Term
| Antibiotics that are SAFE To Use in the Pregnant Female with UTIs |
|
Definition
| Penicillins - ampicillin, amoxicillin, presumably piperacillin-tazobactam (category B); Cephalosporins - including IV cefazolin, ceftriaxone and oral cephalexin (Keflex); Aztreonam - is a category B so can be used if indicated; Aminoglycosides - gentamicin, tobramycin, amikacin could be used carefully; Nitrofurantoin - but this is just a "urinary antiseptic" so it only gets into the urine - so cannot be relied upon to adequately Rx tissue infections (pyelonephritis) or used to prevent recurrent UTIs. Do not give nitrofurantoin when the patient is near term, during labor, or delivery becuase it may cause hemolytic anemia in the newborn, Can cause hemolysis in G6PD deficient patients, Doesn't appear teratogenic |
|
|
Term
| Antibiotics to AVOID in Treating UTIs in the Pregnant Female |
|
Definition
| Tetracycline - generic forms, doxycycline, etc.; Quinolones - eg ciprofloxacin; TMP-SMX - especially in the last trimester |
|
|
Term
| Ascending Route of UTI Infection |
|
Definition
| Women are at greater risk; Coiform organisms colonize the vaginal introitus and spread up the urethra (short in females), Infection spreads up to the bladder with cystitis and (sometimes) kidney (with tissue infection - pyelo) |
|
|
Term
| Hematogenous Seeding of the Kidney in a UTI |
|
Definition
| Rare, except in S.aureus bacteremia; It is rare for gram negative bacilli to "seed" the kidney, but common for kidney infection to be the source of a gram negative bacteremia; NOTE - in the absence of a Foley catheter with manipulation, a S.aureus UTI may be a clinical clue of S.aureus bacteremia |
|
|
Term
| Organism Characteristics Leading to Infection |
|
Definition
| ADHERENCE - ie the ability to attach to mucosal surfaces, Uropathogenic E.coli can adhere to vaginal and uroepithelial cells and the ability of the organism to do so often determines infectivity and in some cases the propensity to develop upper UTIs (pyelonephritis), Often fimbria-mediated, or pili, or nonfilamentous proteins (adhesins) of the outer membrane, S.saprophyticus is more adherent than S.aureus or S.epidermidis, Bacterial adherence to mucosal cells is associated with cytokine release resulting in increase polymorphonuclear cells (pyuria); MOTILITY - motile bacteria may pose an increased risk of pyelo since they can ascend in the ureter against the flow of urine; Uropatheogens (gram negs) may have endotoxins which decrease ureteral peristalsis, or Hemolysins whihc facilitate tissue invasion |
|
|
Term
| Bladder Mucopolysaccharide |
|
Definition
| Decreases adherence of bacteria (especially of a low inoculum) |
|
|
Term
| Classic UTI Sxs in Older Children and Adults |
|
Definition
| Frequency, Dysuria (burning), Urgency; Rule Out - vagninitis in females, urethritis in males |
|
|
Term
|
Definition
| Fever >38.4 degrees C is consistent with upper (pyelo); Rigors are consistent with upper; Failure to respond to recent appropriate short course of antibiotics is consistent with upper |
|
|
Term
| UTI in an Adult Male Without a Foley |
|
Definition
| UTI in such a patient usually implies prostatities; Need antibiotics that get into the prostate - TMP, TMP-SMZ, Quniolones; Need abx therapy for about 3 weeks (2-4 weeks) |
|
|
Term
| Physical Exam in a Patient with a UTI |
|
Definition
| Not too helpful except that a fever indicates an upper UTI and that CVA tenderness may be present in a patient with pyelo (but not always) |
|
|
Term
| Laboratory Findings with UTIs |
|
Definition
| Pyuria - WBCs in the urine (positive dipstick), Absence of pyuria indicates that the patient doesn't have a UTI (unless the patient is leukopenic); Microscopic hematuria in cystitis in women; Urine culture and specificity for "complicated" UTI - classic positive culture/ specificity is 10^5 cfu/ml, >10^2 in women with dysuria is important and is probably a true early UTI; If you're trying to rule out pyelonephritis you need 2 blood cultures 15-20 minutes apart and may want a gram stain of unspun urine because it may help rule out enterococci (gram positive cocci) which would need special antibiotic considerations |
|
|
Term
| What Constitutes an "Uncomplicated" UTI in a Woman? |
|
Definition
| A UTI in a young to middle aged woman |
|
|
Term
| Antibiotic Therapy in Women with "Uncomplicated" UTIs |
|
Definition
| 3 day course of abx preferred; No longer favor single dose regimens; TMP-SMZ vs Quinolone? - recent report suggests that up to 18% of community-acquired E.coli are resistant - if using a quinolone, ciprofloxacin is fine, not a more advanced quinolone, and not trovofloxacin, Cipro is much more expensive than TMP-SMZ, If you overuse quinolones you will select out for increased resistance, Consider saving quinolones unless you suspect resistance (prior abx), or in diabetics, fragile patients, and patients on coumadin in whom TMP-SMZ is contraindicated |
|
|
Term
| Antibiotic Therapy of Pyelonephritis in Women |
|
Definition
| 2 weeks of abx; IV vs PO is an individual decision based on the patient - sometimes IV initially then PO; Many abx options - consider how sick the patient is, whether or not resistance is likely, and whether or not you need to worry about enterococci; Still use TMP-SMZ or quinolones, just for longer |
|
|
Term
| Treatment of Candida in Females |
|
Definition
| Candida is common after antibiotics or a Foley catheter; Treatment is removal of the Foley (if there is one and it's possible to remove it); |
|
|
Term
| Antibiotic Treatment of Recurrent Infections in Women |
|
Definition
| Consider qhs suppression; Abx after intercourse?; Consider self-administered 3 day courses |
|
|
Term
| Asymptomatic Bacteriuria in Women |
|
Definition
| Definition; Usually do not treat - pregnancy is an exception (you treat pregnant women even if they're asymptomatic) |
|
|
Term
|
Definition
| Common; History - perineal discomfort, frequency, urgency, dysuria; ACUTE - positive urine culture, gentle rectal exam (if done), limited useful abx are available (because others don't get into the prostate) and include TMP, TMP-SMZ, and quinolones, Prolonged (2-4 week) treatment; TMP-SMZ is less expensive, but should be avoided in patients on coumadin, and may cause more rashes; ? GU workup for repeat episodes; For true CHRONIC Prostatitis - refer to urology, very difficult issue for some patients |
|
|
Term
| Antibiotic Treatment of Pyelonephritis in Men |
|
Definition
| Treat for 3-4 weeks; Usually want an abx that could also penetrate the prostate (TMP, TMP-SMZ, Quinolones) |
|
|
Term
| Treatment of Recurrent UTIs in Men |
|
Definition
|
|
Term
| Asymptomatic Bacteruria in the Elderly Patient |
|
Definition
| Do not Rx, since Rx will not decrease mortality rates |
|
|
Term
| Treatment of a Lower UTI in an Elderly Female Patient |
|
Definition
| No data on 3 day Rx regimens, so treatment for 7-14 days with abx is usually suggested; Recurrent episodes are a problem; ? role of local estrogen Rx; ? cranberry juice everyday; ? abx suppression qhs (avoid nitrofurantoin in the elderly because of potential side effects) |
|
|
Term
| Treatment of Pyelonephritis in the Elderly Patient |
|
Definition
| 2 weeks of abx in females, ? 3 weeks in males |
|
|
Term
|
Definition
| Asymptomatic bacteriuria - no Rx; For fever, cloudy urine, UTI - do a urine culture/ specificity, Optimal Rx is unclear (foreign body issue, select for resisitance with abx, the compromise is a short course of abx if blood culture and specificity are negative, once urine is sterile (usually 24-48h) change the foley); Don't do "routine", "periodic" urine cultures |
|
|
Term
|
Definition
| "Temporary" obstruction of the ureters is a common finding; Rx asymptomatic bacteruria; Carefully look up each abx you consider; AVOID quinolones in pregnancy; UTI in a pregnant woman is, by definition, a "complicated" UTI; Nitrofurantoin is considered a safe agent - sometimes used as prophylaxis/ suppression; Enlist help for Rx in complex cases |
|
|
Term
|
Definition
| PROBLEMS - UTIs can cause irreversible scarring, want early diagnosis, evaluation and treatment; PATHOGENESIS - ascending route is important, Obstruction with urinary stasis (eg posterior urethral valve, vesicoureteral reflux is the most common abnormality), Uncircumcised males at risk, Others at risk include premature infants with an ICU stay, Girls <5 years of age with prior UTIs, and those with systemic or immunologic disease; Recent data suggest that asymptomatic bacteruria may actually be protective in some patients; MANIFESTATIONS - Vary by age: Neonates (hypo or hyperthermia, failure to thrive, vomiting, diarrhea, sepsis, irritability, lethargy, jaundice, malodorous urine), Toddler (abdominal pain, vomiting, diarrhea, constipation, abnormal voiding pattern, malodorous urine, fever, poor growth), School-Age Child (dysuria, frequency, urgency, abdominal pain, abnormal voiding pattern - including incontinence or secondary enuresis, constipation, malodorous urine, fever), Adolescent (dysuria, frequency, urgency, abdominal discomfort, malodorous urine, fever); DIAGNOSIS - pyuria is helpful if present, Urine culture (may be hard to collect in infants and toddlers, A negative culture/ specificity of a "bag" collected urine specimen helps rule out a UTI), ? blood culture; RADIOGRAPHIC EVALUATION - Indications include child <5 with documented UTI, Child with pyelo; Choice of modality of radiographic imaging depends on facilities available, skill and experience of radiologist, etc.: Renal US (rule out obstruction), Special scans can dx pyelo, Voiding cystourethrogram to detect vesicoureteral reflux, ? refer to pediatric facility; TREATMENT - Do NOT use quinolones, Look up doses |
|
|
Term
|
Definition
| EX Nitrofurantoin; Good urine levels, but not good renal tissue levels; Good for uncomplicated UTI or cystitis (superficial bladder infection); Used for selected prophylaxis or chronic suppression |
|
|
Term
|
Definition
| Usefulness in adults is debated; 300ml/day; May interfere with bacterial adherence |
|
|
Term
|
Definition
| One dose for uncomplicated UTI; Very expensive (20x as expensive as a 3 day course of TMP-SMZ, and 2x as expensive as a 3 day course of ciprofloxacin); Do not advise using it |
|
|
Term
| Methenamine + Acidification |
|
Definition
| Seldom used; Consider if no Foley and a patient with obstructive uropathy, with recurrent UTI; Creates (?) Formaldehyde in acid environment if it sits in the bladder 2-3 hours |
|
|
