Professional Documents
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Uti
Uti
, 30, female, single, Filipino, call center agent, Roman Catholic, born Aug 7,
1979, presently residing at Road 7 Sanyo Novaliches Quezon city. Consulted for the first time in
our institution.
7 days prior to consult, patient experienced painful urination characterized as dull, non
radiating and tolerable. With no associated fever, chills, nausea, vomiting, flank pain, low back
pain, frequency, urgency, hesitancy, dribbling, retention, hematuria, change in urine caliber,
passage of stone or sandy material, and genital pruritus and discharge. No medication was taken,
no consult done.
3 days prior to consult, still with painful urination of unaltered character, now with associated
documented fever of 38.5°C, chills, and flank pain. With no associated frequency, urgency,
hesitancy, dribbling, hematuria, change in urine caliber and genital pruritus and discharge. Patient
self-medicated with ibuprofen 325mg paracetamol 200mg (Alaxan) once and paracetamol
(biogesic) 500mg every 6 hours which offered temporary relief of fever. However, painful urination
persisted. Still no consult done.
One day prior to consult, still with painful urination and associated symptoms. Patient took
amoxicillin 500mg 2 x a day for flank pain and paracetamol 500mg every 6 hours which afforded
temporary relief of fever and flank pain. Still no consult done.
Three hours prior to consult, with the persistence of the above signs and symptoms prompt
the patient to seek consult in our institution.
FAMILY HISTORY;
Her father 62 years old and her mother 57 years old both are alive and apparently well. Her
four other siblings are alive and well. Has a family history of hypertension and diabetes on paternal
side and , asthma on maternal side. She denies of other heredo- familial diseases like liver and
kidney disease and cancer. She denies of any familial diseases such as pneumonia, pulmonary
tuberculosis and hepatitis.
OB/GYNE HISTORY:
Menarche at 13 years old, with regular interval, lasting for 5 days consuming 3-4 pads per
day, moderately soaked with associated headache and dysmenorrhea. Last menstrual period was
May 15-20, 2010 and previous menstrual period was last April 15-20 , 2010. Her ob score is G3P2
(2-0-1-2)
REVIEW OF SYSTEMS
PHYSICAL EXAM:
General survey: Patient is conscious, coherent, ambulatory not in cardiorespiratory distress with
the following vital signs:.
BP – 100/70 Temp- 36.7 PR: 75 RR: 20 Weight 42 kg Height 152 cms BMI : 18 kg/m2
(underweight)
CHEST AND LUNGS: symmetrical chest expansion, no retractions, no lagging, equal and vocal
tactile fremitus, clear breath sounds
HEART: adynamic precordium, point of maximal impulse at 5th ICS left midclavicular line, normal
rate with regular rhythm, no murmurs.
ABDOMEN: flat abdomen, normoactive bowel sounds, soft, non tender on deep and light palpation.
Positive right kidney punch test. Negative rovsings, psoas and obturator sign. No rebound
tenderness.
EXTREMITIES: grossly normal extremities, no cyanosis, no edema, with full and equal pulses on
radial, brachial and dorsalis pedis artery
Internal Examination: External genitalia is grossly normal, vagina accepts 2 finger with ease, cervix
is firm, non-tender, no foul smelling vaginal discharge, no bloody discharge, no mass noted,no
tenderness, uterus is not enlarged
Progress Notes
S> Patient came back with CBC with APC and Urinalysis result. Patient still complains of
dysuria and flank pain. No fever and no chills.
O> Patient is conscious, coherent, ambulatory, not in cardiorespiratory distress with the
following vitals signs of:
BP: 100/ 70 mmhg PR: 75 bpm RR: 19 cpm Temp 36.5
Flabby normoactive bowel sounds soft, non tender on light and deep palpation. (+)
right kidney punch test
URINALYSIS;
MACROSCOPIC ANALYSIS:
Color – yellow
Transparency – turbid
CHEMICAL ANALYSIS
Reaction – alkaline
Specific gravity – 1.015
Sugar – negative
Protein – negative
MICROSCOPIC ANALYSIS
RBC – 15-20
WBC – 25-30
EPITHELIAL CELLS – many
BACTERIA – many
HEMATOLOGY
WBC ct: 4.04 x109/L
Segmenters: 0.62
Lymphocytes: 0.28
Monocytes: 0.09
Eosinophils: 0.01
Salient features:
This is a case of a 30 year old, female who came in with a chief complaint of painful urination
With associated:
Fever
Chills
Flank pain
With no associated:
Nausea
Vomiting
Frequency
Urgency
Hesitancy
Dribbling
Retention
Hematuria
Change in urine caliber
Passage of stone or sandy material
Genital pruritus and discharge
On PMH:
(+) History of Urinary tract infections last 2001 and 2004
(-) history of kidney disease
On FH:
(+) family history of Hypertension and Diabetes on paternal side
On Psychosocial history:
She is fond of eating sweet and salty foods
Drinks 3-4 glasses of water/ day
Has a habit of holding urine
With poor perineal hygiene
Physical Examination was centered on:
ABDOMEN: flat abdomen, normoactive bowel sounds, soft, non tender on deep and light
palpation. Positive kidney punch test. Negative rovsings, psoas and obturator sign. No
rebound tenderness.
Internal Examination: External genitalia is grossly normal, vagina accepts 2 finger with
ease, cervix is firm, non-tender, no foul smelling vaginal discharge, no bloody, no mass noted,
uterus is not enlarged.
Progress Notes
S> Patient came back with CBC with APC and Urinalysis result. Patient still complains of
dysuria and flank pain. No fever and no chills.
O> Patient is conscious, coherent, ambulatory, not in cardiorespiratory distress with the
following vitals signs of:
BP: 100/ 70 mmhg PR: 75 bpm RR: 19 cpm Temp 36.5
Flabby normoactive bowel sounds soft, non tender on light and deep palpation. (+)
kidney punch test
The ureter
• 10 in long muscular tube that extends from kidneys to post. wall of the bladder
• 3 physiologic constrictions:
o ureteropelvic jxn
o as it crosses the pelvic brim
o uretero pelvic junction
• 3 divisions:
o abdominal ureter
o pelvic ureter
o intravesical ureter
• 3 blood supply:
o renal atery- supplies the abdominal ureter
o testiculo-ovarian artery- supplies the pelvic ureter
o superior vesical artery- supplies the intravesical ureter
• Lymphatic drainage: iliac and lateral aortic nodes
The bladder
• receptacle for the storage of urine
• lies behind the pubic bones
• has a maximum capacity of 500ml; conscious desire to urinate at 150 ml
• empty bladder lies in the pelvis, as it fills it rises into the hypogastric region
• has strong muscular wall able to hold 750 to 1000ml
• apex- points anteriorly and immediately behind the upper margin of s.pubis
• base: faces posteriorly; ureters join the bladder at its superolateral angles
• superior surface- covered by peritoneum and related to coils of SI
• inferolateral surface- lie in contact with obturator internus(above) and levator
ani(below)
• neck- rest on the upper surface of prostate in males
• lymphatics: int and ext iliac nodes
• bld supply:superior and inferior vesical artery
• Venous drainage: vesical venous plexus--> internal iliac vein
• nerve supply: inferior hypogastric plexusThe circular component of the muscle coat
condenses as an (involuntary) internal urethral sphincter around the internal orifice. This
can be destroyed without incontinence providing the external sphincter remains intact (as
occurs in prostatectomy).
The urethra
Male urethra
• 8in (20cm) long
• divided into:
o prostatic urethra- 1.25 in ling, traverses the prostate
o membranous urethra- 0.75 in long; pierces the external sphincter urethra
o spongy urethra- traverses the corpus spongiosum of the penis
Female urethra
• 1.5in (4cm) long; it traverses the sphincter urethrae
• lies immediately in front of, indeed embedded in the wall of, the vagina
• external meatus opens 1in (2.5cm) behind the clitoris.
2 sphincters:
Internal:
• involuntary
• stretch receptors transmits impulse to brain once urine volume reaches 300ml
• located at the bladder neck
External:
• voluntary
• located on the terminal portion of urethra
Renal physiology:
Urine formation:
• Glomerular filtration
o filtration of blood occurs in the glomerulus. Fluid, electrolytes and other
substances are filtered out of the blood. The process requires adequate
amount of blood and blood pressure
• Tubular reabsorption
o reabsorption of water, glucose and important ions into the blood occurs
primarlly in the PCT, LOH, and DCT. it reclaims the important substances
needed by the body.(Na, K, Cl, HCO3)
• Tubular secretion
o occurs primarily in DCT; secretion of ions, nitrogenous waste, and drugs.
Substances move from the blood to the filtrate.
Symptoms related to Voiding
Obstructive
• urgency, frequency, hesitancy, intermittency, nocturia, sense of incomplte voiding and weak
urinary stream
• most common cause in men: BPH
• Urethral stricture
Irritative
• Dysuria, frequency, urgency
• imply inflammation of urethra, prostate or bladder
• commonly caused by infection & malignancy in patients w/ symptoms that persist after
treatment with appropriate antibiotics
Urinary Tract Infection (UTI)
exists when pathogenic microorganisms are detected in the urine, urethra, bladder, kidney, or
prostate. In most instances, growth of 105 organisms per milliliter from a properly collected
midstream "clean-catch" urine sample indicates infection. Regardless of symptomatic or
asymptomatic.
(Uropathogens)
E. Coli (>85%)
- normal commensal of GIT
- most common route E Coli from GIT-->colonized in periurethral meatus--> ascend to the
bladder, urethra or even the kidney.
- Hematogenous route
- Lymphatic route: unknown connection between LN to kidney or the renal parenchyma.
Salmonella Infection
- px with Typhoid fever, there is bacteremic base. Evidence of pus cell, bacteria in urine exam
as part of the findings of salmonella infection.
- Hematogenous seeding
Other gm (–) organism such as Klebsiella, Proteus, Pseudomonas.
S. saprophyticus and E. Coli – more common in young sexually active female.
most frequent isolates in patients with renal calculi due to their ability to split urea:
- Proteus
- Klebsiella
- Ureaplasma urealyticum
Organism causing UTI thru hematogenous seeding are:
- S. aureus
- P. aeroginosa
- Salmonella
- Candida
Hemorrhagic cystitis in children is usually due to viral infxn.
Most common bacterial contaminants of urine culture:
- Staph. Epidermidis
- Corynebacteria
- Lactobacilli: N. bacterial flora in vagina.
- Gardnerellla vaginalis
- Anaerobic bacteria
*** In px w/ communication from gut to the bladder or urethra or w/ predisposing factors
(catheter, urinary obstruction) - true polymicrobial infxn.
*** Otherwise, consider it as contaminants.
Although female has shorter urethra and its closer to anus and vagina, there are host defenses.
- Presence of N. bacterial flora of vagina
- Elderly women are more prone to UTI because of the imbalance on hormone production that
maintains the normal flora.
- After broad spectrum antibiotics tx, normal bacterial flora of the vagina may also be
destroyed.
Bladder
- flushing effect during normal emptying of the bladder.
- Even if the organisms were able to attach to bladder mucosa, normal sloughing of bladder
mucosal cells are carried out by micturition.
Ureter
- The opening of the ureter closes due to bladder contraction during micturition. If there is
incompetence of the valve (predisposition to UTI) during bladder contraction, there will be
urine back flow up into the ureter.
- N. peristalsis makes it hard for org to climb up against the continuous flow of urine. in the
occurence of reflux, org will be able to ascend from bladder up to kidneys.
Kidney
- even if the org were able to reach the kidney, fluid in medulla is hypertonic w/c is not a good
medium for bacteria to multiply.
UUTI
may or may not have signs and symptoms of LUTI
most prominent sign is fever
Tissue invasion, stimulating proliferation of leukocyte; therefore, dev leukocytosis and hence
manifested as fever
PE: Positive kidney punch (costovertebral angle tenderness)
Lab Dx
Urinalysis
Pyuria
can be detected only by urinalysis
urine cytometer method: >10 leukocytes/ mm3 is significant
Direct microscopic exam of urinary sediment
- can be done with routine urinalysis
- >10 leukocytes count is significant
Urine dipstick for presence of leukocyte esterase
- Change color from white to violet/ pinkish
Bacteriuria
Direct Microscopy
Gram’s stain of the urinary sediment
Chemical test
•Nitrate production test (dipstick)
• Color change due to the conversion of nitrite to nitrate
Significant Bacteriuria is >100,000 CFU
o Pre-treatment urine C/S, Urine microscopy and dipstick Leukocyte esterase are not
prerequisites for treatment (Grade E).
• Ampicillin and amoxicillin should not be used due to because of consistently high rates of
resistance of E.coli to ampicillin and amoxicillin locally (40% to 80%) (Grade E).
• In healthy elderly women presenting with signs and symptoms of acute cystitis, a three
.day course of any of the antibiotics listed above can be used (Grade A).
• Patients whose symptoms worsen or do not improve after 3 days should have a urine
culture and antimicrobials should be changed empirically, pending result of sensitivity
testing (Grade C).
• Patients whose symptoms improved but do not completely resolve after 3 days,
complete 7 day course of the same antimicrobial.
• Pateints whose symptoms failure resolve after 7 days, should be managed as
complicated UTI (Grade D).
Treatment
Non-pregnant patients with no signs and symptoms of sepsis, who are are likely to
adhere to treatment & return for follow-up treated as Out patients(Grade B).
Initial parenteral dose of ceftriaxone may be given followed by an oral antibiotic
(Grade B).
IV antibiotics can be shifted to oral antibiotics once the patient is afebrile and can
tolerate oral drugs. Choice should be guided by urine culture and sensitivity
results (Grade B).
The following factors are considered indications for admission (Grade B):
Inability to maintain oral hydration or take oral medications (eg. Vomiting
patients).
Concern about adherence to treatment
Presence of complicating conditions
Severe illness w/ high fever, severe pain, marked debility and signs of sepsis
Aminopenicillins & 1st generation cephalosporins are not recommended due to high
prevalence of resistance and increased recurrence rates (Grade C).
TMP-SMX- not given for empiric treatment due high resistance rates and should used
only when the org is susceptible on urine culture and sensitivity (Grade E).
Recommended duration of treatment is 14 days. Selected fluoroquinolones can
be given for 7-10 days (Grade A).
Empiric treatment regimens for uncomplicated acute pyelonephritis
Antibiotic and Dose Frequency and Duration
• ORAL
o Ofloxacin 400 mg BID; 14 days
o Ciprofloxacin 500mg BID; 7-10days
o Gatifloxacin 400 mg OD; 7-10 days
o Levofloxacin 250 mg OD; 7-10 days
o Cefixime 400 mg OD; 14 days
o Cefuroxime 500 mg BID; 14 days
o Amoxicillin-clavulanate 625 mg (when gram stain
o shows gram positive organisms) TID; 14 days
PARENTERAL (given until patient is afebrile)
o Ceftriaxone 1-2gm Q 24
o Ciprofloxacin 200-400mg Q 12
o Levofloxacin 250-500 mg Q 24
o Gatifloxacin 400 mg Q 24
o Gentamicin 3-5 mg/kg BW (+/-ampicillin) Q 24
o Ampi-sulbactam 1.5 gm (if with gram positive
o organisms on gram stain) Q6
o Piperacillin- tazobactam 2.25 – 4.5 gm Q6-8
A 7- to 14-day course of any antibiotics used for acute uncomplicated cystitis can be used
(Grade C)
Screeing and treatment is not recommended in the following group
Treatment
Indicated to reduce the risk that asymptomatic could become symptomatic (acute cystitis or
acute pyelonephritis) as well as to reduce the risk of prematurity or LBW infant.
Antibiotics is being initiated upon diagnosis
Drug: Nitrofurantoin(not for near term)
Amoxiclav,cephalexin and Co-trimoxazole(NEVER in the 1st & 3rd trimester)
Duration of treatment: 7 days(Grade C)
Follow-up culture is needed after completion of treatment to detect any relapse (Grade C).
Diagnostic test
Gram stain of uncentrifuged urine is recommended to differentiate gram (+) from
gram (-) which can guide the choice of empiric antibiotic treatment (Grade B).
Urine culture and sensitivity should be performed routinely to guide the choice of
antimicrobial agents because of the potential for serious sequelae of inappropriate
antimicrobial therapy(Grade B).
Blood cultures are not routinely recommended for pregnant patients with Acute
pyelonephritis (Grade D).
Treatment
Recommended duration of treatment is 10-14 days(Grade B).
Pregnant patients with signs and symptoms of APN should be hospitalized and
immediate antimicrobial therapy instituted(Grade B).
Pregnant patients with no signs and symptoms of sepsis and able to tolerate oral
meds- outpatient therapy(Grade B).
Antibiotics for acute uncomplicated pyelonephritis can be used.
Fluoroquinolones and aminoglycosides- contraindicated(Grade B).
In the absence of urine C/S, empiric choice of antibiotic should be based on local
susceptibility patterns of uropathogens(Grade C).
Post treatment urine culture should be obtained to confirm resolution of
infection(Grade C).
Patients should be monitored in intervals until delivery to confirm continued urine
sterility during pregnancy
Diagnostic work-ups
Routine screening for urologic abnormalities is not recommended for women with
recurrent UTI(Grade E).
Screening is recommended for patients with(Grade C):
gross hematuria during a UTI episode
obstructive symptoms
clinical impression of persistent infection
infection with urea-splitting bacteria
history of pyelonephritis
history of or symptoms suggestive of urolithiasis
history of childhood UTI
elevated serum creatinine
Choice of screening modalities: plain abdominal rediograph + renal UTZ(Grade B).
Patients with abnormalities should be referred to a nephrologist and/or urologist(Grade
C).
Treatment
Any antibiotics for AUC may be used(Grade B).
Diagnostic work up
Urine GS (Grade B)
Urine C/S(Grade B)
Indication for hospitalization
marked debility and signs of sepsis(Grade C)
uncertainty in diagnosis(Grade C)
concern about adherence to treatment(Grade C)
unable to maintain oral hydration or take oral medications(Grade C)
Treatment
mild to moderate illness- oral fluoroquinolones(Grade A)
severely ill patients- parenteral broad-spectrum antibiotics should be used
Recommended duration of treatment is at least 7-14 days of therapy(Grade B).
Duration and type of antibiotics- modified according to the results of the urine C/S.
Patients started with parenteral regimen may be switched to oral therapy upon clinical
improvement.
Antibiotics that may be used as empiric therapy for complicated UTI
Oral Regimen
Ciprofloxacin 250 -500 mg BID x 14 days
Norfloxacin 400 mg BID x 14 days
Ofloxacin 200 mg BID x 14 days
Levofloxacin 250-500 mg OD x 10-14 days
Parenteral Regimen
Ampicillin 1 gm q 6hrs + gentamicin 3 mg/kg/day q 24h
Ampicillin-sulbactam 1.5 gm to 3 gm q 6h
Ceftazidime 1-2 gm q 8h
Ceftriaxone 1-2 gm q 24h
Imipenem-cilastin 250-500 mg q 6-8 h
Piperacillin-Tazobactam 2.25 gm q 6
Ciprofloxacin 200-400 mg q 12hrs
Ofloxacin 200-400 mg q 12h IV
Levofloxacin 500 mg q 24h IV
UTI in DM patients
requires pre-treatment urine GS, culture and a post-treatment urine culture.
At least 7-14 days of oral antibiotics is recommended that achieves high
concentrations both in urine and urinary tract tissues.
Diabetic patients who presents with signs of sepsis should be hospitalized.
Urine and blood cultures prior to initiation of antibiotic therapy are indicated.
Failure to respond within 48-72 hours warrants a plain radiograph of KUB, a
renal UTZ, or a CT-scan (Grade C).
UTI in HIV/ AIDS Patients
Patients should be evaluated to include other non-bacterial pathogens if
clinically suspected and should be referred to an infectious disease specialist
(Grade C).
Urinary Candidiasis
Candiduria is defined as the presence of candida species regardless of the
colony count in properly collected urine specimens on two separate
occasions at least 2 days apart.
Treatment of asymptomatic and minimally symptomatic candiduria is not
recommended because it does not provide clear clinical benefit such as long
term eradication (Grade D).
UTI in renal transplant patients
UTI which develops on the first three months post-transplant
Treated with broad-spectrum antibiotics until urine culture becomes negative-->
shifted to oral agents according to urine culture and sensitivity results and
continued to complete for 4-6 weeks (Grade c).
UTI after the first 3 months post-transplant with no evidence of sepsis --> treat
as out-patient.
VII. Catheter-Associated UTI
Catheterized patients with significant bacteriuria of > 100 cfu/ml of urine, who develop
signs and symptoms of UTI or fever or other signs of bacteremia (Grade B).
Consider antibiotic treatment in the ff subset of catheterized px who have bacteriuria but
assymptomatic (Grade C):
those with org that cause high incidence of bacteremia in their instituion
post solid organ transplant
those who will undergo urologic procedures
neutropenic patient
pregnant patient
Who may be a part of an infection control plan to manage cluster of infections
in a unit
Indwelling catheters should be removed to help eradicate bacteriuria (Grade A).
Long term indwelling catheters should be replaced with new catheters before initiating
antibiotic therapy for asymptomatic UTI (Grade A).
Treatment
Seven-day antibiotic regimens are recommended.
TMP-SMX or fluoroquinolones may be used depending on prevailing susceptibility patterns in
the community or institution
B. PROSTATITIS SYNDROMES
Category Characteristic
I Acute bacterial Acute infection of the prostate gland characterized by fever,
prostatitis chills, low back pain and perineal pain. Irritative voiding
symptoms (dysuria, frequency, urgency, nocturia) are
characteristic. Rectal examination reveals a markedly tender,
swollen prostate.
Diagnostic work-up
DRE
Transrectal ultrasound
Seminal fluid analysis-recommended for the presumptive diagnosis of prostatitis (all
types), whether acute or chronic.
If there is no response within the first week, change the antimicrobial and do culture of EPS(Grade
C).
Inadequately treated acute bacterial prostatitis will cause complication Chronic bacterial
prostatitis
For chronic bacterial prostatitis, first of line treatment is a quinolone such as:
• Ciprofloxacin 500 mg BID for 28 days(Grade C).
• Ofloxacin 200 mg BID for 28 days (Grade C)
• Norfloxacin 400 mg BID for 28 days (Grade C)
Radical transurethral resection of the prostate or total prostatectomy- for men with
recalcitrant chronic bacterial prostatitis
For symptomatic relief, Sitz baths, anti- inflammatory agents, prostatic massage and other
supportive measures can be given(Grade C).
Long-term, low-dose suppressive therapy may be required for patients who do
not respond to full dose treatment. TMP-SMX 80/400 mg once daily is recommended for 4 to
6 weeks(Grade C)
Heat treatment may be useful to relieve chronic pelvic pain syndrome (Grade C).