Difference between revisions of "Genitourinary infection"

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==Background==
 
==Background==
===Definitions===
+
{{UTI types}}
*UTI = significant bacteriuria in presence of symptoms
 
**Described by location: urethritis, cystitis, or pyelonephritis
 
*Relapse
 
**Recurrence of symptoms w/in month despite tx
 
***Caused by same organism and represents treatment failure
 
*Reinfection
 
**Development of symptoms 1-6mo after tx
 
**Usually due to a different organism
 
**If pt has >3 recurrences in 1 yr consider tumor, calculi, DM
 
*Men <50 yr: symptoms of dysuria or urinary frequency usually due to STI
 
*Men >50 yr: incidence of UTI rises dramatically d/t prostatic obstruction
 
*Uncomplicated UTI:
 
**No structural or functional abnormalities w/in urinary tract or kidney
 
**No relevant comorbidities that place pt at risk for more serious adverse outcome
 
**Not associated with GU tract instrumentation
 
===Risk factors for complicated UTI===
 
#Male sex
 
##In young males dysuria is more commonly d/t STI
 
##Suspect underlying anatomic abnormality in men with culture-proven UTI
 
#Anatomic abnormality of urinary tract or external drainage system
 
##Indwelling urinary catheter, stent
 
##Nephrolithiasis, neurogenic bladder, polycystic renal disease, recent instrumentation
 
#Recurrent UTI (three or more per year)
 
#Advanced age in men (BPH, recent instrumentation, recent prostatic biopsy)
 
#Nursing home residency (w/ or w/o indwelling bladder catheter)
 
#Neonatal state
 
#Comorbidities (DM, sickle cell disease)
 
#Pregnancy
 
#Immunosuppression (AIDS, immunosuppressive drugs)
 
#Advanced neurologic disease (CVA w/ disability, spinal cord injuries)
 
#Known or suspected atypical pathogens (Non–E. coli infection)
 
#Known or suspected abx resistance (resistance to cipro predicts multidrug resistance)
 
===Bacteriology===
 
*Most common pathogen is E. coli
 
*Anaerobic organisms are rarely pathogenic (do not grow well in urine)
 
*Complicated UTIs more likely to be caused by pseudomonas or enterococcus
 
 
 
==Diagnosis==
 
===Clinical Features===
 
*UTI dx requires both bacteriuria and clinical symptoms
 
**Cystitis = Dysuria, hematuria, frequency, urgency, suprapubic pain, CVAT
 
**Pyelo = Cystitis sx AND fever/chills/nausea/vomiting
 
***CVAT alone may be referred pain from cystitis
 
***CVAT is only physical examination finding that increases likelihood of a UTI
 
*Urethritis
 
**In males more likely due to chlam/GC
 
**In females more likely due to chlam/GC if:
 
***Stuttering urination symptoms
 
***New sex partner or partner w/ urethritis
 
***Signs/symptoms cervicitis
 
***Sterile pyuria
 
*Complicated UTI
 
**Pts may not have classic symptoms; may only have weakness, fever, abd pain, AMS
 
===Labs===
 
====UA====
 
=====WBC count=====
 
*WBC >5 in pt w/ appropriate symptoms is diagnostic
 
**Lower degrees of pyuria may still be clinically significant in presence of UTI sx
 
***False negative may be due to: dilute urine, systemic leukopenia, obstruction
 
**WBC 1-2 w/ bacteriuria can be significant in men
 
***More likely represents urethritis or prostatitis from STI
 
=====Nitrite=====
 
*Very high specificity (>90%) in confirming diagnosis of UTI
 
*Low sensitivity (enterococcus, pseudomonas, acinetobacter are not detected)
 
====Urine Culture====
 
*Indicated for:
 
**Complicated UTI
 
**Pyelonephritis
 
**Pregnant women
 
**Children
 
**Adult males
 
**Relapse/reinfection
 
====Blood Culture====
 
*Not indicated
 
**Organisms in blood cx matched those in urine cx 97% of time
 
 
 
===Imaging===
 
*Consider if pyelonephritis and any of the following:
 
#History of renal stone
 
#Poor response to abx
 
#Male
 
#Elderly
 
#Diabetic
 
#Severely ill
 
 
 
==Treatment==
 
*Consider local resistance patterns (if >10-20% use a different agent)
 
*Avoid use of fluoroquinolones for uncomplicated cystitis if possible
 
*Consider longer course of tx for uncomplicated cystitis if:
 
**Symptoms >7d
 
**DM
 
**UTI in previous 4wk
 
**Men
 
**Age 65 yr
 
**Women who use spermicides or diaphragm
 
**Relapse
 
===Women, uncomplicated cystitis===
 
*Nonpregnant, few prior UTI episodes, symptoms <7d, no flank pain or fever
 
#Nitrofurantoin ER 100mg BID x 5d OR
 
#TMP-SMX DS (160/800mg) 1 tab BID x 3d OR
 
#Cephalexin 250mg QID x 5d OR
 
#Ciprofloxacin 250mg BID x3d
 
===Women, complicated cystitis/pyelo===
 
*Risks for complicated UTI or symptoms of pyelo
 
#Ciprofloxacin 500mg BID x10-14d OR
 
#Cefpodoxime 200 mg BID x10-14d
 
===Women, uncomplicated cystitis AND urethritis===
 
#CTX 250mg IM x1 AND azithromycin 1gm PO x1 AND nitrofurantoin ER 100mg BID x5d OR
 
#Levofloxacin 500mg QD x 14d (covers UTI pathogens, GC, and chlam)
 
##GC resistance to fluoroquinolones is increasing
 
===Men, cystitis/pyelo===
 
*Consider urethritis and prostatitis
 
#Ciprofloxacin 500mg BID x10-14d OR
 
#Cefpodoxime 200 mg BID x10-14d
 
===Inpatient===
 
*Ciprofloxacin 400mg IV q12hr OR
 
*Ceftriaxone 1gm IV QD OR
 
*Cefotaxime 1-2gm IV q8hr OR
 
*Gentamicin 3mg/kg/day divided q8hr +/- ampicillin 1–2 gm q4hr OR
 
*Piperacillin-tazobactam 3.375 gm IV q6hr OR
 
*Cefepime 2gm IV q8hr OR
 
*Imipenem 500mg IV q8hr
 
 
 
==Disposition==
 
===Uncomplicated UTI===
 
*Admit
 
**Unable to tolerate PO
 
*Discharge
 
**Consider phenazopyridine 100-200mg TID after meals x2d only (bladder analgesic)
 
===Pyelonephritis===
 
*Discharge
 
**Consider if young, otherwise healthy, tolerating PO
 
*Admission
 
**Consider if elderly, calculi, obstruction, recent hospitalization/instrumentation, DM
 
 
 
==Complications==
 
*Suspect in pts who have inadequate or atypical response to tx for presumed pyelo
 
#Acute bacterial nephritis
 
##CT shows ill-defined focal areas of decreased density
 
#Renal/Perinephric abscesses
 
##Sign/symptoms similar to pyelo (fever, CVAT, dysuria)
 
##Occurs in setting of ascending infection w/ obstructed pyelo
 
##Associated w/ DM and renal stones
 
##Also occurs due to bacteremia w/ hematogenous seeding (Staph)
 
#Emphysematous pyelonephritis
 
##Rare gas-forming infection nearly always occurring in pts w/ DM and obstruction
 
###Pts appear toxic and septic; nephrectomy may be required
 
 
 
==Special Populations==
 
===AIDS===
 
*TMP-SMX resistance is increased due to its use in PCP PNA prophylaxis
 
**Fluoroquinolones should be initial antibiotic of choice
 
*Most UTIs are caused by typical pathogens or common STI organisms
 
===Pregnant Women===
 
*Treat all cases of asymptomatic bacteriuria
 
  
 
==See Also==
 
==See Also==
 +
*[[Dysuria]]
 +
*[[Hematuria]]
 +
*[[Flank pain]]
 
*[[UTI (Peds)]]
 
*[[UTI (Peds)]]
*[[Dysuria (DDX)]]
 
 
==Source ==
 
Tintinalli
 
  
[[Category:Nephro]]
+
[[Category:Renal]]
 
[[Category:ID]]
 
[[Category:ID]]
 +
[[Category:Urology]]

Latest revision as of 17:01, 22 March 2016

Background

Genitourinary infection

"UTI" frequently refers specifically to acute cystitis, but may also be used as a general term for all urinary infections; use location-specific diagnosis.

See Also