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APPROACH TO URINARY INFECTION IN PRIMARY CARE

APPROACH TO URINARY INFECTION IN PRIMARY CARE. ASSOC PROF HÜLYA AKAN,MD DEPARTMENT OF FAMILY MEDICINE. Objectives. At the end of this lesson students should be able to explain approach to Acute uncomplicated lower tract infection in women Recurrent lower tract infection in women

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APPROACH TO URINARY INFECTION IN PRIMARY CARE

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  1. APPROACH TO URINARY INFECTION IN PRIMARY CARE ASSOC PROF HÜLYA AKAN,MD DEPARTMENT OF FAMILY MEDICINE

  2. Objectives • At the end of this lesson students should be able to explain approach to • Acute uncomplicated lower tract infection in women • Recurrent lower tract infection in women • Acute upper tract infection (pyelonephritis) in women • UTIs in men • UTI s in children

  3. The urinary tract is comprised of the kidneys, ureters, bladder, and urethra • A urinary tract infection (UTI) is an infection caused by pathogenic organisms (for example, bacteria, fungi, or parasites) in any of the structures that comprise the urinary tract.

  4. Dysuria is the most prominent symptom and accounts for 3% of primary care office visits • Approach to urinary infection differs according to age, sex and underlying diseases

  5. Acute uncomplicated lower tract infection in women • Recurrent lower tract infection in women • Acute upper tract infection (pyelonephritis) in women • UTIs in men, children and geriatric population

  6. The most common causes of UTI infections (about 80% to 90%) are Escherichia coli bacterial strains that usually inhabit the colon. • Klebsiella, Pseudomonas, Enterobacter, Proteus, Staphylococcus, Mycoplasma, Chlamydia, Serratia and Neisseria • Some parasites (Trichomonas, Schistosoma) also may cause UTIs

  7. Differential Diagnosis • Vaginal atrophy • Vaginitis • Urethritis • Interstitial cystitis • Prostatitis • Urethritis

  8. Risk factors • %10-20% of women have epithelium makes easy adherence of m.o. • Colonization of vagina – use of contaceptive cream-jelly, nonoxynol-9 • Barrier use • Shorter distance between urethra and anus- sexual intercourse • Fecal incontinence • Stasis of baldder

  9. Risk factors of pyelonephritis • Recurrent urinary tract infection • Diabetes mellitus • Recent incontinence • New sexual partners • Use of spermicide • Mother with history of UTI

  10. History • Urinary frequency • Dysuria • Nocturia • Suprapubic discomfort • Urgency • Malodorous urine

  11. Probability of symptoms • Dysuria+nocturia: %65 • Malodorus urine and nocturia or urgency or recurrence of symptoms fallowing UTI: 90% • Vaginal complaints, external dysuria: STI /vaginitis

  12. Upper urinary infection (pyelonephritis) Fever Chills Flank pain Abdominal pain Vomitting

  13. Physical Examination • Vital signs • Palpation of mid and lower abdomen • Percussion of flanks • Genital examination (prostatitis, vaginitis)

  14. Red Flags for a complicated Infection • Male gender • Infant or geriatric age • Symptoms more than 7 days • Immunosuppressive condition • Diabetes mellitus • Episode of acute pyelonephritis within the past year • Known anatomic abnormality • Fever • Flank pain or tenderness

  15. Laboratory Tests: Collecting specimen • Midstream urine: First few seconds of urine is not collected • Catheterization in infants and very young • Plastic bag collection

  16. Urinanalysis Dry reagent test strip (dipstick) • Leukocyteesterase: Detects presence of esterase from WBC. False positive: chlamydial infection, high urine pH, high levels of urine glucose, certain drugs • Nitrite: Dietary nitrates are excreted into the urine and converted to nitrit by bacteria False negative: Gram positive ones and Pseudomonas don’t convert nitrate to nitrite, E. Coli need sometime to convert and vegeterians

  17. Leucocyte esterase + nitrite: both positive and both negative is better predictor of infection presence or absence • Blood:Peroxidase like activity False positive: Myoglobin, peroxidase producing bacteria

  18. Direct microscopy: • Centrifuge 10 ml freshly voided urine, decanting the urine than resuspending the sediment • Leukocyte:High-power field (x 400) 5 or more • Bacteria: 10 or more ; if no bacteria rule out • White cell casts

  19. Urine Culture • Not cost-effective in routine care • Do it: • Children, men, geriatric population • Patients with red flags - Younger women: Risk of upper tract infection - Infection with bacteria not likely respond firt line antibiotics

  20. Management: Acute uncomplicated lower tract infection in women • Telephone directed • Ampiric antibiotic treatment: 3 days or 7 days regimen - Trimethoprim/sufamethoxazole - Nitrafurantoin (7 days) - Fluoroquinolone (e.g.ciprofloxacine) • Occult pyelonephritis: 7 days regimen • Phenazopyridine analgesia for severe dysuria

  21. Management: Acute uncomplicated lower tract infection in women • Recurrent infection: Urine culture and treat in the same way • Prevention: • Patient initiated treatment • Unsweetened cranberry juice • Increasing fluid intake • 3 or more a year related STI: single dose antibiotic after intercourse • Behavioral advices( not using pantyhose, wiping font to back, postcoital voiding) have not been proven effective.

  22. Acute Pyelonephritis inYounger Women • Women who are medically stable and maintaining hydration with oral intake: Can be treated as outpatients • Women who, because of severity of infection or underlying disability, are not medically stable or unable to take oral fluids or medications: Refer for hospitilization • Women who have been infection complicated by abcess or obstruction, regardless of ability to take fluids by mouth

  23. Adult Men with UTIs • Differentiate lower or upper UTIs • Differentiate prostatitis and urethritis • Treat as complicated UTIs: - Order urine culture pretreatment - First line usually floroquinalone 14 days • After second infection or first episode of pyelonephritis: Imaging for anatomic abnormality or nephrolithiazis

  24. UTIs in Older Adults • Atypic symptoms: Mental status change, tachpnea, tachycardia, fever, gait instability, or falls • Pretreatment urine culture • 3 days regimen acceptable but 7-14 days are prefered • Frequent relapses: Search for nephrolithiazis or urinary retention • Elder women: Local estrogen decrease repeating gram negative organisms

  25. UTIs in Children • Girls: 5-8 % • Boys: 1-2 % • Noncircumsized v circumsized • Young children: perineal colonization • Older children: stasis • Vesicoureteral reflux: 30-50 %

  26. Vesicoureteral reflux: 30-50 % • Recurrent infection and renal scarring

  27. First year of life: unexplained fever consider UTIs • Neonates: Late-onset jaundice, Poor weight gain, Irritability, Hypothermia • Infants: Diarrrhea , vomiting, failure to thrive • School children: Back pain, abdominal pain, incontinence

  28. Urinanalysis has limited sensitivity in young children; Urine culture routinely • Older children dipstick and urine microscopy have similar sensitivity and specifity as in adults

  29. Older than 3 mo: 3 days antibiotic regimen if no systemic signs TMP/SMX Amoxicillin/clavunate Nitrafurantoin Third generation cephalosporins • Younger than 3 mo: refer for hospitilization; treated with parenteral antibiotics • Urine culture after cpmpletion of treatment to confirm successful treatment

  30. Imaging studies to detect anatomic or functional abnormalities: • < 2 yrs • > 2 yrs with recurrent infections • >2 yrs with single episode of acute pyelonephritis

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