UTI
in adultsDefinition
- Bacterial (fungal) invasion of the urothelium resulting in an inflammatory response
- Uncomplicated vs Complicated
- Complicated UTIs carry a moderate/high risk of causing sepsis, tissue
destruction or significant morbidity/mortality
- Male, elderly, febrile utis, haematuria, diabetes, immunosuppression, pregnancy, obstruction, stones, instrumentation and resistant organisms
- Structural and functional abnormalities
- Isolated
- Unresolved
- Recurrent
- Reinfection
- Persistance
Pathogenesis
- Organisms normal bowel flora
- Facultative Gram neg. anaerobes
- Coliforms E-Coli, Proteus
- Gram neg. aerobic
- Pseudomonas
- Gram pos.
- Staph saprophyticus and ent. faecalis
UTI prophylaxis
- Cranberry Juice
- Contains antiseptic Hippuric acid
- Trials
- colonisation with benign strain
- Immunisation with uropathogens
Recurrent UTI risk groups
- Premenopausal sexually active, spermicide, childhood and maternal
- Postmenopausal oestrogen deficiency, incontinence, cystocoele
- Elderly cognition, incontinence, catheterisation
Bacterial vs host factors
- Bacterial adherance factors, haemolysins (e-coli), urease (proteus), swarming (proteus, klebsiella)
- Host micturition, bactericidal urine, secreted factors, vaginal epithelium cell receptivity
Primary care guidelines for diagnosis
- Females MSSU
- Toddlers/infants pads from nappies/suprapubic aspiration (paraplegic also)
- Males MSSU, VB1(urethral),VB2 (midstream), VB3 (prostate)
- Refrigerate specimens at 4ēC or use specimen pots containing boric acid
- Kass criteria - >105 CFU/ml (70% of those with definite UTI), 30-40% have 103-4 CFU but symptomatic
- The Urethral Syndrome (50%)
- Acute uncomplicated UTI
- Routine culture unnecessary
- Use dipstick tests to decrease antibiotic use and unnecessary investigations
- Lab testing for C+S reserved for
- Pregnancy screening at first antenatal visit
- >2 UTIs in men
- Suspected pyelonephritis
- Elderly with 2 signs of infection especially dysuria, pyrexia or new incontinence
- Recurrent UTI
- Catheterised patients with features of systemic infection
- Failed antibiotic treatment or persistant symptoms
- Abnormalities of GU tract
- Renal impairment
- Remember C. trachomatis (www.hpa.org.uk)
Dipstick urinalysis
Treatment
- Amoxicillin resistance is common
- Those >65 do not treat asymptomatic bacteriuria
- Only treat those with catheter who are systemically unwell
- 25% of young men with UTIs have abnormal IVU
- Pregnant women have x2 incidence of asymptomatic bacteriuria, 2% incidence of pyelonephritis
- Diabetics have x4 risk of pyelonephritis, consider prophylaxis
- Uncomplicated UTI- no fever or flank pain
- Use urine dipstick, perform c+s if treatment fails.
- Trimethoprim 200mg bd for 3 days or
- Nitrofurantoin 50-100mg qds for 3 days or
- Second line: depending on sensitivity of organism isolated, use amoxicillin, cefalexin, co-amoxiclav, quinolone, or pivmecillinam
- UTI in pregnancy and men
- Suggest MSU for susceptibility testing
- Short-term use of trimethoprim or nitrofurantoin in pregnancy is unlikely to cause problems to the foetus
- Nitrofurantoin 50-100qds or
- Trimethoprim 200mg bd or
- Cefalexin 500mg bd or amoxicillin 250mg tds
- All of above for 7 days
- NB texbook of urology suggest first line for pregnancy are gentamicin! and cefalexin
- UTI in children
- Recurrent UTI in women (>3 pa)
- Post coital prophylaxis is as effective as prophylaxis taken nightly
- Nitrofurantoin 50mg or
- Trimethoprim 100mg
- Stat post coital or od at night
- Acute pyelonephritis
- Recent RCT showed 7 days of ciprofloxacin as good as 14 days of co-trimoxazole
- NO response within 48 hours, consider referral
- Ciprofloxacin 500mg bd for 7 days or
- Co-amoxiclav 500/125mg tds for 14 days
- If sensitive, trimethoprim 200mg bd for 14 days
- Follow-up
- Uncomplicated UTI and pyelonephritis in women dipstick urinalysis
- Consider investigation and/or referral:
- Women with recurrent pyelonephritis within 2/52
- Elderly with recurrent UTIs
- Males with recurrent infection and in all cases of pyelonephritis, prostatis, epididymitis and orchitis
