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Urinary Tract Infections

Hongbiao (Hank) Liu MD PhD

Luna Medical Care

Urinary Tract Infections
 Leading cause of morbidity and health

care expenditures in persons of all ages.
 An estimated 50 % of women report

having had a UTI at some point in their lives.
 8.3 million office visits and more than 1

million hospitalizations, for an overall annual cost > $1 billion.

 Aggressive diagnostic work-ups are unwarranted in young women presenting with an uncomplicated episode of cystitis.  Causes: anatomy and certain behavioral factors. sexual activity. and the use of diaphragms and spermicides tract. .Acute Uncomplicated Cystitis  Sexually active young women. including delays in micturition.

85% are caused by Escherichia coli  5-20%are caused by coagulase-negative Staphylococcus saprophyticus  5-12% are caused by other Enterobacteriaceae such as Klebsiella and Proteus. .Acute Uncomplicated Cystitis  The microbiology is limited to a few pathogens.  70%.

suprapubic pain. and nausea or vomiting suggest upper tract infection.Acute Uncomplicated Cystitis  Clinical Features: dysuria. costovertebral angle tenderness. . flank pain. hematuria.  Fever >38C. urgency. frequency.

assessment of CVA tenderness. abdominal exam. . pelvic exam. new sexual partner.  H/o STD’s. gradual onset.Acute Uncomplicated Cystitis  Diagnosis: direct history and PE  PE: Temperature. partner with urethral symptoms.

.Acute Uncomplicated Cystitis  Guidelines for tx of acute cystitis recommend empiric antibiotic tx. presence of > trace urine leukocytes.. .  Unnecessary antibiotic use??  Clinical criteria for Dx: Dysuria. Dysuria and frequency in the absence of vaginal discharge. and presence of nitrites or.

.Acute Uncomplicated Cystitis  UA: Evaluation of midstream urine for pyuria.  Urine Culture: Not necessary  Warranted in: Suspected complicated infection. persistent symptoms following tx.  White blood cell casts in the urine are Dx of upper tract infection. symptoms recur < 1 mo after tx.

sensitivity 75-90%. beets. . sensitivity 35-85%.Acute Uncomplicated Cystitis  Urine dipsticks:  Leukocyte esterase (pyuria).  Microscopic evaluation for pyuria or a culture is indicated in pt with negative leukocyte esterase that have urinary symptoms. specificity 95%  Nitrite (Enterobacteriacea). false positive with phenazopyridine. specificity 95%.

coli     30% isolates resistance to ampicillin and sulfonamides Increasing of resistance to TMP-SMX Resistance to nitrofurantoin is <5% Resistance to fluoroquinolones <5% 3% resistant to TMP-SMX 0% resistant to nitrofurantoin 0.Acute Uncomplicated Cystitis  Susceptibility:  E.4% resistant to ciprofloxacin  S.saprophyticus    .

no antibiotics in the past 3 mo. no recent hospitalization.Acute Uncomplicated Cystitis  Treatment:  Short course vs.  Nitrofurantoin (100mg BID x 5 days)  Analgesia: Phenazopyridine 200mg TIDx2 . prolonged tx  Short course preferred except with beta-lactam agents  TMP-SMX (160/800mg BID x 3) first-line tx if: no allergy to the drug.

Ureaplasma urealyticum .  > 10(2) CFU/mL in women with acute symptomatic pyuria = UTI  Tx as an uncomplicated UTI  Mycoplasma genitalium.Acute Urethral Syndrome  Acute symptomatic women with dysuria and frequency with a midstream culture containing < 10(5) CFU/mL.

coli accounts for fewer than one third of complicated cases. male.DM. CRF. functional or metabolic abnormalities (polycystic.Acute Complicated Cystitis  UTI when/with structural. . pregnant or h/o recurrent UTI)  E. the spectrum of complicated UTIs may range from cystitis to urosepsis with septic shock. indwelling cath. neurogenic bladder) or elderly. child.  Clinically. transplant kidney. solitary.

and Providencia. Klebsiella.coli . Serratia.  These infections are usually associated with high- count bacteriuria (> 10(5) CFU/mL). Pseudomonas.Acute Complicated Cystitis  Urine culture and susceptibility are necessary.  MO: Proteus. staphylococci and fungi AND E. enterococci.

cefepime.Acute Complicated Cystitis  Empiric therapy for these patients should include an agent with a broad spectrum of activity against the expected uropathogens: fluoroquinolone. (Obtain Ucx prior to Tx)  Tx x 7-14 days  Follow-up urine culture should be performed within 14 days after treatment??? . aztreonam. ceftazidime. imipenemcilastatin.

.Recurrent Cystitis  Up to 27% of young women with acute cystitis develop recurrent UTIs.  Relapse: infection with the same organism (multiple relapses = complicated UTIs).  Recurrence: infection with different organisms.  The causative organism should be identified by urine culture.

norfloxacin 200 mg per day. . 3. Acute self-treatment with a three-day course of standard therapy. nitrofurantoin 50 to 100 mg per day.Recurrent Cystitis  >3 UTI recurrences documented by urine Cx within one year can be managed using one of three preventive strategies: 1. Continuous daily prophylaxis TMP-SMX one-half tablet per day (40/200 mg). 2. Postcoital prophylaxis with one-half of a TMP-SMX double-strength tablet (80/400 mg).

abdominal pain  Gram-negative bacteremia.Uncomplicated Pyelonephritis  Suspect if:  Cystitis-like illness and accompanying flank pain  Severe illness with fever. . chills. vomiting. nausea.

confirm with:  UA: pyuria and/or WBC casts  UCx with > 10 (5) CFU/mL (80%)  Tx: 14 days total  Oral: TMP/SMX. quinolones. aztreonam. fluoroquinolones  IV: 3rd gen cephalosporin. aminoglycoside .Uncomplicated Pyelonephritis  DX: Clinical.

Uncomplicated Pyelonephritis  Pt with symptoms after 3 days of appropriate antimicrobial tx should be evaluated by renal US or CT for obstruction or abscess. .

anal sex.  UCx: 10 (3) CFU/mL sensitivity and specificity 97%. .UTI in Men  At risk: Older men with prostatic disease. UT instrumentation. or partner colonized with uropathogens.  Additional studies?  Not necessary in young healthy men who have a single episode.

UTI in Men  Tx:  Uncomplicated  cystitis: TMP/SMX or fluoroquinolones x 7 days  Complicated  cystitis: Fluoroquinolones x 7-14 days  Bacterial  prostatitis: Fluoroquinolone x 6-12 weeks .

 Dx: Ucx 10 (2) CFU/mL  MO: E. Pseudomona. Enterobacter.coli. Serratia.  40% of nosocomial infections  Most common source of gram-negative bacteremia. Proteus. Candida . Enterococcus.Catheter-Associated UTI  Risk of bacteriuria is ~ 5%/day (long term catheter bacteriuria is inevitable).

Catheter-Associated UTI  Mild to mod: oral quinolones10-14days  Severe infection: IV/oral 14-21days  Asymptomatic bacteriuria in pt with an indwelling Foley should not be Tx unless they are immunosuppressed. have risk of bacterial endocarditis or pt who are about to undergo urinary tract instrumentation. .

Asymptomatic Bacteriuria  UCx: > 10(5)CFU/mL with no symptoms  Three groups of pt with asymptomatic bacteruria have been shown to benefit from tx:  Pregnant  Renal transplant  Pt who are about to undergo urinary tract procedures. .

 Nitrofurantoin 100mg BID x 5-7 days  Amoxi/Clav 500mg BID or 250 TID x 7days  Fosfomycin 3g PO x 1 .Pregnant patients  Asymptomatic bacteriuria: two consecutive voided urine specimens with isolation of the same bacterial strain >10(5) or a single cath urine specimen.

 Etiology. urge incontinence with periurethral and suprapubic pain on bladder filling that is improved by voiding. urgency. altered glycosaminoglycal layer. Terminal hematuria may be present. allergic) .Interstitial Cystitis  Frequency. Unclear (autoimmune.

 Dietary modifications  Behavioral modifications  Rx: Pyridium  Pentosan polysulfate 100mg TID x 6mo to 2 years.Interstitial Cystitis  TX  Refer to urology for cystoscopy.  Amitriptyline 10-75mg QHS  .

.Interstitial Cystitis  Intravesical therapies  Dimethyl Sulfoxide instillations q1-2 wks  BCG instilled q1wk x 6-8 wks  Hyaluronic acid instilled q1wk x 4-6wk.