questions 6

Urinary Tract Infections

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Topic updated on 11/27/16 12:43am

Snapshot
  • An afebrile 23-year-old women presents with suprapubic pain, dysuria, and increased frequency of urination. A urinary sediment exam reveals clumps of neutrophils, occasional red blood cells, and rod shaped bacteria. No casts or crystals are found(Acute Cystitis)
Introduction
  • Urinary tract infections encompasses
    • cystitis
    • pyelonephritis
    • urosepsis 
  • Usually initiated as an ascending infection from the GI tract
  • Ambulatory UTI
    • 80% are by Escherichia Coli.
    • Staph saprophyticus (10-20%)
    • Klebsiella (8-10%)
  • Nosocomial (SEEKS PP)
    • E. Coli
    • Proteus (suspect with an alkaline urine pH)
    • Enterococcus
    • Serratia
    • Pseudomonas
  • Risk factors include
    • Foley catheters
    • previous UTIs
    • diabetes mellitus
    • pregnancy
    • oral contraceptives
    • antibiotics
    • poor hygiene
Acute Cystitis
  • Infection of the bladder
  • Symptoms
    • increase urinary frequency
    • dysuria
    • urgency
    • suprapubic pain
    • bedwetting in children
  • Urine dipstick shows
    • increased leukocyte esterase
    • elevated nitrites, elevated pH (Proteus)
    • hematuria
  • Urinary Sediment findings include
    • clumps of neutrophils (pyuria)
    • scattered RBC
    • bacteria without the presence of casts
  • Microscopic analysis may show
    • > 5 leukocytes/hpf
    • a bacterial pathogen
  • Gold standard is clean catch urine culture with >100,000 bacteria/ml
Acute Pyelonephritis
  • Symptoms
    • nausea
    • vomiting
    • fever
    • flank pain
    • urinary frequency
    • dysuria
    • urgency
  • Urinary Sediment findings include
    • clumps pf neutrophils (pyuria)
    • scattered RBC
    • bacteria with the presence of WBC casts
  • Microscopic analysis may show
    • > 5 leukocytes/hpf
    • a bacterial pathogen
  • Gold standard is clean catch urine culture with >100,000 bacteria/ml 
Urosepsis
  • Urosepsis must be considered in any elderly with altered mental status
Treatment
  • Treat healthy females on outpatient basis with TMP-SMX PO X 3 days
    • if allergic use ciprofloxacin or nitrofurantoin
  • Treat pregnant women with nitrofurantoin
  • Elderly or comorbid should be hospitalized and given IV ABX
    • ciprofloxacin or ampicillin/gentamicin
  • Perform ultrasound if a child < 2 years old presents with repeated UTIs and fever to determine if structural abnormalities are the cause of the UTIs
  • Prophylactic Abx may be given to those with recurrent UTIs
  • Treat asymptomatic bacteriuria only if 
    • pregnant
      • treat with nitrofurantoin
    • urologic intervention
    • hip arthroplasty


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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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