|
|
| (46 intermediate revisions by the same user not shown) |
| Line 13: |
Line 13: |
| ** There may be serious difficulties in diagnosing spinal cord–injured and elderly patients who may be unable to localize the site of their discomfort. | | ** There may be serious difficulties in diagnosing spinal cord–injured and elderly patients who may be unable to localize the site of their discomfort. |
| * '''Chronic pyelonephritis:''' a shrunken, scarred kidney, diagnosed by morphologic, radiologic, or functional evidence of renal disease that may be post-infectious but is frequently not associated with UTI. | | * '''Chronic pyelonephritis:''' a shrunken, scarred kidney, diagnosed by morphologic, radiologic, or functional evidence of renal disease that may be post-infectious but is frequently not associated with UTI. |
| * '''Uncomplicated vs. complicated infection''' | | * '''<span style="color:#ff0000">Uncomplicated vs. complicated infection''' |
| ** '''Uncomplicated: infection in a healthy patient with a structurally and functionally normal urinary tract. The majority of these patients are women''' | | ** '''<span style="color:#ff0000">Uncomplicated: infection in a healthy patient with a structurally and functionally normal urinary tract. The majority of these patients are women''' |
| ** '''Complicated: infection associated with factors that increase the chance of acquiring bacteria and decrease the efficacy of therapy. Examples include (12):''' | | ** '''<span style="color:#ff0000">Complicated UTIs requires either (5):[https://www.auanet.org/meetings-and-education/for-medical-students/medical-students-curriculum/adult-uti §]''' |
| **# '''Male gender''' | | **# '''<span style="color:#ff0000">Anatomic or functional abnormality of urinary tract (outlet obstruction, stone disease, diverticulum, neurogenic bladder, VUR etc.)''' |
| **# '''Pregnancy'''
| | **# '''<span style="color:#ff0000">Urinary instrumentation or foreign bodies in the urinary tract (i.e. catheters, stents, nephrostomy tubes)''' |
| **# '''Elderly'''
| | **# '''<span style="color:#ff0000">Systemic disease (renal insufficiency, diabetes, immunodeficiency, organ transplantation)''' |
| **# '''Diabetes'''
| | **# '''<span style="color:#ff0000">Pregnancy''' |
| **# '''Immunosuppression'''
| | **# '''<span style="color:#ff0000">Multi–drug resistant bacteria''' |
| **# '''Functional or anatomic abnormality of urinary tract'''
| |
| **# '''Indwelling urinary catheter''' | |
| **# '''Urinary tract instrumentation'''
| |
| **# '''Recent antimicrobial agent use''' | |
| **# '''Hospital-acquired infection''' | |
| **# '''Childhood UTI''' | |
| **# '''Symptoms for > 7 days at presentation'''
| |
| * Chronic is a poor term that should be avoided in the context of UTIs, except for chronic pyelonephritis or bacterial prostatitis, because the duration of the infection is not defined. | | * Chronic is a poor term that should be avoided in the context of UTIs, except for chronic pyelonephritis or bacterial prostatitis, because the duration of the infection is not defined. |
| * UTIs may also be defined by their relationship to other UTIs: | | * UTIs may also be defined by their relationship to other UTIs: |
| Line 195: |
Line 188: |
|
| |
|
| === Labs === | | === Labs === |
| * '''Urine collection'''
| | |
| ** '''Voided and catheterized specimens'''
| | ==== Urine collection ==== |
| *** '''Males'''
| | * '''Voided and catheterized specimens''' |
| **** '''In circumcised males, voided specimens require no preparation. For males who are not circumcised, the foreskin should be retracted and the glans penis washed with soap and then rinsed with water before specimen collection.'''
| | ** '''Males''' |
| **** '''The first 10 mL of urine (representative of the urethra) and a midstream specimen (representative of the bladder) should be obtained.'''
| | *** '''In circumcised males, voided specimens require no preparation. For males who are not circumcised, the foreskin should be retracted and the glans penis washed with soap and then rinsed with water before specimen collection.''' |
| **** '''Prostatic fluid is obtained by performing digital prostatic massage''' and collecting the expressed prostatic fluid on a glass slide. In addition, '''collection of the first 10 mL of voided urine after massage will reflect the prostatic fluid added to the urethral specimen.'''
| | *** '''The first 10 mL of urine (representative of the urethra) and a midstream specimen (representative of the bladder) should be obtained.''' |
| **** Catheterization of a male patient for urine culture is not indicated unless the patient cannot urinate.
| | *** '''Prostatic fluid is obtained by performing digital prostatic massage''' and collecting the expressed prostatic fluid on a glass slide. In addition, '''collection of the first 10 mL of voided urine after massage will reflect the prostatic fluid added to the urethral specimen.''' |
| *** '''Females'''
| | *** Catheterization of a male patient for urine culture is not indicated unless the patient cannot urinate. |
| **** '''In females, contamination of a midstream urine specimen with introital bacteria and WBCs is common, particularly when the woman has difficulty spreading and maintaining separation of the labia. Therefore, females should be instructed to spread the labia, wash and cleanse the periurethral area with moist gauze, and then collect a midstream urine specimen.'''
| | ** '''Females''' |
| ***** '''Cleansing with antiseptics is not recommended''' because they may contaminate the voided specimen and provide a false-negative urine culture.
| | *** '''In females, contamination of a midstream urine specimen with introital bacteria and WBCs is common, particularly when the woman has difficulty spreading and maintaining separation of the labia. Therefore, females should be instructed to spread the labia, wash and cleanse the periurethral area with moist gauze, and then collect a midstream urine specimen.''' |
| **** '''The voided specimen is contaminated if it shows evidence of vaginal epithelial cells and lactobacilli on urinalysis,''' and a catheterized specimen should be collected.
| | **** '''Cleansing with antiseptics is not recommended''' because they may contaminate the voided specimen and provide a false-negative urine culture. |
| ** '''Suprapubic aspiration'''
| | *** '''The voided specimen is contaminated if it shows evidence of vaginal epithelial cells and lactobacilli on urinalysis,''' and a catheterized specimen should be collected. |
| *** '''Advantage: highly accurate'''
| | * '''Suprapubic aspiration''' |
| *** '''Disadvantages:''' '''some morbidity'''
| | ** '''Advantage: highly accurate''' |
| *** '''Limited clinical usefulness''' except for a patient who cannot urinate on command such as patients with spinal cord injuries and newborns
| | ** '''Disadvantages:''' '''some morbidity''' |
| *** Steps to perform procedure available in CW11 page 250
| | ** '''Limited clinical usefulness''' except for a patient who cannot urinate on command such as patients with spinal cord injuries and newborns |
| ** '''Bag specimens'''
| | ** Steps to perform procedure available in CW11 page 250 |
| *** '''Unreliable and unacceptable for diagnosis of UTI in high-risk populations and infants'''.
| | * '''Bag specimens''' |
| **** '''Generally, if a UTI is suspected in a child who is not yet toilet trained, only a catheterized or needle-aspirated specimen is acceptable for diagnosis''' because bagged urinary specimens have an unacceptably high false-positive rate.
| | ** '''Unreliable and unacceptable for diagnosis of UTI in high-risk populations and infants'''. |
| ***** Under special collection circumstances when the perineum is cleaned well and the bag removed and processed promptly after voiding, a bagged specimen or even a diaper specimen that shows no growth is useful in eliminating bacteriuria as a diagnosis.
| | *** '''Generally, if a UTI is suspected in a child who is not yet toilet trained, only a catheterized or needle-aspirated specimen is acceptable for diagnosis''' because bagged urinary specimens have an unacceptably high false-positive rate. |
| * '''Urinalysis (UA)'''
| | **** Under special collection circumstances when the perineum is cleaned well and the bag removed and processed promptly after voiding, a bagged specimen or even a diaper specimen that shows no growth is useful in eliminating bacteriuria as a diagnosis. |
| ** '''Provides rapid identification of bacteria and WBCs and presumptive diagnosis of UTI'''
| | |
| *** '''Assess for bacteria, epithelial cells, pyuria, hematuria, nitrites'''
| | ==== Urinalysis (UA) ==== |
| *** '''Diagnosis is confirmed by urine culture'''
| | * '''Provides rapid identification of bacteria and WBCs and presumptive diagnosis of UTI''' |
| **** UA does not replace urine culture and may be more relevant for screening in asymptomatic patients
| | ** '''Assess for bacteria, epithelial cells, pyuria, hematuria, nitrites''' |
| ** Usually, the sediment from an ≈5-10-mL specimen obtained by centrifugation for 5 minutes at 2000 rpm is analyzed.
| | ** '''Diagnosis is confirmed by urine culture''' |
| ** '''Bacteriuria'''
| | *** UA does not replace urine culture and may be more relevant for screening in asymptomatic patients |
| *** Definition of bacteriuria: presence of bacteria in the urine, which is normally free of bacteria
| | * Usually, the sediment from an ≈5-10-mL specimen obtained by centrifugation for 5 minutes at 2000 rpm is analyzed. |
| **** The term "significant bacteriuria" has a clinical connotation and is used to describe the number of bacteria in a suprapubically aspirated, catheterized, or voided specimen that exceeds the number usually caused by bacterial contamination of the skin, the urethra, or the prepuce or introitus, respectively.
| | * '''Bacteriuria''' |
| *** '''Can be symptomatic or asymptomatic'''
| | ** Definition of bacteriuria: presence of bacteria in the urine, which is normally free of bacteria |
| *** '''Found in > 90% of infections with counts of ≥105 colony-forming units (cfu) per milliliter of urine and''' '''is a highly specific finding'''.
| | *** The term "significant bacteriuria" has a clinical connotation and is used to describe the number of bacteria in a suprapubically aspirated, catheterized, or voided specimen that exceeds the number usually caused by bacterial contamination of the skin, the urethra, or the prepuce or introitus, respectively. |
| **** Bacteria are usually not detectable microscopically with lower cfu (102-104/mL).
| | ** '''Can be symptomatic or asymptomatic''' |
| *** '''Causes of false-negative UA and culture:'''
| | ** '''Found in > 90% of infections with counts of ≥105 colony-forming units (cfu) per milliliter of urine and''' '''is a highly specific finding'''. |
| ***# '''Early in an infection'''
| | *** Bacteria are usually not detectable microscopically with lower cfu (102-104/mL). |
| ***# '''In context of increased fluid intake and subsequent dilute urine'''
| | ** '''Causes of false-negative UA and culture:''' |
| **** '''A negative urinalysis for bacteria never excludes the presence of bacteria'''
| | **# '''Early in an infection''' |
| *** '''Causes of false-positive UA and culture:'''
| | **# '''In context of increased fluid intake and subsequent dilute urine''' |
| ***# '''Contamination of an abacteriuric specimen during collection'''
| | *** '''A negative urinalysis for bacteria never excludes the presence of bacteria''' |
| ***#* '''Contamination can be considered if numerous squamous epithelial cells''' (indicative of preputial, vaginal, or urethral contaminants) '''are present'''
| | ** '''Causes of false-positive UA and culture:''' |
| ***#** The possibility of contamination increases as the reliability of the collection technique decreases from suprapubic aspiration to catheterization to voided specimens
| | **# '''Contamination of an abacteriuric specimen during collection''' |
| ** '''Pyuria'''
| | **#* '''Contamination can be considered if numerous squamous epithelial cells''' (indicative of preputial, vaginal, or urethral contaminants) '''are present''' |
| *** '''Definition of pyuria:''' presence of white blood cells in the urine, '''generally indicative of infection and/or an inflammatory response''' of the urothelium to the bacterium, stones, or other indwelling foreign body.
| | **#** The possibility of contamination increases as the reliability of the collection technique decreases from suprapubic aspiration to catheterization to voided specimens |
| *** '''The absence of pyuria should cause the diagnosis of UTI to be questioned until urine culture results are available.'''
| | * '''Pyuria''' |
| *** '''Bacteriuria without pyuria is generally indicative of bacterial colonization without infection of the urinary tract.'''
| | ** '''Definition of pyuria:''' presence of white blood cells in the urine, '''generally indicative of infection and/or an inflammatory response''' of the urothelium to the bacterium, stones, or other indwelling foreign body. |
| *** '''Sterile pyuria (pyruria without bacteriuria) warrants evaluation for tuberculosis, stones, or cancer. Many other causes§'''
| | ** '''The absence of pyuria should cause the diagnosis of UTI to be questioned until urine culture results are available.''' |
| **** '''Almost any injury to the urinary tract''', from chlamydial urethritis to glomerulonephritis and interstitial cystitis, '''can elicit large numbers of fresh polymorphonuclear leukocytes'''
| | ** '''Bacteriuria without pyuria is generally indicative of bacterial colonization without infection of the urinary tract.''' |
| *** '''Tests for detecting pyuria by determining leukocyte esterase activity have been developed'''
| | ** '''Sterile pyuria (pyruria without bacteriuria) warrants evaluation for tuberculosis, stones, or cancer. Many other causes§''' |
| ** '''Nitrites'''
| | *** '''Almost any injury to the urinary tract''', from chlamydial urethritis to glomerulonephritis and interstitial cystitis, '''can elicit large numbers of fresh polymorphonuclear leukocytes''' |
| *** '''Bacteria may convert urinary nitrates into nitrites and this may be used as evidence of UTI.'''
| | ** '''Tests for detecting pyuria by determining leukocyte esterase activity have been developed''' |
| **** '''Gram-negative bacteria of the Enterobacteriaceae family (Escherichia coli, Klebsiella, Proteus, Enterobacter, Serratia, or Citrobacter) commonly convert nitrates to nitrites, while Gram-positive species (enterococcus, staphylococcus) generally do not.'''
| | * '''Nitrites''' |
| ***** '''One very important gram-negative exception is Pseudomonas, which does not contain the enzymatic machinery to convert nitrates to nitrites'''
| | ** '''Bacteria may convert urinary nitrates into nitrites and this may be used as evidence of UTI.''' |
| ** Hematuria
| | *** '''Gram-negative bacteria of the Enterobacteriaceae family (Escherichia coli, Klebsiella, Proteus, Enterobacter, Serratia, or Citrobacter) commonly convert nitrates to nitrites, while Gram-positive species (enterococcus, staphylococcus) generally do not.''' |
| *** Indicator of an inflammatory response
| | **** '''One very important gram-negative exception is Pseudomonas, which does not contain the enzymatic machinery to convert nitrates to nitrites''' |
| *** Microscopic hematuria is found in 40-60% of cases of cystitis and is uncommon in other dysuric syndromes
| | * Hematuria |
| * '''Urine culture'''
| | ** Indicator of an inflammatory response |
| ** Techniques available (2): direct surface plating and dip slides
| | ** Microscopic hematuria is found in 40-60% of cases of cystitis and is uncommon in other dysuric syndromes |
| ** '''Urine must be refrigerated immediately on collection and should be cultured within 24 hours of refrigeration.'''
| | |
| ** '''A cut-off of ≥105/mL has been proposed to define significant bacteruria [from a midstream specimen]'''
| | ==== Urine culture ==== |
| *** '''However, 20-40% of women with symptomatic UTIs present with bacteria counts of 102-104 cfu/mL of urine; therefore, in dysuric patients, an appropriate threshold value for defining significant bacteriuria is 102 cfu/mL of a known pathogen.'''
| | * Techniques available (2): direct surface plating and dip slides |
| *** The ≥105 cut-off may also lead to overdiagnosis in patients with contaminated urine.
| | * '''Urine must be refrigerated immediately on collection and should be cultured within 24 hours of refrigeration.''' |
| * Localization
| | * '''A cut-off of ≥105/mL has been proposed to define significant bacteruria [from a midstream specimen]''' |
| ** Kidney
| | ** '''However, 20-40% of women with symptomatic UTIs present with bacteria counts of 102-104 cfu/mL of urine; therefore, in dysuric patients, an appropriate threshold value for defining significant bacteriuria is 102 cfu/mL of a known pathogen.''' |
| *** Fever and flank pain are common in pyelonephritis, but can also occur in infections localized to the bladder
| | ** The ≥105 cut-off may also lead to overdiagnosis in patients with contaminated urine. |
| *** Ureteral catherization allows separation of bacterial persistence into upper and lower urinary tracts and also separation of laterality of kidney infection.
| | |
| | ==== Localization ==== |
| | * Kidney |
| | ** Fever and flank pain are common in pyelonephritis, but can also occur in infections localized to the bladder |
| | ** Ureteral catherization allows separation of bacterial persistence into upper and lower urinary tracts and also separation of laterality of kidney infection. |
|
| |
|
| === Imaging === | | === Imaging === |
| Line 272: |
Line 269: |
| *# '''Unusual infecting organisms, such as tuberculosis, fungus, or urea-splitting organisms (e.g., Proteus, Pseudomonas, Klebsiella, Staphylococcus, and Mycoplasma)''' | | *# '''Unusual infecting organisms, such as tuberculosis, fungus, or urea-splitting organisms (e.g., Proteus, Pseudomonas, Klebsiella, Staphylococcus, and Mycoplasma)''' |
| * '''Options: ultrasound, CT/MRI, VUCG (to assess for vesicoureteral reflux), and radionuclide studies''' | | * '''Options: ultrasound, CT/MRI, VUCG (to assess for vesicoureteral reflux), and radionuclide studies''' |
| == Management == | | == Bladder Infections == |
|
| |
|
| === Antibiotics === | | === Risk Factors === |
| * Factors to consider when selecting
| | * '''Reduced urine flow''' |
| ** Empirical therapy include whether the infection is complicated or uncomplicated, spectrum of activity of the drug against the probable pathogen, history of hypersensitivity, potential side effects, and cost
| | ** '''Outflow obstruction (BPH, prostate cancer, urethral stricture, foreign body (calculus)''') |
| ** Duration of therapy include the extent and duration of tissue invasion, bacterial concentration in urine, achievable urine concentration of the antimicrobial agent, and risk factors that impair the host and natural defense mechanisms
| | ** '''Neurogenic bladder''' |
| * '''Principles of antibiotic therapy'''
| | ** '''Inadequate fluid uptake''' (dehydration) |
| ** '''Antimicrobials are excreted in a concentrated form compared to their serum concentrations.'''
| | * '''Promote colonization''' |
| *** Resolution of infection is associated with the susceptibility of the bacteria to the concentration of the antimicrobial agent in the urine.
| | ** '''Sexual activity'''—increased inoculation |
| *** '''Susceptibility testing is based on concentrations obtained in the serum'''
| | ** '''Spermicide'''—increased binding |
| **** '''Some antibiotics do not achieve adequate serum concentration levels to be considered effective for bacteriemia, but could be effective at its achievable urinary concentration.'''
| | ** '''Estrogen depletion'''—increased binding |
| ***** For example, E. Coli susceptible testing may show resistance to amoxicillin, even though amoxicillin may actually be effective for urinary E. Coli because of the high concentrations achieved.
| | ** '''Antibiotic use'''—decreased indigenous flora |
| **** '''The concentration of the antimicrobial agent achieved in blood is not important in treatment of uncomplicated UTIs. However, blood levels are critical in patients with bacteremia and febrile urinary infections consistent with parenchymal involvement of the kidney and prostate'''
| | * '''Facilitate ascent''' |
| *** '''In patients with renal insufficiency, dosage modifications are necessary for antibiotics that are renally cleared, including:'''
| | ** '''Catheterization''' |
| ***# '''Ciprofloxacin'''
| | ** '''Urinary incontinence''' |
| ***# '''Nitrofurantoin'''
| | ** '''Fecal incontinence''' |
| ***# '''Trimethoprim/sulfamethoxazole'''
| | ** Residual urine with ischemia of bladder wall |
| ***# '''Trimethoprim'''
| |
| ***# '''Amoxicillin'''
| |
| ***# '''Piperacillin/tazobactam'''
| |
| ***# '''Cephalexin'''
| |
| ***# '''Cefuroxime'''
| |
| ***# '''Levofloxacin'''
| |
| ***# '''Clarithromycin'''
| |
| ***# '''Tetracyclin'''
| |
| **** '''In renal failure, the kidneys may not be able to concentrate an antimicrobial agent in the urine; hence, difficulty in eradicating bacteria may occur.'''
| |
| *** Urinary tract obstruction may reduce concentration of antimicrobial agents within the urine.
| |
| ** '''Bacterial resistance'''
| |
| *** '''Mechanisms (3)'''
| |
| ***# '''Inherited chromosomal-mediated''' | |
| ***# '''Acquired chromosomal''' | |
| ***# '''Extrachromosomal (plasmid)-mediated'''
| |
| **** '''Inherited chromosomal resistance'''
| |
| ***** Exists in a bacterial species because of the absence of the proper mechanism on which the antimicrobial agent can act. For example, '''Proteus and Pseudomonas species are always resistant to nitrofurantoin''' | |
| **** '''Acquired chromosomal resistance'''
| |
| ***** '''Caused by exposure of an organism to antimicrobial agents'''
| |
| **** '''Extrachromosomal-mediated resistance'''
| |
| ***** '''May be acquired and transferable via plasmids, which contain the genetic material for the resistance'''
| |
| ****** '''This so-called R-factor resistance occurs in the bowel flora and is much more common than selection of pre-existing mutants in the urinary tract.'''
| |
| ****** '''All antibiotic classes are capable of causing plasmid-mediated resistance. However, for the fluoroquinolones, resistance is rarely transmitted by plasmids, and nitrofurantoin plasmid-mediated resistance has not been reported.'''
| |
| ******* '''Clinical implication: because the bowel flora is the major reservoir for bacteria that ultimately colonize the urinary tract, infections that occur after antibiotic therapy and that can cause plasmid-mediated resistance are commonly caused by organisms with multidrug resistance. However, resistant E. coli in the bowel flora that infect the urinary tract almost always show susceptibility to nitrofurantoin or to the quinolones.'''
| |
| *** '''Antibiotic resistance is also influenced by the duration and amount of antibiotic agent used.''' | |
|
| |
|
| === Mechanism of action of common antimicrobials used in the treatment of urinary tract infections === | | === Uncomplicated Acute Bacterial Cystitis === |
| {| class="wikitable"
| |
| |'''Drug or drug class'''
| |
| |'''Mechanism of action'''
| |
| |'''Mechanisms of drug resistance'''
| |
| |-
| |
| |'''β-Lactams (penicillins, cephalosporins, carbapenems, aztreonam)'''
| |
| |'''Inhibits bacterial cell wall synthesis'''
| |
| |Production of β-lactamase
| |
|
| |
|
| Alteration in binding site of penicillin-binding protein
| | ==== Definition ==== |
|
| |
|
| Changes in cell wall porin size (decreased penetration)
| | * '''<span style="color:#ff0000">Diagnosis of acute bacterial cystitis requires (2):''' |
| |-
| | *# '''<span style="color:#ff0000">Laboratory confirmation of significant bacteriuria AND''' |
| |'''Vancomycin'''
| | *# '''<span style="color:#ff0000">Acute-onset symptoms (lower urinary tract symptoms)''' |
| |'''Inhibits bacterial cell wall synthesis'''
| |
| |Enzymatic alteration of peptidoglycan at different point
| |
|
| |
|
| than target
| | ==== Pathophysiology ==== |
| |-
| | * '''Pathogens''' |
| |'''Fosfomycin'''
| | ** '''<span style="color:#ff0000">E. coli is the causative organism in 75-90% of cases of acute cystitis in young women.''' |
| |'''Inhibits bacterial cell wall synthesis'''
| | ** '''<span style="color:#ff0000">S. saprophyticus, a commensal organism of the skin, is the second most common cause of acute cystitis in young women, accounting for 10-20% of these infections. Other organisms less commonly involved include Klebsiella and Proteus species and Enterococcus.''' |
| |Novel amino acid substitutions or the loss of function of transporters
| | ** '''<span style="color:#ff0000">In men, E. coli and other Enterobacteriaceae are the most commonly identified organisms.''' |
| |-
| | * '''Sexual transmission of uropathogens has been suggested''' by demonstrating identical E. coli in the bowel and urinary flora of sex partners |
| |'''Aminoglycosides (gentamicin, tobramycin, etc.)'''
| |
| |'''Inhibits ribosomal protein synthesis'''
| |
| |Downregulation of drug uptake into bacteria
| |
|
| |
|
| Bacterial production of aminoglycoside-modifying enzymes
| | ==== Diagnosis and Evaluation ==== |
| |-
| |
| |'''Clindamycin, macrolides (erythromycin, clarithromycin, azithromycin)'''
| |
| |'''Inhibits ribosomal protein synthesis'''
| |
| |
| |
| |-
| |
| |'''Quinolones (ciprofloxacin, levofloxacin, etc.)'''
| |
| |'''Inhibits bacterial DNA gyrase'''
| |
| |Mutation in DNA gyrase-binding site
| |
|
| |
|
| Changes in cell wall porin size (decreased penetration)
| | * '''<span style="color:#ff0000">Differential Diagnosis (11):</span>''' |
| | #'''<span style="color:#ff0000">Interstitial cystitis/bladder pain syndrome</span>''' |
| | #'''<span style="color:#ff0000">Overactive Bladder</span>''' |
| | #'''<span style="color:#ff0000">Urinary calculi</span>''' |
| | #'''<span style="color:#ff0000">Infectious bacterial or fungal vaginitis</span>''' |
| | #'''<span style="color:#ff0000">Urethral infections caused by sexually transmitted pathogens</span>''' |
| | #'''<span style="color:#ff0000">Vulvar dermatitis</span>''' |
| | #'''<span style="color:#ff0000">Non-infectious vulvovestibulitis</span>''' |
| | #'''<span style="color:#ff0000">Vulvodynia</span>''' |
| | #'''<span style="color:#ff0000">Hypertonic pelvic floor muscle dysfunction</span>''' |
| | #'''<span style="color:#ff0000">Genitourinary syndrome of menopause</span>''' |
| | # '''<span style="color:#ff0000">CIS of the bladder</span>''' (less commonly) |
| | ===== History and Physical Exam ===== |
| | * '''<span style="color:#ff0000">History''' |
| | ** '''<span style="color:#ff0000">Signs and Symptoms''' |
| | ***Variable presenting symptoms of cystitis |
| | ***'''<span style="color:#ff0000">Usually include dysuria, frequency, and/or urgency''' |
| | ***'''<span style="color:#ff0000">Suprapubic pain, incontinence, hematuria, or foul-smelling urine may develop''' |
| | *** '''In older adults, the symptoms of UTI may be less clear''' |
| | **** Given the subjective nature of these symptoms, '''careful evaluation of their chronicity becomes an important consideration.''' |
| | ***** Older females frequently have nonspecific symptoms that may be perceived as a UTI, such as dysuria, cloudy urine, vaginal dryness, vaginal/perineal burning, bladder or pelvic discomfort, urinary frequency and urgency, or urinary incontinence, but these tend to be more chronic |
| | ***** '''Acute-onset dysuria, particularly when associated with new or worsening storage symptoms, remains a reliable diagnostic criterion in older females''' living both in the community and in long-term care facilities. |
| | *** '''By definition, acute cystitis is a superficial infection of the bladder mucosa, so <span style="color:#ff0000">fever, chills, and other signs of dissemination are not present.''' |
| | * '''<span style="color:#ff0000">Physical Exam''' |
| | ** '''Most have no diagnostic physical findings''' |
| | **'''<span style="color:#ff0000">Abdomen''' |
| | ***Some patients may experience suprapubic tenderness |
| | ** '''<span style="color:#ff0000">Pelvis''' |
| | ***'''<span style="color:#ff0000">Prolapse, urethral tenderness, urethral diverticulum''' |
| | ***'''<span style="color:#ff0000">Skene’s gland cyst, or other enlarged or infected vulvar or vaginal cysts''' |
| | ***'''<span style="color:#ff0000">Any other infectious and inflammatory conditions (vaginitis, vulvar dermatitis, herpes, and vaginal atrophy</span>''' (genitourinary syndrome of menopause) |
| | ***'''Pelvic floor musculature''' for tone, tenderness, and trigger points |
|
| |
|
| Active efflux
| | ===== Laboratory ===== |
| |-
| | * '''<span style="color:#ff0000">Urinalysis''' |
| |'''Trimethoprim-sulfamethoxazole'''
| | ** '''<span style="color:#ff0000">The presumptive laboratory diagnosis of acute cystitis is based on microscopic urinalysis, which indicates microscopic pyuria, bacteriuria, and occasionally hematuria.''' |
| |'''Competitive inhibition of dihydrofolate reductase'''
| | * '''<span style="color:#ff0000">Urine culture''' |
| |Draws folate from environment (enterococci)
| | ** '''<span style="color:#ff0000">Remains the definitive test''' |
| |-
| | ***'''Clinical judgment is needed to determine when a culture result represents clinically significant bacteriuria considering the patient presentation, urine collection method, and the presence of other suggestive factors such as pyuria.''' |
| |'''Nitrofurantoin'''
| | ****'''<span style="color:#ff0000">The definition for clinically significant bacteriuria of >10<sup>5</sup> colony forming units (CFU)/mL represents an arbitrary cut-off.</span>''' |
| |'''Inhibits several bacterial enzyme''' '''systems'''
| | ****'''Although > 10<sup>5</sup> CFU/mL for bacterial growth on midstream voided urine may help distinguish bladder bacteriuria from contamination in asymptomatic, pre-menopausal women, <span style="color:#ff0000">a lower 10<sup>2</sup> CFU/mL threshold may be appropriate in symptomatic individuals</span>''' |
| |Not fully elucidated—develops slowly with prolonged exposure
| | **'''Obtain repeat urine studies when an initial urine specimen is suspect for contamination, with consideration for obtaining a catheterized specimen''' |
| |}
| | ***'''Urine culture contamination should be suspected when (3):''' |
| | ***#'''Mixed cultures containing ≥2 organisms''' |
| | ***#'''Low quantities (<103 CFU/mL) of a pathogenic organism in an asymptomatic patient''' |
| | ***#'''Specimen exhibits growth of normal vaginal flora (e.g. Lactobacilli, Group B Streptococci, Corynebacteria, or non-saprophyticus coagulase-negative Staphylococci)''' |
| | ***#*'''Growth of these organisms are thought to be contaminant and generally do not require treatment''' |
| | ***'''Concomitant urinalysis can also be useful (presence of epithelial cells or mucus on microscopic urinalysis may also suggest contaminant).''' |
| | ***'''When there is high suspicion for contamination, consider obtaining a catheterized specimen for further evaluation prior to treatment.''' |
| | ***'''Urine specimens should not sit at room temperature for > 30 minutes to facilitate lab diagnosis of UTI.''' |
|
| |
|
| * '''Reliable coverage of antibiotics used in the treatment of UTIs from commonly encountered pathogens''' | | ==== Management ==== |
| | * '''<span style="color:#ff0000">Antibiotic regimen''' |
| | **'''<span style="color:#ff0000">Preferred (3)''' |
| | **# '''<span style="color:#ff0000">Fosfomycin 3 gram PO x single dose''' |
| | **# '''<span style="color:#ff0000">Nitrofurantoin 100 mg PO BID x 5 days''' |
| | **# '''<span style="color:#ff0000">Trimethoprim-sulfamethoxazole DS 1 pill PO BID x 3 days''' |
| | **'''<span style="color:#ff0000">Alternative when bacteria are resistant to the preferred antibiotics: ciprofloxacin, 250 mg BID x 3 days''' |
| | ***'''<span style="color:#ff0000">Fluoroquinolone antibiotics should not be the first line treatment of uncomplicated cystitis.''' |
| | *'''≈90% of women are asymptomatic within 72 hours after initiating antibiotics''' |
| | * '''A follow-up visit or culture is not required in young women who are asymptomatic after therapy.''' |
| | ** A follow-up visit, urinalysis, and urine culture are recommended in older women or those with potential risk factors and in men. |
| | ** '''Urologic evaluation is unnecessary in women and is usually unnecessary in young men who respond to therapy. However, UTIs in most men should be considered complicated until proven otherwise.''' |
| | * '''If a patient does not respond to therapy, appropriate microbiologic and urologic evaluations should be undertaken for the causes of unresolved and complicated UTIs.''' |
|
| |
|
| {| class="wikitable"
| | === Complicated Cystitis in Females === |
| |'''Antibiotic agent or class'''
| | * '''Complicated UTIs requires either (5):''' |
| |'''Gram-positive pathogens'''
| | *# '''Anatomic or functional abnormality of urinary tract (outlet obstruction, stone disease, diverticulum, neurogenic bladder, VUR etc.)''' |
| |'''Gram-negative pathogens'''
| | *# '''Urinary instrumentation or foreign bodies in the urinary tract (i.e. catheters, stents, nephrostomy tubes)''' |
| |-
| | *# '''Systemic disease (renal insufficiency, diabetes, immunodeficiency, organ transplantation)''' |
| |'''Penicillins'''
| | *# '''Pregnancy''' |
| |
| | *# '''Multi–drug resistant bacteria''' |
| |
| | * '''Diagnosis and Evaluation''' |
| |-
| | **'''Labs''' |
| |'''Broad-spectrum penicillins'''
| | ***'''Urine cultures''' |
| |
| | ****'''Mandatory to identify the bacteria and its antibiotic susceptibility''' |
| |
| | ****Prior cultures should be reviewed and empiric selection of those results |
| |-
| | * '''Management''' |
| | ''' Amoxicillin or ampicillin'''
| | ** '''Patients who are candidates for outpatient therapy:''' |
| |'''''Streptococcus'''''
| | *** '''Oral ciprofloxacin 500 mg BID x 7 days''' |
| | *** Once daily oral fluoroquinolone (ciprofloxacin 1000 mg ER x 7 days or levofloxacin 750 mg x 5 days) |
| | *** Oral TMP-SMX DS BID x 14 days (not for Enterococcus or Pseudomonas) |
|
| |
|
| '''Enterococci'''
| | === Cystitis in Males === |
| |'''''Proteus mirabilis'''''
| |
| |-
| |
| | ''' Amoxicillin with clavulanate'''
| |
| |'''''Streptococcus'''''
| |
|
| |
|
| '''Enterococci''' | | * '''Diagnosis and Evaluation''' |
| |'''''Proteus, Klebsiella'''''
| | ** '''Labs''' |
| |-
| | *** '''Urine cultures''' |
| | ''' Ampicillin with sublactam'''
| | **** '''Mandatory to identify the bacteria and its antibiotic susceptibility''' |
| |'''''Staphylococcus'' (not MRSA)'''
| | ** '''Imaging''' |
| | *** '''Complicated UTI in an older male warrants urologic evaluation such as CT urogram and cystoscopy due to the high incidence of associated urologic abnormalities such as obstruction from either urethral or ureteral strictures, tumor, or stones''' |
| | **** ≈50% of males with UTIs have a significant abnormality |
| | *** '''Uncomplicated cystitis in a young sexually active male may not require investigation beyond a follow-up urine culture.''' |
|
| |
|
| '''Enterococci''' | | *'''Management''' |
| |'''''Proteus, Klebsiella'''''
| | ** '''Preferred:''' |
| | *** '''Trimethoprim/sulfamethoxazole DS (160/800 mg) 1 pill PO BID''' |
| | *** Levofloxacin 500 mg po daily |
| | *** Ciprofloxacin 500 mg po BID |
| | *** Ciprofloxacin ER 1000 mg po daily |
| | ** '''Treatment is generally for 7-14 days, optimal duration is not known''' |
| | === Unresolved UTIs === |
| | * Indicates that initial therapy has been inadequate in eliminating symptoms and/or bacterial growth in the urinary tract. |
| | * '''If the symptoms of UTI do not resolve by the end of treatment or if symptoms recur shortly after therapy, urinalysis and urine culture with susceptibility testing should be obtained.''' |
| | ** If the patient’s symptoms are significant, empirical therapy with a fluoroquinolone is appropriate, pending results of the culture and susceptibility testing. |
| | * '''Causes of Unresolved Bacteriuria, in Descending Order of Importance''' |
| | *# '''Pre-existing bacterial resistance''' to the drug selected for treatment |
| | *# '''Development of resistance from initially susceptible bacteria''' |
| | *# '''Bacteriuria caused by 2 different bacterial species with mutually exclusive susceptibilities''' |
| | *# '''Rapid re-infection with a new, resistant species''' during initial therapy for the original susceptible organism |
| | *# '''Renal failure''' (inability to deliver an adequate concentration of antibiotics into the urinary tract) |
| | *# '''Papillary necrosis from analgesic abuse''' (defects in the medullary concentrating ability dilutes the antibiotic) |
| | *# '''Staghorn calculi''' (large mass of bacteria) |
| | *# '''Self-inflicted infections or deception in taking antimicrobial drugs''' (a variant of Munchausen syndrome) |
| | * '''The first 4 causes that are associated with resistant bacteria require no further evaluation. However, if re-culture shows that the bacteria are sensitive to the antimicrobial agent the patient is taking, renal function and radiologic evaluation should be performed to identify renal or urinary tract abnormalities.''' |
| | * '''Management''' |
| | ** '''Initial empirical antimicrobial selection for unresolved UTI should be based on the assumption that the bacteria are resistant and an''' antibiotic different from the original agent should be selected. |
| | *** Fluoroquinolones offer excellent coverage in most cases and should be given for 7 days. |
| | ** When the bacterial susceptibilities are available, adjustments can be made if necessary. |
| | ** Urine cultures should be performed during and 7 days after therapy to ensure microbiologic efficacy. |
|
| |
|
| '''''H. influenzae''''' | | === Recurrent UTI === |
| |-
| | * '''See [[AUA & CUA Recurrent UTI (2019)|AUA/CUA Guideline Notes]]''' |
| |'''Anti-staphylococcal penicillins (methicillin, nafcillin, oxacillin, cloxacillin and dicloxacillin)'''
| | * '''Recurrent UTIs are caused by either re-emergence of bacteria from a site within the urinary tract (bacterial persistence) or new infections from bacteria outside the urinary tract (re-infection).''' |
| |'''''Streptococcus'''''
| | ** Clinical identification of these two types of recurrence is based on the pattern of recurrent infections. Bacterial persistence must be caused by the same organism in each instance, and infections that occur at close intervals are characteristic. Conversely, reinfections usually occur at varying and sometimes long intervals and often are caused by different species. |
| | ** The distinction between bacterial persistence and reinfection is important in management because '''patients with bacterial persistence can usually be cured of the recurrent infections by identification and surgical removal or correction of the focus of infection. Conversely, women with reinfection usually do not have an alterable urologic abnormality and require long-term medical management.''' |
| | ** '''The probability of recurrent UTIs''' |
| | *** '''Increases with the number of previous infections''' |
| | *** '''Decreases in inverse proportion to the elapsed time between the first and the second infections''' |
| | * '''Bacterial persistence''' |
| | ** Once the bacteriuria has resolved (i.e., the urine shows no growth for several days after the antimicrobial agent has been stopped), recurrence with the same organism can arise from a site within the urinary tract that was excluded from the high urine concentrations of the antimicrobial agent. |
| | ** '''Correctable urologic abnormalities that cause bacteria to persist within the urinary tract between episodes of recurrent bacteriuria:''' |
| | **# '''Infection stones''' |
| | **# '''Chronic bacterial prostatitis''' |
| | **# '''Foreign bodies''' |
| | **# '''Urethral diverticula and infected periurethral glands''' |
| | **# '''Unilateral infected atrophic kidney''' |
| | **# '''Ureteral duplication and ectopic ureters''' |
| | **# '''Unilateral medullary sponge kidney''' |
| | **# '''Non-refluxing, normal-appearing, infected ureteral stumps after nephrectomy''' |
| | **# '''Infected urachal cysts''' |
| | **# '''Infected communicating cysts of the renal calyces''' |
| | **# '''Papillary necrosis''' |
| | **# '''Perivesical abscess with fistula to bladder''' |
| | * '''Re-infections''' |
| | ** Patients with recurrent infections caused by different species or occurring at long intervals almost invariably have reinfections. These reinfections most often occur in females and are associated with ascending colonization from the bowel flora. Reinfections in men are often associated with a urinary tract abnormality. |
| | ** '''The possibility of a vesicoenteric or vesicovaginal fistula should be considered when the patient has any history of pneumaturia, fecaluria, diverticulitis, obstipation, previous pelvic surgery, or radiation therapy.''' |
| | ** Evaluation for presumed reinfections must be individualized. |
|
| |
|
| '''''Staphylococcus'' (not MRSA)''' | | === Asymptomatic Bacteriuria === |
| | *'''<span style="color:#ff0000">Definition: bacteriuria of any magnitude without symptoms</span>''' |
| | *'''<span style="color:#ff0000">Management</span>''' |
| | **'''<span style="color:#ff0000">DO NOT routinely treat or screen for asymptomatic bacteriuria</span>''' |
| | ***No evidence that treatment of asymptomatic bacteriuria improves outcomes |
| | **'''<span style="color:#ff0000">Indications for screening/treatment of asymptomatic bacteriuria (2):</span>'''**#'''<span style="color:#ff0000">Pregnant females</span>''' |
| | **#'''<span style="color:#ff0000">Patients undergoing elective urologic surgery</span>''' |
| | **#'''Neonatal candiduria, not technically bacteruria but should be treated even if asymptomatic''' |
| | **#*'''Treat candiduria in neonates with parenteral fluconazole''' |
| | ** '''Asymptomatic bacteriuria and struvite stones''' |
| | ***'''Routine treatment of urease-producing bacteriuria in the absence of UTI symptoms or documented urinary tract stones is not recommended''' |
| | ***There is no clear evidence that identification and treatment of asymptomatic bacteriuria caused by urease-producing organisms (recall that urease-producing organisms include proteus, pseudomonas, klebsiella, mycoplasma, and staphylococcus) prevents struvite stone formation. However, '''in certain patients with recurrent struvite stones, screening for and treating urease-producing bacteriuria may be indicated if other measures have not been able to prevent stone formation.''' |
|
| |
|
| '''Not enterococci'''
| | === Pyocystis === |
| |'''None'''
| | * '''Occurs in ≈20% of patients who undergo supravesical diversion''' |
| |-
| | * Patients typically have a malodorous discharge and may develop sepsis |
| |'''Anti-pseudomonal penicillins (piperacillin, ticaracillin)'''
| | * '''Management''' |
| |'''''Streptococcus'''''
| | ** '''Conservative: routine bladder irrigations''' |
| | | ** '''If conservative measures fail, vaginal vesicostomy (creation of a large vesico-vaginal fistula), is an effective method of preventing pyocystis in females.''' |
| '''Enterococci'''
| |
| |'''Most, including ''Pseudomonas'''''
| |
| |-
| |
| |'''Cephalosporins'''
| |
| |'''Not enterococci'''
| |
| |
| |
| |-
| |
| |'''First-generation cephalosporins (e.g. cefazolin, cephalexin)'''
| |
| |'''''Streptococcus'''''
| |
| | |
| '''''Staphylococcus'' (not MRSA)'''
| |
| | |
| '''Enterococci''' (CW12 p442)
| |
| |'''''E. coli, Proteus, Klebsiella'''''
| |
| |-
| |
| |'''Second-generation cephalosporins (cefamandole, cefuroxime, cefaclor)'''
| |
| |'''''Streptococcus'''''
| |
| | |
| '''''Staphylococcus'' (not MRSA)'''
| |
| |'''''E. coli, Proteus, Klebsiella'''''
| |
| | |
| '''''H. influenzae'''''
| |
| |-
| |
| |'''Second-generation cephalosporins (cefoxitin, cefotetan)'''
| |
| |'''''Streptococcus'''''
| |
| |'''''E. coli, Proteus''''' (including indole-positive), '''''Klebsiella'''''
| |
| | |
| '''''H. influenzae'''''
| |
| |-
| |
| |'''3rd-generation cephalosporins (ceftriaxone)'''
| |
| |'''''Streptococcus'''''
| |
| | |
| '''''Staphylococcus'' (not MRSA)'''
| |
| |'''Most, excluding ''P. aeruginosa'''''
| |
| |-
| |
| |'''3rd-generation cephalosporins (ceftazidime)'''
| |
| |'''''Streptococcus'''''
| |
| |'''Most, including ''P. aeruginosa'''''
| |
| |-
| |
| |Aztreonam
| |
| |None
| |
| |Most, including ''P. aeruginosa''
| |
| |-
| |
| |'''Aminoglycosides (gentamicin, tobramycin)'''
| |
| |'''''Staphylococcus'' (urine)'''
| |
| |'''Most, including ''P. aeruginosa'''''
| |
| |-
| |
| |'''Fluoroquinolones (e.g. ciprofloxacin)'''
| |
| |'''''Streptococcus''''' ''(depending which fluoroquinolone)''
| |
| | |
| '''Not enterococci'''
| |
| |'''Most, including ''P. aeruginosa'''''
| |
| |-
| |
| |'''Nitrofurantoin'''
| |
| |'''''Staphylococcus'' (not MRSA)'''
| |
| | |
| '''Enterococci'''
| |
| |'''Many Enterobacteriaceae (not ''Klebsiella, Proteus)'''''
| |
| | |
| '''''Does not cover P. aeruginosa, Providencia, Serratia, Acinetobacter'''''
| |
| |-
| |
| |'''Fosfomycin'''
| |
| |'''Enterococci'''
| |
| | |
| Variable activity against s. saprophyticus
| |
| |'''Most Enterobacteriaceae''' (variable activity against Klebsiella and Enterobacter)
| |
| | |
| '''Does not cover ''P. aeruginosa'')'''
| |
| |-
| |
| |Pivmecillinam
| |
| |None
| |
| |Most, excluding ''P. aeruginosa''
| |
| |-
| |
| |'''Trimethoprim-sulfamethoxazole'''
| |
| |'''''Streptococcus'''''
| |
| | |
| '''''Staphylococcus'''''
| |
| | |
| '''Not enterococci'''
| |
| |'''Most Enterobacteriaceae'''
| |
| | |
| '''Does not cover ''P. aeruginosa'''''
| |
| |-
| |
| |'''Vancomycin''' (can be used in penicillin allergy for gram-positive coverage)
| |
| |'''All, including MRSA'''
| |
| |'''None'''
| |
| |-
| |
| |'''Clindamycin''' (can be used in penicillin allergy for gram-positive coverage)
| |
| |'''''Streptococcus'''''
| |
| | |
| '''''Staphylococcus'''''
| |
| | |
| '''''NOT Enterococci'''''
| |
| |'''Anaerobes'''
| |
| | |
| '''NOT Enterobacteriaceae'''
| |
| |-
| |
| |'''Macrolides (clarithromycin, erythromycin, azithromycin)'''
| |
| |
| |
| |
| |
| |-
| |
| |'''Carbapenams (ertapenem, imipenem, meropenem)'''
| |
| |
| |
| |'''Ertapenam has weak pseudomonas coverage compared to meropenam'''
| |
| |}
| |
| | |
| * '''Common adverse reactions, precautions, and contraindications for antibiotics used in treatment of UTIs'''
| |
| | |
| {| class="wikitable"
| |
| |'''Drug or drug class'''
| |
| |'''Common adverse reactions'''
| |
| |'''Precautions and contraindications'''
| |
| |-
| |
| |'''Amoxicillin or ampicillin'''
| |
| | |
| '''Ampicillin with sulbactam'''
| |
| |
| |
| ** '''Hypersensitivity (immediate or delayed)'''
| |
| ** '''Diarrhea (especially with ampicillin), GI upset'''
| |
| ** '''Antimicrobial-associated pseudomembranous colitis'''
| |
| ** '''Maculopapular rash (not hypersensitivity)'''
| |
| ** '''Decreased platelet aggregation'''
| |
| |
| |
| ** '''Increased risk of rash with concomitant viral disease,allopurinol therapy'''
| |
| |-
| |
| |'''Amoxicillin with clavulanic acid'''
| |
| |
| |
| ** '''Increased diarrhea, GI upset'''
| |
| |
| |
| |-
| |
| |'''Anti-staphylococcal penicillins'''
| |
| |
| |
| ** '''Same as with amoxicillin/ampicillin'''
| |
| ** '''GI upset (with oral agents)'''
| |
| ** '''Acute interstitial nephritis (especially withmethicillin)'''
| |
| |
| |
| |-
| |
| |'''Anti-pseudomonal penicillins'''
| |
| |
| |
| ** '''Same as with amoxicillin/ampicillin'''
| |
| ** '''Hypernatremia (these drugs are given as sodium salt; especially carbenicillin, ticarcillin)'''
| |
| ** '''Local injection site reactions'''
| |
| |
| |
| ** '''Use with caution in patients very sensitive to sodiumloading'''
| |
| |-
| |
| |'''Cephalosporins'''
| |
| |
| |
| ** '''Hypersensitivity (less than with penicillins)'''
| |
| ** '''GI upset (with oral agents)'''
| |
| ** '''Antimicrobial-associated pseudomembranous colitis'''
| |
| ** '''Local injection site reactions'''
| |
| ** '''Positive Coombs test'''
| |
| ** '''Decreased platelet aggregation (especially''' '''with cefotetan, cefamandole, cefoperazone)'''
| |
| |
| |
| ** '''Avoid in patients with immediate hypersensitivity to penicillins; may use with caution in patients with delayed hypersensitivity reactions'''
| |
| ** '''Ceftriaxone is contraindicated in neonates'''
| |
| |-
| |
| |Aztreonam
| |
| |
| |
| ** Hypersensitivity (less than with penicillins)
| |
| |
| |
| ** <1% incidence of cross-reactivity in penicillin- or cephalosporin-allergic patients; may be used with caution in these patients
| |
| |-
| |
| |'''Aminoglycosides'''
| |
| | |
| '''(gentamicin, tobramycin)'''
| |
| |
| |
| ** '''Ototoxicity: vestibular and auditorycomponents'''
| |
| ** '''Nephrotoxicity: nonoliguric azotemia'''
| |
| ** '''Neurotoxicity: neuromuscular blockade with high levels'''
| |
| |
| |
| ** '''Avoid in pregnant patients, except in pyelonephritis.'''
| |
| ** '''Avoid, if possible, in patients with severely impaired renal function, diabetes, or hepatic failure'''
| |
| ** '''Use with caution in myasthenia gravis patients (owing to potential for neuromuscular blockade)'''
| |
| ** '''Use with caution with other potentially ototoxic andnephrotoxic drugs.'''
| |
| |-
| |
| |'''Fluoroquinolones'''
| |
| |
| |
| ** '''<span style="color:#ff0000">Tendon rupture</span>''' (incidence 20 cases/100,000), should be discontinued at the first sign of tendon pain
| |
| ** '''<span style="color:#ff0000">Aortic rupture</span>''' (incidence 20 cases/100,000), should be discontinued at the first sign of tendon pain
| |
| ** '''<span style="color:#ff0000">QT interval prolongation;'''should be avoided in patients with known prolongation of the QT interval, patients with uncorrected hypokalemia or hypomagnesemia, and patients receiving some antiarrhythmic agents
| |
| ** '''Photosensitivity'''
| |
| ** '''Mild GI effects'''
| |
| ** '''Central nervous system effects, including''' '''dizziness, tremors, confusion, mood disorder, hallucinations, light-headedness'''
| |
| ** '''Hypoglycemia and hyperglycemia''' have been reported in patients treated concurrently with fluoroquinolones and anti-diabetic agents; '''avoid or monitor glucose levels closely in patients on anti-diabetic drugs'''
| |
| |
| |
| ** '''Avoid in children or pregnant patients due to arthropathic effects.'''
| |
| ** '''Concomitant antacid, iron, zinc, or sucralfate usedramatically decreases oral absorption'''; use another antimicrobial agent or discontinue sucralfate use while on quinolones. Space administration of quinolones from antacids, iron, or zinc products by at least 2 hr to ensure adequate absorption.
| |
| ** '''Can significantly increase theophylline plasma levels; avoid quinolones or monitor theophylline levels closely.'''
| |
| ** '''Can lower seizure threshold'''; avoid in patients with epilepsy and in patients with other risk factors (medications or illness) that may lower the seizure threshold.
| |
| ** '''Avoid in patients receiving warfarin; can enhance warfarin effects'''; closely monitor coagulation tests.
| |
| ** '''Avoid with other drugs that prolong QT interval, such as amiodarone'''
| |
| |-
| |
| |'''Fosfomycin'''
| |
| |
| |
| ** '''Headache'''
| |
| ** '''GI upset'''
| |
| ** '''Vaginitis'''
| |
| |
| |
| |-
| |
| |Pivmecillinam
| |
| |
| |
| ** Rash GI upset
| |
| |
| |
| ** Use with caution in patients with penicillin hypersensitivity
| |
| |-
| |
| |'''Nitrofurantoin'''
| |
| |
| |
| ** '''<span style="color:#ff0000">Pulmonary</span> hypersensitivity reactions can range from acute to chronic and include cough, dyspnea, fever, and interstitial changes [e.g. fibrosis].'''
| |
| ** '''<span style="color:#ff0000">Hepatoxicity'''
| |
| ** '''<span style="color:#ff0000">Peripheral neuropathy''' (especially in patients with impaired renal function, anemia, diabetes, electrolyte imbalance, vitamin B deficiency, and debilitated)
| |
| ** '''<span style="color:#ff0000">GI upset'''
| |
| ** '''<span style="color:#ff0000">Hemolysis in patients with G6PD deficiency'''
| |
| | |
| |
| |
| ** '''Avoid in patients with decreased renal function(<50 mL/min) because adequate urine concentrations will not be achieved.'''
| |
| ** '''Avoid concomitant probenecid use, which blocks renal excretion of nitrofurantoin.'''
| |
| ** '''Monitor long-term patients closely.'''
| |
| ** '''Avoid concomitant magnesium or quinolones, which are antagonistic to nitrofurantoin''' | |
| ** '''Can be given safely to patients receiving warfarin'''
| |
| ** '''See below regarding use in pregnancy'''
| |
| |-
| |
| |'''Trimethoprim-sulfamethoxazole'''
| |
| |
| |
| ** '''Hypersensitivity, rash'''
| |
| ** '''GI upset'''
| |
| ** '''Photosensitivity'''
| |
| ** '''Hematologic toxicity (AIDS patients)'''
| |
| |
| |
| ** '''Higher incidence of all adverse reactions occurs in AIDS patients and the elderly.'''
| |
| ** '''Avoid TMP-SMX in pregnancy because of early potential for teratogenicity and late potential for kernicterus'''
| |
| ** '''Avoid TMP-SMX in neonates due to risk of kernicterus from hyperbilirubinemia'''
| |
| ** '''Trimethoprim alone should be avoided in pregnancy due to risk of megaloblastic anemia'''
| |
| ** '''Trimethoprim alone can be used in neonates'''
| |
| ** '''Avoid in patients receiving warfarin; can enhance warfarin effects'''; closely monitor coagulation tests.
| |
| ** '''Avoid with other anti-arrhythmics, such as amiodarone''' | |
| |-
| |
| |'''Vancomycin'''
| |
| |
| |
| ** '''“Red-man syndrome”: flushing, fever, chills,''' '''rash, hypotension (histaminic effect)''' | |
| ** '''Nephrotoxicity and/or ototoxicity when combined with other nephrotoxic and/or ototoxic drugs''' | |
| ** '''Local injection site reactions'''
| |
| |
| |
| ** '''Use with caution with other potentially ototoxic andnephrotoxic drugs.'''
| |
| |}
| |
| | |
| * '''Aminopenicillins'''
| |
| ** Ampicillin and amoxicillin have been used often in the past for the treatment of UTIs, but the '''emergence of resistance''' in 40-60% of common urinary '''isolates has lessened the usefulness of these drugs (See Toronto antibiograms''')
| |
| ** '''The effects of ampicillin and amoxocillin on the normal bowel and vaginal flora can''' predispose patients to reinfection with resistant strains and '''often lead to candida vaginitis'''
| |
| ** '''The addition of the β-lactamase inhibitor clavulanate to amoxicillin greatly improves activity against β-lactamase–producing bacteria resistant to amoxicillin alone. However, its high cost and frequent gastrointestinal side effects limit its usefulness.'''
| |
| ** '''The extended-spectrum penicillin derivatives (e.g., pivmecillinam, piperacillin, mezlocillin, azlocillin) retain ampicillin’s activity against enterococci and offer activity against many ampicillin-resistant gram-negative bacilli'''
| |
| ** '''Safe for use in pregnancy'''
| |
| * '''Cephalosporins'''
| |
| ** '''In general, as a group, activity is high against Enterobacteriaceae and poor against enterococci'''
| |
| ** First-generation cephalosporins have greater activity against gram-positive organisms, as well as common uropathogens such as E. coli and Klebsiella pneumoniae, whereas second-generation cephalosporins have activity against anaerobes. Third-generation cephalosporins are more reliably active against community-acquired and nosocomial gram-negative organisms than other β-lactam antimicrobials.
| |
| ** Use of these broad-spectrum agents should be limited complicated infections and situations in which parenteral therapy is required and resistance to standard antimicrobial agents is likely.
| |
| ** '''Safe for use during pregnancy'''
| |
| ** '''Ceftriaxone is contraindicated in neonates'''
| |
| * '''Nitrofurantoin'''
| |
| ** '''Effective against common uropathogens'''; '''not effective against Pseudomonas and Proteus'''
| |
| ** Rapidly excreted in the urine but '''does not obtain therapeutic levels in most body tissues. Therefore, not useful for upper tract and complicated infections.'''
| |
| ** '''Minimal effects on the resident bowel and vaginal flora''' and has been used effectively in prophylactic regimens
| |
| ** Acquired bacterial resistance is exceedingly low
| |
| ** '''Pregnancy'''
| |
| *** '''2017 American College of Obstetricians and Gynecologists recommendations'''§''':'''
| |
| **** '''First trimester'''
| |
| ***** Consider and discuss with patients the benefits as well as the potential unknown risks of teratogenesis and fetal and maternal adverse reactions.
| |
| ***** '''Prescribing sulfonamides or nitrofurantoin in the first trimester is still considered appropriate when no other suitable alternative antibiotics are available.'''
| |
| **** '''Second and third trimesters'''
| |
| ***** '''Can be used as first-line agents''' for the treatment and prevention of urinary tract infections and other infections caused by susceptible organisms.
| |
| **** Contraindicated in patients with glucose-6-phosphate dehydrogenase deficiency, or in pregnant women identified to be at risk of this condition.
| |
| *** '''CW12 page 1186-1187'''
| |
| **** '''First and second trimester'''
| |
| ***** '''May be used safely in patients without glucose-6-phosphate dehydrogenase deficiency'''
| |
| **** '''Third trimester'''
| |
| ***** '''Should be discontinued at 35 weeks''' because of an increased risk of hemolytic anemia in the neonate.
| |
| * '''Trimethoprim (TMP)-sulfamethoxazole (SMX)'''
| |
| ** '''TMP alone or in combination with SMX is effective against most common uropathogens; not effective against Enterococcus and Pseudomonas.'''
| |
| *** TMP alone is as effective as the combination for most uncomplicated infections and may be associated with fewer side effects; however, the addition of SMX contributes to efficacy in the treatment of upper tract infection via a synergistic bactericidal effect and may diminish the emergence of resistance and attains therapeutic levels in most tissues.
| |
| ** Advantages are inexpensive and have '''minimal adverse effects on the bowel flora'''
| |
| ** Disadvantages are relatively common adverse effects, consisting primarily of rashes and gastrointestinal complaints.
| |
| ** '''Trimethoprim blocks the tubular secretion of creatinine.'''
| |
| *** Since creatinine is produced at a steady state, the serum creatinine will rise, but the GFR does not change
| |
| ** '''TMP-SMX should be avoided during pregnancy because of early potential for teratogenicity and late potential for kernicterus'''
| |
| ** '''Trimethoprim alone should be avoided in pregnancy due to risk of megaloblastic anemia; trimethoprim alone can be used in neonates'''
| |
| * '''Fosfomycin'''
| |
| ** Effective against most uropathogens; '''not effective against Pseudomonas'''
| |
| ** Effective against the majority of gram-negative organisms and vancomycin-resistant Enterococcus (VRE)
| |
| ** Limited cross-resistance between most other common antibacterial agents
| |
| ** Shown to be effective as a single-dose agent when used as an empirical treatment for uncomplicated cystitis
| |
| ** Generally well tolerated with low incidences of GI upset and headache and very rare adverse events
| |
| * '''Fluoroquinolones'''
| |
| ** '''Broad spectrum of activity'''
| |
| *** '''Highly effective against Enterobacteriaceae and P. aeruginosa'''
| |
| *** '''Activity is also high against S. aureus and S. saprophyticus, but, in general, anti-streptococcal coverage is marginal'''
| |
| *** '''Modest activity against enterococcus'''
| |
| ** '''Most anaerobic bacteria are resistant to these drugs; therefore, the normal vaginal and bowel flora are not altered'''
| |
| ** '''Increasing rates of resistance due to indiscriminate use of these agents'''
| |
| ** Not nephrotoxic, but renal insufficiency prolongs the serum half-life, '''requires dose adjustment in patients with creatinine clearances of <30 mL/min.'''
| |
| ** '''Contraindicated in children, adolescents, and pregnant or nursing women due to concerns of damage to developing cartilage'''
| |
| ** '''Drug interactions''':
| |
| *** '''Rare increases in the anticoagulant effects of warfarin when taken with fluoroquinolones'''.
| |
| *** '''Concomitant antacid''' (containing magnesium or aluminum)''', iron, zinc, or sucralfate use dramatically decreases oral absorption'''
| |
| *** Antacids containing magnesium or aluminum interfere with absorption of fluoroquinolones.
| |
| *** Certain fluoroquinolones (enoxacin and ciprofloxacin) elevate plasma levels of theophylline and prolong its half-life
| |
| *** '''Avoid with other drugs that prolong QT interval, such as amiodarone'''
| |
|
| |
|
| == Bladder infections == | | === Urachal cyst infection === |
| | | * '''The cyst material consists of desquamated epithelial cells. These cells can become infected''' |
| * '''Risk factors for bladder UTI'''
| | * '''Staphylococcus aureus has been identified as the most common organism.''' |
| ** '''Reduced urine flow'''
| |
| *** '''Outflow obstruction (BPH, prostate cancer, urethral stricture, foreign body (calculus)''')
| |
| *** '''Neurogenic bladder'''
| |
| *** '''Inadequate fluid uptake''' (dehydration)
| |
| ** '''Promote colonization'''
| |
| *** '''Sexual activity'''—increased inoculation
| |
| *** '''Spermicide'''—increased binding
| |
| *** '''Estrogen depletion'''—increased binding
| |
| *** '''Antibiotic use'''—decreased indigenous flora
| |
| ** '''Facilitate ascent'''
| |
| *** '''Catheterization'''
| |
| *** '''Urinary incontinence'''
| |
| *** '''Fecal incontinence'''
| |
| *** Residual urine with ischemia of bladder wall
| |
| * '''Uncomplicated cystitis'''
| |
| ** '''Pathophysiology'''
| |
| *** '''Pathogens'''
| |
| **** '''E. coli is the causative organism in 75-90% of cases of acute cystitis in young women.'''
| |
| **** '''S. saprophyticus, a commensal organism of the skin, is the second most common cause of acute cystitis in young women, accounting for 10-20% of these infections. Other organisms less commonly involved include Klebsiella and Proteus species and Enterococcus.'''
| |
| **** '''In men, E. coli and other Enterobacteriaceae are the most commonly identified organisms.'''
| |
| *** '''Sexual transmission of uropathogens has been suggested''' by demonstrating identical E. coli in the bowel and urinary flora of sex partners
| |
| ** '''Diagnosis and Evaluation'''
| |
| *** '''History and Physical Exam'''
| |
| **** '''History'''
| |
| ***** Variable presenting symptoms of cystitis but usually include dysuria, frequency, and/or urgency. Suprapubic pain, hematuria, or foul-smelling urine may develop.
| |
| ***** '''By definition, acute cystitis is a superficial infection of the bladder mucosa, so fever, chills, and other signs of dissemination are not present.'''
| |
| ***** Cystitis must be differentiated from other inflammatory infectious conditions in which dysuria may be the most prominent symptom, including:
| |
| ****** Vaginitis
| |
| ****** Urethral infections caused by sexually transmitted pathogens
| |
| ****** Miscellaneous non-inflammatory causes of urethral discomfort
| |
| **** '''Physical exam'''
| |
| ***** Some patients may experience suprapubic tenderness, but most have no diagnostic physical findings.
| |
| ***** In females, physical examination should include the possibility of vaginitis, herpes, and urethral pathology, such as a diverticulum.
| |
| *** '''Laboratory'''
| |
| **** '''Urinalysis'''
| |
| ***** The presumptive laboratory diagnosis of acute cystitis is based on microscopic urinalysis, which indicates microscopic pyuria, bacteriuria, and occasionally hematuria.
| |
| **** '''Urine culture'''
| |
| ***** '''Remains the definitive test'''
| |
| ****** '''In symptomatic patients, presence of ≥102 cfu/mL bacteria usually indicates infection'''
| |
| ** '''Management'''
| |
| *** '''≈90% of women are asymptomatic within 72 hours after initiating antibiotics'''
| |
| *** '''A follow-up visit or culture is not required in young women who are asymptomatic after therapy.'''
| |
| **** A follow-up visit, urinalysis, and urine culture are recommended in older women or those with potential risk factors and in men.
| |
| **** '''Urologic evaluation is unnecessary in women and is usually unnecessary in young men who respond to therapy. However, UTIs in most men should be considered complicated until proven otherwise.'''
| |
| *** '''If a patient does not respond to therapy, appropriate microbiologic and urologic evaluations should be undertaken for the causes of unresolved and complicated UTIs.'''
| |
| *** See CW11 Table 12-10 for Treatment Regimens for Acute Cystitis
| |
| | |
| * '''Asymptomatic bacteriuria'''
| |
| ** '''Screening for or treatment of asymptomatic bacteriuria is not appropriate and should be discouraged'''
| |
| *** '''Exceptions (populations in whom treatment has been documented to be beneficial)'''
| |
| **** '''Pregnant females'''
| |
| **** '''Patients undergoing urologic interventions'''
| |
| **** '''Candiduria in neonates''' (not technically a "bacter"uria")
| |
| ***** '''Treat candiduria in neonates with parenteral fluconazole'''
| |
| * '''Complicated cystitis'''
| |
| ** '''Complicated UTIs are those that occur in a patient with a compromised urinary tract (see list above) or that are caused by a very resistant pathogen'''
| |
| ** '''Urine cultures are mandatory to identify the bacteria and its antibiotic susceptibility'''
| |
| ** '''While uncomplicated cystitis in a young sexually active male may not require investigation beyond a follow-up urine culture, a complicated UTI in an older male warrants urologic evaluation such as CT urogram and cystoscopy due to the high incidence of associated urologic abnormalities such as obstruction from either urethral or ureteral strictures, tumor, or stones.'''
| |
| *** ≈50% of males with UTIs have a significant abnormality
| |
| ** '''Management:''' See CW11 Table 12-13
| |
| | |
| ** '''Unresolved UTIs'''
| |
| *** Indicates that initial therapy has been inadequate in eliminating symptoms and/or bacterial growth in the urinary tract.
| |
| *** '''If the symptoms of UTI do not resolve by the end of treatment or if symptoms recur shortly after therapy, urinalysis and urine culture with susceptibility testing should be obtained.'''
| |
| **** If the patient’s symptoms are significant, empirical therapy with a fluoroquinolone is appropriate, pending results of the culture and susceptibility testing.
| |
| *** '''Causes of Unresolved Bacteriuria, in Descending Order of Importance'''
| |
| ***# '''Pre-existing bacterial resistance''' to the drug selected for treatment
| |
| ***# '''Development of resistance from initially susceptible bacteria'''
| |
| ***# '''Bacteriuria caused by 2 different bacterial species with mutually exclusive susceptibilities'''
| |
| ***# '''Rapid re-infection with a new, resistant species''' during initial therapy for the original susceptible organism
| |
| ***# '''Renal failure''' (inability to deliver an adequate concentration of antibiotics into the urinary tract)
| |
| ***# '''Papillary necrosis from analgesic abuse''' (defects in the medullary concentrating ability dilutes the antibiotic)
| |
| ***# '''Staghorn calculi''' (large mass of bacteria)
| |
| ***# '''Self-inflicted infections or deception in taking antimicrobial drugs''' (a variant of Munchausen syndrome)
| |
| *** '''The first 4 causes that are associated with resistant bacteria require no further evaluation. However, if re-culture shows that the bacteria are sensitive to the antimicrobial agent the patient is taking, renal function and radiologic evaluation should be performed to identify renal or urinary tract abnormalities.'''
| |
| *** '''Management'''
| |
| **** '''Initial empirical antimicrobial selection for unresolved UTI should be based on the assumption that the bacteria are resistant and an''' antibiotic different from the original agent should be selected.
| |
| ***** Fluoroquinolones offer excellent coverage in most cases and should be given for 7 days.
| |
| **** When the bacterial susceptibilities are available, adjustments can be made if necessary.
| |
| **** Urine cultures should be performed during and 7 days after therapy to ensure microbiologic efficacy.
| |
| ** '''Recurrent UTI'''
| |
| *** '''See AUA/CUA Guideline Notes'''
| |
| *** '''Recurrent UTIs are caused by either re-emergence of bacteria from a site within the urinary tract (bacterial persistence) or new infections from bacteria outside the urinary tract (re-infection).'''
| |
| **** Clinical identification of these two types of recurrence is based on the pattern of recurrent infections. Bacterial persistence must be caused by the same organism in each instance, and infections that occur at close intervals are characteristic. Conversely, reinfections usually occur at varying and sometimes long intervals and often are caused by different species.
| |
| **** The distinction between bacterial persistence and reinfection is important in management because '''patients with bacterial persistence can usually be cured of the recurrent infections by identification and surgical removal or correction of the focus of infection. Conversely, women with reinfection usually do not have an alterable urologic abnormality and require long-term medical management.'''
| |
| **** '''The probability of recurrent UTIs'''
| |
| ***** '''Increases with the number of previous infections'''
| |
| ***** '''Decreases in inverse proportion to the elapsed time between the first and the second infections'''
| |
| *** '''Bacterial persistence'''
| |
| **** Once the bacteriuria has resolved (i.e., the urine shows no growth for several days after the antimicrobial agent has been stopped), recurrence with the same organism can arise from a site within the urinary tract that was excluded from the high urine concentrations of the antimicrobial agent.
| |
| **** '''Correctable urologic abnormalities that cause bacteria to persist within the urinary tract between episodes of recurrent bacteriuria:'''
| |
| ****# '''Infection stones'''
| |
| ****# '''Chronic bacterial prostatitis'''
| |
| ****# '''Foreign bodies'''
| |
| ****# '''Urethral diverticula and infected periurethral glands'''
| |
| ****# '''Unilateral infected atrophic kidney'''
| |
| ****# '''Ureteral duplication and ectopic ureters'''
| |
| ****# '''Unilateral medullary sponge kidney'''
| |
| ****# '''Non-refluxing, normal-appearing, infected ureteral stumps after nephrectomy'''
| |
| ****# '''Infected urachal cysts'''
| |
| ****# '''Infected communicating cysts of the renal calyces'''
| |
| ****# '''Papillary necrosis'''
| |
| ****# '''Perivesical abscess with fistula to bladder'''
| |
| *** '''Re-infections'''
| |
| **** Patients with recurrent infections caused by different species or occurring at long intervals almost invariably have reinfections. These reinfections most often occur in females and are associated with ascending colonization from the bowel flora. Reinfections in men are often associated with a urinary tract abnormality.
| |
| **** '''The possibility of a vesicoenteric or vesicovaginal fistula should be considered when the patient has any history of pneumaturia, fecaluria, diverticulitis, obstipation, previous pelvic surgery, or radiation therapy.'''
| |
| **** Evaluation for presumed reinfections must be individualized.
| |
| ** '''Pyocystis'''
| |
| *** '''Occurs in ≈20% of patients who undergo supravesical diversion'''
| |
| *** Patients typically have a malodorous discharge and may develop sepsis
| |
| *** '''Management'''
| |
| **** '''Conservative: routine bladder irrigations'''
| |
| **** '''If conservative measures fail, vaginal vesicostomy (creation of a large vesico-vaginal fistula), is an effective method of preventing pyocystis in females.'''
| |
| ** '''Urachal cyst infection'''
| |
| *** '''The cyst material consists of desquamated epithelial cells. These cells can become infected'''
| |
| *** '''Staphylococcus aureus has been identified as the most common organism.'''
| |
|
| |
|
| == Kidney infections == | | == Kidney infections == |
| Line 851: |
Line 489: |
| *** However, pyelonephritis, when associated with urinary tract obstruction or granulomatous renal infection, may lead rapidly to significant inflammatory complications, renal failure, or even death. | | *** However, pyelonephritis, when associated with urinary tract obstruction or granulomatous renal infection, may lead rapidly to significant inflammatory complications, renal failure, or even death. |
|
| |
|
| ==== Acute pyelonephritis ==== | | ==== Acute Pyelonephritis ==== |
| * '''Pathogens'''
| | |
| ** '''E. coli (80% of cases)''' constitutes a unique subgroup that possesses special virulence factors
| | ===== Pathogens ===== |
| ** More resistant species, such as Proteus, Klebsiella, Pseudomonas, Serratia, Enterobacter, or Citrobacter, should be suspected in patients who have recurrent UTIs, are hospitalized, have indwelling catheters, or have had recent urinary tract instrumentation.
| | * '''E. coli (80% of cases)''' constitutes a unique subgroup that possesses special virulence factors |
| ** Except for E. faecalis, S. epidermidis, and S. aureus, gram-positive bacteria rarely cause pyelonephritis.
| | * More resistant species, such as Proteus, Klebsiella, Pseudomonas, Serratia, Enterobacter, or Citrobacter, should be suspected in patients who have recurrent UTIs, are hospitalized, have indwelling catheters, or have had recent urinary tract instrumentation. |
| * '''Diagnosis and Evaluation'''
| | * Except for E. faecalis, S. epidermidis, and S. aureus, gram-positive bacteria rarely cause pyelonephritis. |
| ** '''History and physical exam'''
| | |
| *** The clinical spectrum ranges from gram-negative sepsis to cystitis with mild flank pain.
| | ====== Differential Diagnoses ====== |
| *** The classic presentation is an abrupt onset of chills, fever, and unilateral or bilateral flank or costovertebral angle pain and/or tenderness. These signs and symptoms, referred to as upper tract signs, are often accompanied by LUTS such as dysuria, increased urinary frequency, and urgency | | |
| *** Differential diagnoses: acute appendicitis, diverticulitis, and pancreatitis can cause a similar degree of pain, but the location of the pain often is different | | # '''<span style="color:#ff0000">Acute appendicitis''' |
| *** On physical examination, there often is tenderness to deep palpation in the costovertebral angle | | # '''<span style="color:#ff0000">Diverticulitis''' |
| ** '''Laboratory'''
| | # '''<span style="color:#ff0000">Pancreatitis''' |
| *** CBC
| | |
| **** May have leukocytosis with a predominance of neutrophils.
| | * '''Can cause a similar degree of pain, but the location of the pain often is different''' |
| *** Urinalysis | | |
| **** Usually reveals numerous WBCs, often in clumps, and bacterial rods or chains of cocci.
| | ===== Diagnosis and Evaluation ===== |
| **** '''The presence of large amounts of granular or leukocyte casts in the urinary sediment is suggestive of acute pyelonephritis.'''
| | |
| *** '''Urine cultures'''
| | ====== History and Physical Exam ====== |
| **** '''Usually positive'''
| | * The clinical spectrum ranges from gram-negative sepsis to cystitis with mild flank pain. |
| ***** '''≈20% of patients have''' urine cultures with < 105 cfu/mL and therefore '''negative results on Gram staining of the urine'''
| | * '''<span style="color:#ff0000">History''' |
| *** '''Blood cultures'''
| | **'''<span style="color:#ff0000">Signs and Symptoms''' |
| **** '''Should not be routinely obtained for the evaluation of uncomplicated pyelonephritis in females.'''
| | ***'''<span style="color:#ff0000">Upper tract signs (3):''' |
| ***** '''Positive in ≈25% of cases of uncomplicated pyelonephritis in females and the majority replicate the urine culture and do not influence decisions regarding therapy.'''
| | ***#'''<span style="color:#ff0000">Abrupt onset of chills''' |
| **** '''Should be performed in males and females with systemic toxicity or in those requiring hospitalization or with risk factors such as pregnancy'''
| | ***#'''<span style="color:#ff0000">Fever''' |
| ** '''Imaging'''
| | ***#'''<span style="color:#ff0000">Unilateral or bilateral flank or costovertebral angle pain and/or tenderness''' |
| *** '''Renal US and CT are commonly used to evaluate patients initially for complicated UTIs or factors or to reevaluate patients who do not respond after 72 hours of therapy'''
| | ***'''<span style="color:#ff0000">Often accompanied by LUTS such as (3):''' |
| *** '''In patients with presumed uncomplicated pyelonephritis who will be managed as outpatients, initial radiologic evaluation can usually be deferred.'''
| | ***#'''<span style="color:#ff0000">Dysuria''' |
| **** However, if there is any reason to suspect a problem or if the patient will not have reasonable access to imaging if there should be no change in condition, renal US can rule out stones or obstruction.
| | ***#'''<span style="color:#ff0000">Increased urinary frequency''' |
| **** In patients with known or suspected complicated pyelonephritis, CT provides excellent assessment of the status of the urinary tract and the severity and extent of the infection. | | ***#'''<span style="color:#ff0000">Urgency''' |
| * '''Management''' | | * '''<span style="color:#ff0000">Physical Exam''' |
| ** '''For patients with community-acquired infections who will be managed as outpatients, single-drug oral therapy with a fluoroquinolone is more effective than TMP-SMX'''. | | ** '''<span style="color:#ff0000">Tenderness to deep palpation in the costovertebral angle''' |
| *** Many physicians administer a single parenteral dose of an antimicrobial agent (ceftriaxone, gentamicin, or a fluoroquinolone) before initiating oral therapy. | | |
| *** If a gram-positive organism is suspected, amoxicillin or amoxicillin/clavulanic acid is recommended | | ====== Labs ====== |
| ** If a patient has an uncomplicated infection but is sufficiently ill to require hospitalization (high fever, high WBC count, vomiting, dehydration, evidence of sepsis), has complicated pyelonephritis, or fails to improve during the initial outpatient treatment period, a parenteral fluoroquinolone, an aminoglycoside with or without ampicillin, or an extended-spectrum cephalosporin with or without an aminoglycoside is recommended. | | * '''<span style="color:#ff0000">CBC''' |
| | ** May have leukocytosis with a predominance of neutrophils. |
| | * '''<span style="color:#ff0000">Urinalysis''' |
| | ** Usually reveals numerous WBCs, often in clumps, and bacterial rods or chains of cocci. |
| | ** '''The presence of large amounts of granular or leukocyte casts in the urinary sediment is suggestive of acute pyelonephritis.''' |
| | * '''<span style="color:#ff0000">Urine cultures''' |
| | ** '''Usually positive''' |
| | *** '''≈20% of patients have''' urine cultures with < 105 cfu/mL and therefore '''negative results on Gram staining of the urine''' |
| | * '''<span style="color:#ff0000">Blood cultures''' |
| | ** '''<span style="color:#ff0000">Should not be routinely obtained for the evaluation of uncomplicated pyelonephritis in females.''' |
| | *** '''Positive in ≈25% of cases of uncomplicated pyelonephritis in females and the majority replicate the urine culture and do not influence decisions regarding therapy.''' |
| | ** '''Should be performed in males and females with systemic toxicity or in those requiring hospitalization or with risk factors such as pregnancy''' |
| | '''Imaging''' |
| | * '''In patients with presumed uncomplicated pyelonephritis who will be managed as outpatients, initial radiologic evaluation can usually be deferred.''' |
| | ** However, if there is any reason to suspect a problem or if the patient will not have reasonable access to imaging if there should be no change in condition, renal US can rule out stones or obstruction. |
| | * '''In patients with known or suspected complicated pyelonephritis, CT provides excellent assessment of the status of the urinary tract and the severity and extent of the infection.''' |
| | *'''Renal US and CT are commonly used to evaluate patients initially for complicated UTIs or factors or to reevaluate patients who do not respond after 72 hours of therapy''' |
| | |
| | ===== Management ===== |
| | * '''Any substantial obstruction must be relieved expediently by the safest and simplest means.''' |
| | **An obstructed kidney has difficulty concentrating and excreting antimicrobial agents. |
| | *'''Antibiotics''' |
| | **'''Oral''' |
| | ***'''Options[https://www.nice.org.uk/guidance/ng111/documents/draft-guideline-2 §]''' |
| | ****Amoxicillin / Clavulanic acid 625mg PO TID x 7 days |
| | *****If a gram-positive organism is suspected, amoxicillin or amoxicillin/clavulanic acid is recommended |
| | ****Ciprofloxacin 500mg PO BID x 7 days |
| | ****Levofloxacin 500mg PO daily x 7 days |
| | ***Many physicians administer a single parenteral dose of an antimicrobial agent (ceftriaxone, gentamicin, or a fluoroquinolone) before initiating oral therapy. |
| | **'''IV''' |
| | ***'''Options§''' |
| | ****Ceftriaxone 1-2g IV q24h |
| | ****Ciprofloxacin 400mg IV TID |
| | ****Gentamicin 5-7mg/kg q24h |
| | *** For patients sufficiently ill to require hospitalization (high fever, high WBC count, vomiting, dehydration, evidence of sepsis), has complicated pyelonephritis, or fails to improve during the initial outpatient treatment period |
| *** If gram-positive cocci are causative, ampicillin/sulbactam with or without an aminoglycoside is recommended. | | *** If gram-positive cocci are causative, ampicillin/sulbactam with or without an aminoglycoside is recommended. |
| *** See CW11 Table 12-15 | | *'''Follow-up''' |
| **An obstructed kidney has difficulty concentrating and excreting antimicrobial agents. Any substantial obstruction must be relieved expediently by the safest and simplest means.
| |
| **'''Repeat urine cultures should be performed after 5-7 days of therapy and 10-14 days after discontinuing antimicrobial therapy to ensure that the urinary tract remains free of infections.''' | | **'''Repeat urine cultures should be performed after 5-7 days of therapy and 10-14 days after discontinuing antimicrobial therapy to ensure that the urinary tract remains free of infections.''' |
| ***10-30% of individuals with acute pyelonephritis relapse after a 14-day course of therapy. | | ***10-30% of individuals with acute pyelonephritis relapse after a 14-day course of therapy. |
| Line 927: |
Line 598: |
| * '''Usually results from rupture of an acute cortical abscess into the perinephric space or from hematogenous seeding from sites of infection.''' | | * '''Usually results from rupture of an acute cortical abscess into the perinephric space or from hematogenous seeding from sites of infection.''' |
| * Diabetes mellitus is present in ≈1/3rd of patients | | * Diabetes mellitus is present in ≈1/3rd of patients |
| * '''Diagnosis and Evaluation'''
| | |
| ** '''The onset of symptoms is typically insidious. Symptoms are present for > 5 days in most patients'''
| | ===== Diagnosis and Evaluation ===== |
| ** Perinephric abscess should be suspected in a patient with UTI and abdominal or flank mass or persistent fever after 4 days of antimicrobial therapy.
| | * '''The onset of symptoms is typically insidious. Symptoms are present for > 5 days in most patients''' |
| ** '''Factors that differentiate perinephric abscess and acute pyelonephritis (2):'''
| | * Perinephric abscess should be suspected in a patient with UTI and abdominal or flank mass or persistent fever after 4 days of antimicrobial therapy. |
| **# '''Most patients with uncomplicated pyelonephritis are symptomatic for < 5 days before hospitalization, whereas most with perinephric abscesses are symptomatic for > 5 days'''
| | * '''Factors that differentiate perinephric abscess and acute pyelonephritis (2):''' |
| **# No patient with acute pyelonephritis remained febrile for longer than 4 days once appropriate antimicrobial agents were started. All patients with perinephric abscesses had a fever for at least 5 days, with a median of 7 days.
| | *# '''Most patients with uncomplicated pyelonephritis are symptomatic for < 5 days before hospitalization, whereas most with perinephric abscesses are symptomatic for > 5 days''' |
| * Management
| | *# No patient with acute pyelonephritis remained febrile for longer than 4 days once appropriate antimicrobial agents were started. All patients with perinephric abscesses had a fever for at least 5 days, with a median of 7 days. |
| ** Antimicrobial agents should be immediately started upon diagnosis of perinephric abscess.
| | |
| ** '''For small perinephric abscesses (<3 cm), antibiotics alone can appropriately treat immune-competent patients'''
| | ===== Management ===== |
| ** '''For larger collections or those not responsive to initial antibiotic therapy, intervention is the next step in treatment.'''
| | * Antimicrobial agents should be immediately started upon diagnosis of perinephric abscess. |
| *** '''Unlike in renal abscesses, early drainage of abscesses > 3 cm in diameter is recommended'''.
| | * '''<span style="color:#ff0000">For small perinephric abscesses (<3 cm), antibiotics alone can appropriately treat immune-competent patients''' |
| *** Once the perinephric abscess has been drained, the underlying problem must be dealt with.
| | * '''For larger collections or those not responsive to initial antibiotic therapy, intervention is the next step in treatment.''' |
| | ** '''<span style="color:#ff0000">Unlike in renal abscesses, early drainage of abscesses > 3 cm in diameter is recommended'''. |
| | ** Once the perinephric abscess has been drained, the underlying problem must be dealt with. |
|
| |
|
| ==== Chronic pyelonephritis ==== | | ==== Chronic pyelonephritis ==== |
| Line 1,076: |
Line 749: |
| == Bacteriuria in the elderly == | | == Bacteriuria in the elderly == |
|
| |
|
| * '''Epidemiology'''
| | === Epidemiology === |
| ** '''> 20% of women and 10% of men age > 65 have bacteriuria'''
| | * '''> 20% of women and 10% of men age > 65 have bacteriuria''' |
| * Pathogenesis
| | |
| ** Age-related changes related to increased risk of bacteruria include:
| | === Pathogenesis === |
| **# Decline in cell-mediated immunity
| | * Age-related changes related to increased risk of bacteruria include: |
| **# Neurogenic bladder dysfunction
| | *# Decline in cell-mediated immunity |
| **# Increased perineal soiling as a result of fecal and urinary incontinence
| | *# Neurogenic bladder dysfunction |
| **# Increased incidence of urethral catheter placement
| | *# Increased perineal soiling as a result of fecal and urinary incontinence |
| **# In women, changes in the vaginal environment associated with estrogen depletion
| | *# Increased incidence of urethral catheter placement |
| * '''Pathogens'''
| | *# In women, changes in the vaginal environment associated with estrogen depletion |
| ** '''E. coli remains the most common uropathogen, causing 75% of these infections.'''
| | |
| ** '''S. saprophyticus is not seen in this population.'''
| | === Pathogens === |
| * '''Diagnosis and Evaluation'''
| | * '''E. coli remains the most common uropathogen, causing 75% of these infections.''' |
| ** '''Diagnosis of bacteriuria and UTIs in the elderly can be difficult.'''
| | * '''S. saprophyticus is not seen in this population.''' |
| ** Most elderly patients with bacteriuria are asymptomatic
| | |
| ** '''Urinary tract symptoms are often absent, and concomitant disease can mask or mimic UTI. Even severe upper tract infections may not be associated with fever or leukocytosis'''
| | === Diagnosis and Evaluation === |
| ** '''Screening for asymptomatic bacteriuria in elderly residents in the community or long-term care facilities is not recommended.'''
| | * '''Diagnosis of bacteriuria and UTIs in the elderly can be difficult.''' |
| *** In RCTs of antimicrobial vs. no therapy in elderly male and female nursing home residents with asymptomatic bacteriuria, no decrease in symptomatic episodes and no improvement in survival. In fact, treatment with antimicrobial therapy increases the occurrence of adverse drug effects and reinfection with resistant organisms and increases the cost of treatment.
| | * Most elderly patients with bacteriuria are asymptomatic |
| * '''Management'''
| | * '''Urinary tract symptoms are often absent, and concomitant disease can mask or mimic UTI. Even severe upper tract infections may not be associated with fever or leukocytosis''' |
| ** '''Asymptomatic'''
| | * '''Screening for asymptomatic bacteriuria in elderly residents in the community or long-term care facilities is not recommended.''' |
| *** '''Not recommended'''
| | ** In RCTs of antimicrobial vs. no therapy in elderly male and female nursing home residents with asymptomatic bacteriuria, no decrease in symptomatic episodes and no improvement in survival. In fact, treatment with antimicrobial therapy increases the occurrence of adverse drug effects and reinfection with resistant organisms and increases the cost of treatment. |
| *** '''The treatment of asymptomatic bacteriuria to improve incontinence has not been justified'''
| | |
| ** '''Symptomatic'''
| | === Management === |
| *** '''For elderly patients with symptomatic UTI, 7 days of therapy is recommended.'''
| | * '''Asymptomatic''' |
| **** The goal in this population is to eliminate symptoms but not sterilize the urine
| | ** '''Not recommended''' |
| ** '''Other scenarios'''
| | ** '''The treatment of asymptomatic bacteriuria to improve incontinence has not been justified''' |
| *** '''Bacteriuria that leads to UTIs in elderly in the presence of underlying structural urinary tract abnormalities''' '''(e.g., obstruction with hydronephrosis) or systemic conditions (e.g., severe diabetes mellitus) are clinically significant, can''' '''lead to renal failure, and require prompt therapy.'''
| | * '''Symptomatic''' |
| *** '''UTIs caused by urea-splitting bacteria, such as Proteus or Klebsiella species that cause formation of infection stones, may also lead to severe renal damage.'''
| | ** '''For elderly patients with symptomatic UTI, 7 days of therapy is recommended.''' |
| **** '''Urea in the urine is split into large amounts of ammonia by urea-splitting bacteria which is absorbed systemically and may result in encephalopathy or even coma at high levels, particularly in obstruction'''
| | *** The goal in this population is to eliminate symptoms but not sterilize the urine |
| | * '''Other scenarios''' |
| | ** '''Bacteriuria that leads to UTIs in elderly in the presence of underlying structural urinary tract abnormalities''' '''(e.g., obstruction with hydronephrosis) or systemic conditions (e.g., severe diabetes mellitus) are clinically significant, can''' '''lead to renal failure, and require prompt therapy.''' |
| | ** '''UTIs caused by urea-splitting bacteria, such as Proteus or Klebsiella species that cause formation of infection stones, may also lead to severe renal damage.''' |
| | *** '''Urea in the urine is split into large amounts of ammonia by urea-splitting bacteria which is absorbed systemically and may result in encephalopathy or even coma at high levels, particularly in obstruction''' |
|
| |
|
| == Catheter-associated bacteriuria == | | == Catheter-associated bacteriuria == |
|
| |
|
| * '''Epidemiology'''
| | === Epidemiology === |
| ** '''Most common nosocomial infection'''
| | * '''Most common nosocomial infection''' |
| *** 80% of nosocomial UTIs are secondary to an indwelling urethral catheter
| | ** 80% of nosocomial UTIs are secondary to an indwelling urethral catheter |
| * Pathogenesis
| | |
| ** '''Closed drainage is the most effective measure at reducing catheter-associated UTI'''
| | === Pathogenesis === |
| * Diagnosis and Evaluation
| | * '''Closed drainage is the most effective measure at reducing catheter-associated UTI''' |
| ** Most patients are asymptomatic
| | |
| * '''Management'''
| | === Diagnosis and Evaluation === |
| ** '''Patients with indwelling catheters should be treated only if they become symptomatic (e.g., febrile).'''
| | * Most patients are asymptomatic |
| *** '''Urine cultures should be performed before initiating antimicrobial therapy.'''
| | |
| *** The antimicrobial agent should be discontinued within 48 hours of resolution of the infection.
| | === Management === |
| *** '''If the catheter has been indwelling for several weeks, encrustation may shelter bacteria from the antimicrobial agent; therefore the catheter should be changed. [Unclear but likely does not need to be changed if asymptomatic]'''
| | * '''Patients with indwelling catheters should be treated only if they become symptomatic (e.g., febrile).''' |
| | ** '''Urine cultures should be performed before initiating antimicrobial therapy.''' |
| | ** The antimicrobial agent should be discontinued within 48 hours of resolution of the infection. |
| | ** '''If the catheter has been indwelling for several weeks, encrustation may shelter bacteria from the antimicrobial agent; therefore the catheter should be changed. [Unclear but likely does not need to be changed if asymptomatic]''' |
|
| |
|
| == UTIs in patients with spinal-cord injury (SCI) == | | == UTIs in patients with spinal-cord injury (SCI) == |
|
| |
|
| * Pathogenesis
| | === Pathogenesis === |
| ** Risk factors include impaired voiding, overdistention of the bladder, elevated intravesical pressure, increased risk of urinary obstruction, vesicoureteral reflux, instrumentation, increased incidence of stones, decreased fluid intake, poor hygiene, perineal colonization, decubiti, and other evidence of local tissue trauma, and reduced host defense associated with chronic illness
| | * Risk factors include impaired voiding, overdistention of the bladder, elevated intravesical pressure, increased risk of urinary obstruction, vesicoureteral reflux, instrumentation, increased incidence of stones, decreased fluid intake, poor hygiene, perineal colonization, decubiti, and other evidence of local tissue trauma, and reduced host defense associated with chronic illness |
| * Pathogens
| | |
| ** Most bacteriuria in short-term catheterization is of a single organism, whereas patients catheterized for longer than a month will usually demonstrate a polymicrobial flora caused by a wide range of gram-negative and gram-positive bacterial species
| | === Pathogens === |
| * '''Diagnosis and Evaluation'''
| | * Most bacteriuria in short-term catheterization is of a single organism, whereas patients catheterized for longer than a month will usually demonstrate a polymicrobial flora caused by a wide range of gram-negative and gram-positive bacterial species |
| ** The majority of patients with SCI with bacteriuria are asymptomatic. Because of a loss of sensation, patients usually do not experience frequency, urgency, or dysuria. More often, they complain of flank, back, or abdominal discomfort, leakage between catheterizations, increased spasticity, malaise, lethargy, and/or cloudy, malodorous urine.
| | |
| ** '''UTI is the most common cause of fever in the SCI patient'''
| | === Diagnosis and Evaluation === |
| * '''Managment'''
| | * The majority of patients with SCI with bacteriuria are asymptomatic. Because of a loss of sensation, patients usually do not experience frequency, urgency, or dysuria. More often, they complain of flank, back, or abdominal discomfort, leakage between catheterizations, increased spasticity, malaise, lethargy, and/or cloudy, malodorous urine. |
| ** '''CIC has been shown to decrease lower urinarcy tract complications by maintaining low intravesical pressure and reducing the incidence of stones. CIC also appears to reduce complications associated with an indwelling catheter, such as UTI, fever, bacteremia, and local infections such as epididymitis and prostatitis.'''
| | * '''UTI is the most common cause of fever in the SCI patient''' |
| *** Suprapubic catheters and indwelling urethral catheters eventually have an equivalent infection rate. However, the onset of bacteriuria may be delayed using a suprapubic catheter compared with a urethral catheter (different than NLUTD guidelines which suggest decreased infection rate with suprapubic compared to indwelling)
| | |
| *** '''In the absence of vesicoureteral reflux, asymptomatic bacteruria in patients managed with clean intermittent catheterization is not a significant risk factor for renal damage and does not require antibiotic therapy.'''
| | === Management === |
| ** '''Only symptomatic patients require therapy'''.
| | * '''CIC has been shown to decrease lower urinarcy tract complications by maintaining low intravesical pressure and reducing the incidence of stones. CIC also appears to reduce complications associated with an indwelling catheter, such as UTI, fever, bacteremia, and local infections such as epididymitis and prostatitis.''' |
| *** Because of the diverse flora and high probability of bacterial resistance, a urine culture must be obtained before initiating empirical therapy.
| | ** Suprapubic catheters and indwelling urethral catheters eventually have an equivalent infection rate. However, the onset of bacteriuria may be delayed using a suprapubic catheter compared with a urethral catheter (different than NLUTD guidelines which suggest decreased infection rate with suprapubic compared to indwelling) |
| *** '''For afebrile patients, an oral fluoroquinolone is the agent of choice.'''
| | ** '''In the absence of vesicoureteral reflux, asymptomatic bacteruria in patients managed with clean intermittent catheterization is not a significant risk factor for renal damage and does not require antibiotic therapy.''' |
| ** '''An indwelling catheter should be changed to ensure maximal drainage and eliminate bacterial foci in catheter encrustations'''.
| | * '''Only symptomatic patients require therapy'''. |
| ** '''Antimicrobial prophylaxis is not supported for most patients who have neurogenic bladder caused by spinal cord injury'''
| | ** Because of the diverse flora and high probability of bacterial resistance, a urine culture must be obtained before initiating empirical therapy. |
| | ** '''For afebrile patients, an oral fluoroquinolone is the agent of choice.''' |
| | * '''An indwelling catheter should be changed to ensure maximal drainage and eliminate bacterial foci in catheter encrustations'''. |
| | * '''Antimicrobial prophylaxis is not supported for most patients who have neurogenic bladder caused by spinal cord injury''' |
|
| |
|
| == Periurethral abscess == | | == Periurethral abscess == |
| Line 1,149: |
Line 832: |
| * '''Management''' | | * '''Management''' |
| ** '''Consists of immediate suprapubic urinary drainage and wide debridement''' | | ** '''Consists of immediate suprapubic urinary drainage and wide debridement''' |
|
| |
| == Clostridium Difficile Infection (CDI) ==
| |
|
| |
| * Epidemiology
| |
| ** Incidence is increasing with a preponderance of the NAP1 hypervirulent strain of C. difficile found in recent epidemics.
| |
| *** The NAP1 strain is more likely to cause severe and fulminant colitis, characterized by marked leukocytosis, renal failure, hemodynamic instability, and toxic megacolon.
| |
| *** It is believed the NAP1 strain arose due to the widespread use of fluoroquinolone antibiotics.
| |
| * '''Management'''
| |
| ** '''Options:'''
| |
| **# '''Oral vancomycin (more effective)'''
| |
| **# '''Oral metronidazole'''
| |
| ** '''Neither I.V. vancomycin nor I.V. metronidazole have been found to be more effective than the oral form of the medications for treatment of CDI.'''
| |
| ** '''No role for fluoroquinolones.'''
| |
| ** Metronidazole should be avoided in patients on warfarin
| |
| *** Metronidazole interferes with warfarin metabolism
| |
| ** '''Worsening diarrhea, fever, and leukocytosis despite appropriate antibiotics is an absolute indication for surgical consultation.'''
| |
| *** '''Subtotal colectomy with end ileostomy is the procedure of choice for fulminant CD colitis nonresponsive to medications and has been documented to result in improved survival.'''
| |
|
| |
| == Antibiotic Prophylaxis ==
| |
|
| |
| === Urinary Catheter Removal ===
| |
|
| |
| * '''Does not significantly reduce risk of UTIs in patients undergoing radical prostatectomy or TURP'''
| |
| ** '''2021 Systematic Review and Meta-Analysis'''
| |
| *** '''8 randomized trials evaluating antibiotic prophylaxis for UTIs after extraction of a temporary (≤14 days) urinary catheter.'''
| |
| **** '''2 trials were laparoscopic radical prostatectomy patients'''
| |
| **** '''1 trial was TURP patients'''
| |
| *** '''Results'''
| |
| **** '''Only 2 studies showed that antibiotic prophylaxis can significantly reduce the consequent UTIs after extraction of urinary catheters while 6 did not.'''
| |
| ***** '''None of the 3 urological trials found a significant benefit of antibiotic prophylaxis'''
| |
| *****2 trials that found benefit were in patients undergoing abdominal surgery or women on medical and surgical wards with bacteriuria
| |
| **** Overall, antibiotic prophylaxis was associated with reduced UTIs (RR, 0.47, 95% confidence interval [CI] 0.28-0.72, P< .01, I2 = 31%).
| |
| **** Subgroup analysis suggested that patients who could get more benefit from antibiotic prophylaxis included
| |
| ***** Are > 60
| |
| ***** Received Trimethoprim/sulfamethoxazole (TMP/SMX
| |
| ***** indwelling catheters > 5 days
| |
| *** [https://pubmed.ncbi.nlm.nih.gov/32763348/ Liu, Linhu, et al.] "Antibiotic prophylaxis after extraction of urinary catheter prevents urinary tract infections: A systematic review and meta-analysis." ''American Journal of Infection Control'' 49.2 (2021): 247-254.
| |
|
| |
|
| == Questions == | | == Questions == |
|
| |
|
| # What is the mechanism of action of: | | # |
| ## TMP/SMX
| |
| ## Nitrofurantoin
| |
| ## Ciprofloxacin
| |
| ## Ampicillin
| |
| ## Fosfomycin
| |
| ## Gentamicin
| |
| # Which antibiotics should be avoided in patients on warfarin?
| |
|
| |
|
| == Answers == | | == Answers == |
|
| |
|
| # What is the mechanism of action of: | | # |
| ## TMP/SMX
| |
| ## Nitrofurantoin
| |
| ## Ciprofloxacin
| |
| ## Ampicillin
| |
| ## Fosfomycin
| |
| ## Gentamicin
| |
| # Which antibiotics should be avoided in patients on warfarin?
| |
| ## Fluoroquinolones
| |
| ## TMP/SMX
| |
| ## Metronidazole
| |
| ## Ketoconazole (antifungal, not technically antibiotic)
| |
|
| |
|
| == References == | | == References == |
|
| |
|
| * Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, vol 2, chap 12 | | * Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, vol 2, chap 12 |