UTI in adults*

Definition

  • Bacterial (fungal) invasion of the urothelium resulting in an inflammatory response
  • Uncomplicated vs Complicated
  • Complicated UTIs carry a moderate/high risk of causing sepsis, tissue destruction or significant morbidity/mortality
        • Male, elderly, febrile utis, haematuria, diabetes, immunosuppression, pregnancy, obstruction, stones, instrumentation and resistant organisms
        • Structural and functional abnormalities
  • 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 4ºC 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/li>
  • 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
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