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UTI- an infection of the kidneys, bladder, or urethra - Coggle Diagram
UTI- an infection of the kidneys, bladder, or urethra
Classification
Lower- Cystitis, urethritis and Prostatitis
Upper- pyelonephritis
main causative bacteria E.Coli
Anatomy
Ureters
ureteropelvic junction, ureteral segment, ureterovesical junction
Transport urine to bladder
Bladder
muscular organ that holds urine
4 walls- adventitia, detrusor muscle, lamina propria, urothelium
Kidneys
sit between T11 nd L3. The left kidney sits higher than the right. Divided into 3 sections, Cortex, Medulla and Sinus
Arterial blood supplied by Aorta-Renal Artery- Segmental Artery-Interlobular artery-cortical radiate artery- afferent arteriole- glomerulus
Venous Drainage -GLOMERULUS → Efferent arteriole (has branches forming the Vasa recta) → Arcuate vein → Interlobar vein → Renal Vein → Inferior vena cava
Nephrons divided into cortical and juxtamedullary
make the urine
Urethra
passageway through urine is excreted out the body
female 3-4cm, male +18cm
Risk Factors
Female gender, menopause, pregnancy, recurrent UTIs, FHx UTIs, catheterisation, elderly, reduced functional status, sexual intercourse, diabetes, urinary obstruction, immunosuppressed, GU malformation, incontinence. Reduced fluid intake
Signs and Symptoms
Upper UTI- Loin pain, fever, Nausea/Vomiting, Diarrhoea, General Malaise
Other symptoms particularly in elderly - lethargy, delirium, falls, acute confusion, reduced dietary and fluid intake, change in level of function with ADL.
Lower UTI- frequency, dysuria, nocturia, haematuria, suprapubic discomfort, urgency. Urine may be discoloured, cloudy or odour
Pyelonephritis - fever, flank/back pain, nausea/vomiting
References
https://handbook.ggcmedicines.org.uk/guidelines/infections/urinary-tract-infections-utis/
https://armandoh.org/disease/urinary-tract-infection/
https://cks.nice.org.uk/urinary-tract-infection-lower-women
https://www.guidelines.co.uk/infection/sign-suspected-uti-in-adults-guideline/252604.article
https://www.nhsggc.org.uk/media/256411/infection-management-in-adults-guidance-for-primary-care-poster-2019.pdf
https://www.rcgp.org.uk/clinical-and-research/resources/toolkits/-/media/30AFCD12F74F4EA3B456ECF9B21D0F80.ashx
Differential
DKA or HSS
Appendicitis
Other source of infection
constipation
Pancreatitis/Gallstones
dehydration
AAA
STI
renal colic
cancer
sepsis
Diagnosis
Ix- in non pregnant women ie no fever or flank pain.
Perform culture in all treatment failures
Examination- Vital signs. Abdominal examination.- Palpate for suprapubic tenderness and kidney tenderness to confirm Lower or Upper UTI. Review of all systems, in elderly may require Respiratory examination to exclude other infections.
Hx of symptoms over minimum of 3 days. PMHx, DHx, FHx, SHx, surgical Hx. Affect on life and other systems.. Recent hx of infection. What measures have they tried recently and in the past. Past egfr
Ix- lower UTI in adult men. Lower UTI in pregnant women. Acute prostatitis- always perform culture
Ix - CAUTI-Catheter associated UTI (.UTI) Antibiotic treatment if one of the following symptoms • New onset costovertebral tenderness, • Rigors, • New-onset delirium, • Fever > 37.9 degrees
Ix-Upper UTI/Pyelonephritis (men/non-pregant females) (.UTI) Send MSU for culture and start empiric treatment immediately
Ix - Recurrent UTI (≥ 3 a year or 2 in 6 months)
Management
Lower UTI in pregnancy
Short-term nitrofurantoin is unlikely to cause problems to the foetus 1st line: Nitrofurantoin (1st or 2nd trimester) 50mg QDS or 100mg MR BD 2nd line: Amoxicillin (ONLY if susceptible) 500mg TDS or *Cefalexin 500mg TDS Duration 7 days
Acute Prostatitis
*Ciprofloxacin 500mg BD or Trimethoprim 200 mg BD Duration 14 days then review
Lower UTI adult men
Trimethoprim 200 mg BD or Nitrofurantoin 100mg M/R BD or 50mg QDS Duration 7 days
Uncomplicated lower UTI
Treat empirically if ≥ 3 symptoms or dysuria and frequency (consider dipstick testing to guide requirement for treatment if mild/ ≤ 2 symptoms, otherwise well and < 65 years)
Trimethoprim 200 mg BD or Nitrofurantoin 100mg M/R BD or 50mg QDS Duration 3 days
CAUTI
catheter change first
Nitrofurantoin 100mg M/R BD 50mg QDS or Trimethoprim 200 mg BD Duration 7 days
Do not treat asymptomatic bacteriuria unless pregnant. Consider self management with NSAID / delayed prescribing if only mild UTI symptoms in non-pregnant women
In patients with eGFR<30ml/min trimethoprim should be used with caution and nitrofurantoin is
contraindicated (use nitrofurantoin with caution at eGFR 30-44ml/min for short term use only)
Upper UTI/Pyelonephritis
Trimethoprim 200mg BD (if sensitive organism suspected) or
Co-amoxiclav 625mg TDS or if true penicillin allergy
Ciprofloxacin 500mg BD Duration 7 days
If sepsis or vomiting or if no response within 24 hours admit
Recurrent UTIs
lifestyle measures (e.g. hydration) 2. post coital / stand by antibiotics 3. trial of nightly prophylaxis for 3-6 months Nitrofurantoin 50mg at night (or 100mg stat) or Trimethoprim 100mg at night (or 200mg stat) Stat when exposed to trigger or od at night for 3-6 months
Referral
Immediately if sepsis suspected
no response to treatment within 24 hours
uncertainty with diagnosis