A #MedTweetorial on Infections Down Under: UTIs in Adults. Compliments of @EMBoardBombs @blakebriggsMD @IltifatMD @MedTweetorials
UTIs, more common than #COVID19, and something we deal with daily. let's cover risks, complications, and treatments.
UTIs, more common than #COVID19, and something we deal with daily. let's cover risks, complications, and treatments.
UTIs comprise a broad group encompassing infections of the urethra (urethritis), prostate (prostatitis), bladder/lower urinary tract (cystitis), & infection of the kidney/upper urinary tract (pyelonephritis)
Separating the 2 “hemispheres” of the urinary tract will be critical when discussing symptoms, complications, and eventual management of this condition.
A UTI develops following the pathogenic colonization of the vaginal introitus or urethral meatus.
These bacteria are often from fecal flora or bacteria introduced by sexual activity that ascends via the urethra into the bladder, causing inflammation &, the classic UTI symptoms
These bacteria are often from fecal flora or bacteria introduced by sexual activity that ascends via the urethra into the bladder, causing inflammation &, the classic UTI symptoms
Rarely, pyelonephritis can also be caused by bacteremia. I recently learned about this on one of the @CPSolvers Virtual Morning Reports from @tony_breu
E. coli, a gram-negative encapsulated bacilli, is the most common culprit regardless of location along the urinary tract. The bacteria uses fimbriae to adhere to host cells (1). It is the most common cause of UTI’s, responsible for upwards of 80-90% of cases
There are several other potential causes of UTI’s, with complicated acute cystitis often attributable to either Pseudomonas (healthcare exposures or recent GU instrumentation) or Enterococcus. Staph saprophyticus is an occasional cause in healthy young women.
Rates of antibiotic resistance have been steadily increasing worldwide, in particular ESBL and carbapenem resistance. It should also not be forgotten that some of the commonly used antibiotics, like ciprofloxacin and Bactrim, are a lot less effective at treating E. Coli.
Several factors are associated with increased risks of UTIs. First and foremost, female gender, neurological conditions affecting bladder control and emptying, and anatomic abnormalities, male factors include BPH, lack of circumcision, and anal intercourse.
Classic symptoms for acute cystitis include dysuria, urinary frequency, urgency, and/or suprapubic pain
Hematuria can be seen but is rare as a presenting symptom.
If a patient is >65, the diagnosis may be harder to tease out, with complaints of nocturia, incontinence
Hematuria can be seen but is rare as a presenting symptom.
If a patient is >65, the diagnosis may be harder to tease out, with complaints of nocturia, incontinence
Symptoms are probably the best tool we can use to isolate the location of a UTI within the urinary tract.
Simple cystitis will not have any systemic symptoms if isolated to the bladder.
Simple cystitis will not have any systemic symptoms if isolated to the bladder.
Conversely, infections ascending beyond the bladder (pyelonephritis) will often show systemic signs like fever, chills, abdominal pain, altered mental status, fatigue, flank pain, & costovertebral angle tenderness. By definition, pyelonephritis is a complex UTI & tx differently
In sexually active females, a pelvic exam may be warranted if symptoms are not convincing for UTI especially in the presence of concerning sexual history.
In males, acute prostatitis is a great mimicker, and there should be a low threshold for rectal examination
In males, acute prostatitis is a great mimicker, and there should be a low threshold for rectal examination
In the elderly, nonspecific symptoms such as falls, change in functional status, & even change in mood ARN'T reliable indicators of infection, however it is difficult in clinical practice to truly determine which symptoms are or arent relevant to the patient’s acute presentation.
For all suspected simple UTI cases, only a UA should be ordered- it has been shown cultures do not change management in simple cystitis. DO NOT SEND CULTURES on uncomplicated UTIs! DO NOT send a urinalysis on an asymptomatic patient who has an indwelling foley
Most all foley catheters are colonized within the first few weeks to 30 days and a culture will almost always be positive. The overtreatment of these patients will ultimately lead to microbial resistance and other antibiotic related complications.
Urine cultures are indicated if there is suspicion of a complicated UTI, the patient is pregnant, male, the patient is a child, or is immunocompromised (including those with diabetes)or the patient is a male.
The overwhelming majority of cases can be managed as outpatients. The indications for admission would be an inability to tolerate liquids or medications PO or if a patient is presenting as a complicated UTI warranting IV antibiotics, inpatient interventions or general monitoring
Nitrofurantoin is usually the go-to for initial therapy for an uncomplicated UTI. The next best therapies include a first-generation cephalosporin like cephalexin to a third-generation cephalosporin like cefdinir. A 5-day oral course is sufficient enough in almost all cases
The older commonly used drugs like ciprofloxacin and to TMP-SMX, and from fosfomycin to cephalexin, there are many equally effective treatment options have mounting resistance and shouldnt be used as initial therapies unless someone has prior known cultures or there is an allergy
One rule that can help guide treatment is avoiding the use of fluoroquinolones as first-line treatment of uncomplicated urinary tract infections (UTIs) in women Therapy length of 5 days for cystitis & 10-14 days for pyelonephritis.
Don't forget about a one-time dose of 3g-Fosfomycin (given its long ½ life) is a great choice for those with ESBL, E-coli, or enterococcus infections. static1.squarespace.com/static/5b27ebc…
