprim 200mg bd for 14 days
follow up
Follow-up
  • Uncomplicated UTI and pyelonephritis in women – dipstick urinalysis
  • Consider investigation and/or referral:
    • Women with recurrent pyelonephritis within 2/52
    • Elderly with recurrent UTIs
    • Males with recurrent infection and in all cases of pyelonephritis, prostatis, epididymitis and orchitis