questions 9

Urinary Tract Infections

Topic updated on 08/21/17 6:49pm

Overview
 

 
Snapshot
  • A 25-year-old, G1P0, woman who is 14 weeks pregnant presents to her obstetrician for routine prenatal screening. She reports feeling well except for mild nausea. She denies any dysuria, urinary frequency, or abnormal bleeding from the vagina or seen in the urine. A clean catch mid-stream urine sample is collected for urine culture. Urine culture reveals bacteriuria of ≥ 105 cfu/mL. She is started on oral nitrofurantoin for 5 days. (Asymptomatic bacteriuria in pregnancy)
Introduction
  • Clinical definition
    • urinary tract infections (UTI) can either be asymptomatic or symptomatic and encompasses
      • asymptomatic bacturia (ASB)
        • there is bacteria in the urinary tract; however, the patient has no symptoms
        • typically patients do not require treatment
          • pregnant women require screening and treatment
            • this is because ASB in pregnancy is associated with
              • pre-term birth
              • perinatal death
              • pyelonephritis in the mother
      • cystitis
      • prostatitis
      • pyelonephritis
    • it is important to distinguish between uncomplicated and complicated UTI
      • uncomplicated UTI
        • this describes acute cystitis or pyelonephritis in outpatient women who are not pregnant and do not have anatomic abnormalities or instrumentation within the urinary tract
      • complicated UTI
        • this describes UTI that is not uncomplicated
  • Epidemiology
    • incidence
      • 50-80% of women acquire at least 1 UTI
      • 20-30% of women with 1 UTI have recurrent infections
    • demographics
      • more common in women, elderly, and infants
        • infants should receive a renal and bladder ultrasound to identify abnormalities of the genitourinary tract 
    • location
      • bladder
      • prostate
      • kidneys
    • risk factors
      • female
      • benign prostatic hyperplasia
      • frequent sexual intercourse
      • history of UTI
      • incontinence
      • diabetes mellitus
      • vasicoureteral reflux
      • spermicide use
      • indwelling catheter
        • intermittent catheterization can prevent a UTI
  • Pathogenesis
    • in most cases bacteria ascends from the urethra to the bladder (cystitis)
      • bacterial organisms can further ascend through the ureter and infect the kidney causing a renal parenchymal infection (pyelonephritis)
      • note that infection and symptom development depends on the
        • host
          • e.g., genetic background, behavioral factors, and underlying disease
        • pathogen
        • environmental factors
          • e.g., vaginal microflora, medical devices (e.g., indwelling catheters), and urinary retention
        • for example, voiding and the host's innate immune response eliminates bacterial colonization in the bladder after sexual intercourse
          • however, an indwelling catheter, stone, or any other foreign body provides a surface where bacteria can colonize
      • hematogenous spread to the urinary tract can also result in a UTI; however, this is rare
        • e.g., Salmonella, S. aureus, and Candida
  • Prognosis
    • ASB in elderly or catheterized patients does not increase the risk of death
    • recurrent UTI in children and adults does not result in chronic pyelonephritis or renal failure
      • this is true when there are not anatomic abnormalities
 
Microbiology of Urinary Tract Infections
Microbe
Findings
Comments
E. coli 
  • Green metallic sheen on EMB agar
  • Most common cause of UTI
S. saprophyticus
-
  • Second most common cause in sexually active women
K. pneumoniae
  • Large mucoid capsule and viscous colonies
  • Third most common cause
S. marcescens
  • Red pigment production by select strains
-
Enterococcus -
  • Typically a nosocomial infection that is drug-resistant
P. mirabilis
  • "Swarming" appearance on agar
  • Urease positive
  • Can result in struvite stone formation
-
P. aeruginosa
  • Blue-green pigment
  • Typically a nosocomial infection that is drug-resistant
 
Presentation
  • Symptoms/physical exam/findings
    • ASB
      • asymptomatic patient with an incidental finding of bacteruria on urine culture
    • cystitis
      • dysuria
      • urinary frequency
      • urgency
      • nocturia
      • suprapubic discomfort
      • gross hematuria
    • prostatitis
      • dysuria
      • frequency
      • pain in the prostatic pelvic or perineal area
      • bladder outlet obstruction
      • fever and chills
    • pyelonephritis 
      • fever
        • this is the main feature that distinguishes pyelonephritis from cystitis
      • costovertebral angle pain
        • may be absent in mild pyelonephritis
      • obstructive uropathy in patients with diabetes
        • this is secondary to acute papillary necrosis that results in the papillae to slough and subsequently obstruct the ureter
      • emphysematous pyelonephritis in patients with diabetes
        • gas is produced in the renal and perinephric areas
Imaging
  • Ultrasound
    • indications
      • in children < 2-years-old with a first febrile UTI
      • in children who are appropriately responding to antimicrobial treatment of UTI
  • Voiding cystourethrogram
    • indication
      • this is the test of choice to determine the presence of a vesicourethral reflux
Studies
  • Labs
    • urine dipstick
      • nitrite positivity suggests an E. coli infection or other infection of the Enterobacteriaceae family
      • leukocyte esterase positive
      • urease positivity suggests an S. saprophyticus, Proteus, or Klebsiella infection
    • urinalysis
      • > 10 white blood cells (WBCs)/mL
      • > 1000 CFU/mL
      • white blood cell casts 
        • a diagnostic finding of an upper urinary tract infection (e.g., pyelonephritis)
    • urine culture
      • gold standard for diagnosing UTI
  • Histology
    • chronic pyelonephritis
      • "thyroidization" of tubules due to eosinophilic casts contained in the tubules
Differential
  • Acute hemorrhagic cystitis
    • can be caused by adenovirus 
  • Urethritis
  • Nephrolithiasis
  • Genitourinary malignancy
Treatment
  • Medical
    • TMP-SMX or nitrofurantoin
      • indications
        • first-line for uncomplicated UTI
          • second-line agents include a fluoroquinolone or β-lactam
        • nitrofurantoin, ampicillin, and cephalosporins can be used in the treatment of UTI in pregnant women
          • parenteral β-lactam with or without aminoglycosides is used in pregnant women with pyelonephritis
          • sulfonamides should not be used due to its possible teratogenic effects (in first trimester) and kernicterus development (near term)
          • fluoroquinolones should also be avoided in pregnancy due to its negative effect on the development of fetal cartilage
        • TMP-SMX or a fluoroquinolone is used in the treatment of prostatitis
    • fluoroquinolones (e.g., ciprofloxacin)
      • indication
        • first-line for acute uncomplicated pyelonephritis
    • fluconazole
      • indication
        • first-line treatment for Candida-related UTI
  • Operative
    • nephrectomy
      • indications
        • treatment for xanthogranulomatous pyelonephritis
    • percutaneous drainage
      • indications
        • treatment for emphysematous pyelonephritis and it may be followed by elective nephrectomy
Complications
  • Uncomplicated UTI
    • complications are uncommon
  • Complicated UTI
    • bacteremia
    • urosepsis
    • systemic inflammatory response syndrome (SIRS)
    • renal and perinephric abscess
    • emphysematous pyelonephritis
    • xanthogranulomatous pyelonephritis
      • associated with long-term urinary tract obstruction and infection
        • this results in chronic destruction of the renal parenchyma via a granulomatous process
    • malakoplakia
    • renal papillary necrosis
  • UTI in pregnancy
    • pyelonephritis
    • sepsis
    • chorioamnionitis
    • preterm labor
    • low birth weight
    • hypertension and pre-eclampsia
  • UTI in men
    • acute or chronic prostatitis
    • urethritis
    • acute epididymitis
    • orchitis
 



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Qbank (4 Questions)

TAG
(M3.RL.3) A 29-year-old G1P0 female at 24 weeks gestation presents to her physician with complaints of pain with urination, and she reports that she has been urinating much more frequently than usual over the past several days. Examination is significant for suprapubic pain on palpation; she denies any costovertebral angle tenderness. Urinalysis shows increased leukocyte esterase, elevated nitrites, 55 leukocytes/hpf, and bacteria. Urine microscopy is shown in Figure A. The physician prescribes a 7-day course of nitrofurantoin. Which of the following is the next best step in management? Topic Review Topic
FIGURES: A          

1. Switch from nitrofurantoin to trimethoprim-sulfamethoxazole
2. Add penicillin to antibiotic regimen
3. Initiate regular self-catheterizations until the infection resolves
4. Order clean catch urine culture
5. Discontinue nitrofurantoin

PREFERRED RESPONSE ▶
TAG
(M2.RL.1) A 74-year-old woman was admitted to the hospital for a CHF exacerbation. The urinalysis shows >100,000 colonies/mL of E. coli. The patient denies chest pain, shortness of breath, nausea/vomiting, dysuria, hematuria, and changes in urinary frequency. She has no known drug allergies. Which of the following is the most appropriate treatment for this patient? Topic Review Topic

1. No treatment
2. Levofloxacin
3. Ceftriaxone
4. Trimethoprim-sulfamethoxazole
5. Piperacillin-tazobactam

PREFERRED RESPONSE ▶
TAG
(M2.RL.26) A women who is 20-weeks pregnant presents to your clinic with mild dysuria and increased urinary frequency. She is afebrile. Physical exam is negative for costovertebral angle tenderness. What is the best agent to treat this condition? Topic Review Topic

1. Trimethoprim-sulfamethoxazole
2. Nitrofurantoin
3. Ciprofloxacin
4. Ampicillin
5. Penicillin

PREFERRED RESPONSE ▶
TAG
(M2.RL.44) A 63-year-old female presents to the emergency room with left-sided back pain. Her past medical history includes persistent urinary retention, for which she has a foley catheter in place 24 hours/day. Her blood pressure is 117/75 mmHg, pulse is 103/min, and temperature is 99.0 deg F (37.2 deg C). Urinalysis shows too numerous to count white blood cells, 5-10 red blood cells per high-powered field, positive leukesterase, and a pH of 7.31 (nl 5-6). Which of the following images is most likely to be associated with this patient's symptoms? Topic Review Topic
FIGURES: A   B   C   D   E  

1. Figure A
2. Figure B
3. Figure C
4. Figure D
5. Figure E

PREFERRED RESPONSE ▶
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