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Urinary Tract Infections

Urinary Tract Infections. 22 September 2004. Definition. Bacterial (fungal) invasion of the urothelium resulting in an inflammatory response Uncomplicated vs Complicated Complicated UTIs carry a moderate/high risk of causing sepsis, tissue destruction or significant morbidity/mortality

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Urinary Tract Infections

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  1. Urinary Tract Infections 22 September 2004

  2. Definition • Bacterial (fungal) invasion of the urothelium resulting in an inflammatory response • Uncomplicated vs Complicated • Complicated UTIs carry a moderate/high risk of causing sepsis, tissue destruction or significant morbidity/mortality • Male, elderly, febrile utis, haematuria, diabetes, immunosuppression, pregnancy, obstruction, stones, instrumentation and resistant organisms • Structural and functional abnormalities

  3. Definitions II • Isolated • Unresolved • Recurrent • Reinfection • Persistance

  4. Pathogenesis • Organisms normal bowel flora • Facultative Gram neg. anaerobes • Coliforms – E-Coli, Proteus • Gram neg. aerobic • Pseudomonas • Gram pos. • Staph saprophyticus and ent. faecalis

  5. UTI Prophylaxis • Cranberry Juice • Contains antiseptic Hippuric acid • Trials • colonisation with benign strain • Immunisation with uropathogens

  6. Recurrent UTI Risk Groups • Premenopausal – sexually active, spermicide, childhood and maternal • Postmenopausal – oestrogen deficiency, incontinence, cystocoele • Elderly – cognition, incontinence, catheterisation

  7. Bacterial vs Host factors • Bacterial – adherance factors, haemolysins (e-coli), urease (proteus), swarming (proteus, klebsiella) • Host – micturition, bactericidal urine, secreted factors, vaginal epithelium cell receptivity

  8. Primary Care Guidelines for Diagnosis • Females – MSSU • Toddlers/infants – pads from nappies/suprapubic aspiration (paraplegic also) • Males – MSSU, VB1(urethral),VB2 (midstream), VB3 (prostate) • Refrigerate specimens at 4ºC or use specimen pots containing boric acid

  9. Diagnosis II • Kass criteria - >105 CFU/ml (70% of those with definite UTI), 30-40% have 103-4 CFU but symptomatic • The Urethral Syndrome (50%) • Acute uncomplicated UTI • Routine culture unnecessary • Use dipstick tests to decrease antibiotic use and unnecessary investigations

  10. Dipstick Urinalysis

  11. Diagnosis III • Lab testing for C+S reserved for • Pregnancy screening at first antenatal visit • >2 UTIs in men • Suspected pyelonephritis • Elderly with 2 signs of infection especially dysuria, pyrexia or new incontinence • Recurrent UTI • Catheterised patients with features of systemic infection • Failed antibiotic treatment or persistant symptoms • Abnormalities of GU tract • Renal impairment • Remember C. trachomatis (www.hpa.org.uk)

  12. Treatment • Amoxicillin resistance is common • Those >65 do not treat asymptomatic bacteriuria • Only treat those with catheter who are systemically unwell • 25% of young men with UTIs have abnormal IVU • Pregnant women have x2 incidence of asymptomatic bacteriuria, 2% incidence of pyelonephritis • Diabetics have x4 risk of pyelonephritis, consider prophylaxis

  13. Treatment II • Uncomplicated UTI- no fever or flank pain • Use urine dipstick, perform c+s if treatment fails. • Trimethoprim 200mg bd for 3 days or • Nitrofurantoin 50-100mg qds for 3 days or • Second line: depending on sensitivity of organism isolated, use amoxicillin, cefalexin, co-amoxiclav, quinolone, or pivmecillinam

  14. Treatment III • UTI in pregnancy and men • Suggest MSU for susceptibility testing • Short-term use of trimethoprim or nitrofurantoin in pregnancy is unlikely to cause problems to the foetus • Nitrofurantoin 50-100qds or • Trimethoprim 200mg bd or • Cefalexin 500mg bd or amoxicillin 250mg tds • All of above for 7 days • NB texbook of urology suggest first line for pregnancy are gentamicin! and cefalexin

  15. Treatment IV • Children • Recurrent UTI in women (>3 pa) • Post coital prophylaxis is as effective as prophylaxis taken nightly • Nitrofurantoin 50mg or • Trimethoprim 100mg • Stat post coital or od at night

  16. Treatment V • Acute pyelonephritis • Recent RCT showed 7 days of ciprofloxacin as good as 14 days of co-trimoxazole • NO response within 48 hours, consider referral • Ciprofloxacin 500mg bd for 7 days or • Co-amoxiclav 500/125mg tds for 14 days • If sensitive, trimethoprim 200mg bd for 14 days

  17. Follow-up • Uncomplicated UTI and pyelonephritis in women – dipstick urinalysis • Consider investigation and/or referral: • Women with recurrent pyelonephritis within 2/52 • Elderly with recurrent UTIs • Males with recurrent infection and in all cases of pyelonephritis, prostatis, epididymitis and orchitis

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