URINARY TRACT INFECTIONS URINARYTRACTINFECTIONS

BerylNavti
SEPTPharmacyDepartment
24/06/2013 BerylNavti,ClinicalPharmacist,SEPT
TheGenitourinarySystem
Theorganssystemofthereproductiveorgansandurinary
system
G d t th b f th i i it t h th Groupedtogetherbecauseoftheirproximitytoeachother
Thegenitourinarysystemisthethirdofthebodyssystems
open to the outside world opentotheoutsideworld
Pathogensusethisasaportalforentryintothebody
Healthcare professionals see many infections in this area Healthcareprofessionalsseemanyinfectionsinthisarea
Thispresentationdealsspecificallywithurinarytract
infections as they are commonly seen in mental health infectionsastheyarecommonlyseeninmentalhealth
hospitalwards
24/06/2013 BerylNavti,ClinicalPharmacist,SEPT
Urinarysysteminfections
Urineissterile
Presenceofinflammatorycellsorpathogensinurineindicate
i t t i f ti (UTI) aurinarytractinfection(UTI)
Urinarytractinfectionisthemostcommonbacterialinfection
managed in general medical practice managedingeneralmedicalpractice
Accountsfor13%ofconsultations
Up to 50% of women will have a UTI at some point in their life Upto50%ofwomenwillhaveaUTIatsomepointintheirlife
UTIuncommoninmenexceptovertheageof60when
urinary tract obstruction due to prostatic hypertrophy may urinarytractobstructionduetoprostatichypertrophymay
occur
24/06/2013 BerylNavti,ClinicalPharmacist,SEPT
UrinarySystemInfections
Serious problem in hospitals Seriousprobleminhospitals
Causemorbidity
Pathogens can travel up the ureters and reach the kidneys in a Pathogenscantraveluptheuretersandreachthekidneysina
smallminorityofcases,causingrenaldamageandkidney
failure
UTIsarenamedaccordingtheplaceofinfection
Intheurethra=Urethritis
Inthebladder=Cystitis
Inthekidneys=Nephritis y p
Intheprostate(men)=prostatitis
Majorityofinfectionsarecausedbybacteria,thoughsome j y y , g
arefungal
24/06/2013 BerylNavti,ClinicalPharmacist,SEPT
B i f A BriefAnatomy
24/06/2013 BerylNavti,ClinicalPharmacist,SEPT
OOVERVIEW

InfectionsoftheGenitourinarySystem

y y

UrinaryTractInfections
(UTIs)
ReproductiveSystemInfections

ViralInfectionsof
thereproductive
t
Fungalinfectionsof
thereproductive
t
Bacterialinfections
ofthe
d ti
UTIinthe
community
UTIinthe
hospital
system system reproductive
system
Organisms
causingUTIinthe
community:
Escherichiacoli
Proteus
Escherichiacoli
Streptococci
Klebsiella
species
Proteus
Pseudomonas
Streptococci
Staphylococus
24/06/2013 BerylNavti,ClinicalPharmacist,SEPT
aureus
Bacterial UTIs BacterialUTIs
Urineisanexcellentculturemediumforbacteria
Bacteriaenteringthebladderfromtheexternalenvironmentorblood
passingthroughtherenalarterycannormallybeflushedoutduring
urination
Infectionsoccurwhenbacteriagetintotheurineandremain
Asallportionsoftheurinarytractconnecttoeachother,infectionspreads
il easily
Moreeasilyinwomenbecauseofashorterurethraandabsenceof
bacteriostaticprostaticsecretions(asinmen)
Catheterisationmayalsointroduceorganismsintothebladder
24/06/2013 BerylNavti,ClinicalPharmacist,SEPT
RiskFactorsforUrinaryTractInfection
Incompletebladderemptying: p p y g
Bladderoutflowobstruction
Neurologicalproblems(eg multiplesclerosis,diabetic g p ( g p ,
neuropathy)
Gynaecologicalabnormalities(eg uterineprolapse)
Foreignbodies:
Urethral catheters Urethralcatheters
Uretericstent
Lossofhostdefences:
Atrophicurethritisandvaginitisinpostmenopausalwomen
Diabetes mellitus
24/06/2013 BerylNavti,ClinicalPharmacist,SEPT
Diabetesmellitus
SymptomsofUTIs
Typicalfeaturesofcystitis andurethritis include:
Abruptonsetoffrequencyofmicturition(urination)
Scaldingpainintheurethraduringmicturition(dysuria)
L b k i bd i l i d t d bl dd Lowerbackpain,abdominalpainandtendernessoverbladder
Suprapubic painduringandaftervoiding
Intense desire to pass more urine after micturition due to spasm of Intensedesiretopassmoreurineaftermicturitionduetospasmof
inflamedbladder(urgency)
Urinethatmayappearcloudyandhaveanunpleasantsmell
Presenceofbloodintheurine(haematuria)
Cystitishasmoreacuteonsetandseveresymptoms
Systemic symptoms suggestive of pyelonephritis: Systemicsymptomssuggestiveofpyelonephritis:
Feverabove38.3C
Loin pain Loinpain
maybeindicationforhospitalisation
24/06/2013 BerylNavti,ClinicalPharmacist,SEPT
Symptoms continued Symptomscontinued
Prostatitis is suggested by Prostatitisissuggestedby
Paininthelowerback,perirectalareaandtesticles
Highfever,chillsandsymptomssimilartobacterialcystitis g , y p y
Inflammatoryswellingofprostate,whichcanleadtourethral
obstruction
h h b f l Urinaryretention,whichcancauseabscessformationorseminal
vesiculitis
24/06/2013 BerylNavti,ClinicalPharmacist,SEPT
DiagnosingUTIs g g
Basedonexaminationoftheurine
Requires collection of a clean voided midstream Requirescollectionofacleanvoidedmidstream
sample
Urine dipstick tests can be used to test for UTI UrinedipsticktestscanbeusedtotestforUTI
Onetestsfornitritemosturinarypathogens
can reduce nitrate to nitrite canreducenitratetonitrite
Anothertestsforleucocyteesterase,suggestingthepresence
of neutrophils. If either test is positive, UTI is probable and if ofneutrophils.Ifeithertestispositive,UTIisprobableandif
botharenegative,UTIisunlikely
Mostpositivewaytoconfirmisagramstainofurinesample p y g p
andonebacteriumperoilimmersionfieldindicatesinfection
Definitivediagnosisrestsoncombinationoftypicalclinical
24/06/2013 BerylNavti,ClinicalPharmacist,SEPT
featureswithfindingsintheurine
Investigationstodetectunderlyingfactors
MostlyforpatientswithrecurrentUTIs:
Cultureofmidsteam urinesample(MSU)orurinefromsupra
bi i ti pubicaspiration
Microscopicexaminationorcytometry for
hi d d ll whiteandredcells
Dipstickexaminationofurineforblood,
d l proteinandglucose
Bloodcultureiffever,rigorsorevidenceofsepticshock
PelvicexaminationforwomenwithrecurrentUTI
Cystoscopyifpatientshavesuspectedbladderlesion
24/06/2013 BerylNavti,ClinicalPharmacist,SEPT
Treatment of UTIs TreatmentofUTIs
AntibioticsarerecommendedinallprovencasesofUTI
Treatmentisbestguidedbyantimicrobial g y
susceptibilitytests
However,whereaurineculturehasbeenperformed
treatmentcancommencewhilewaitingforresults
Treatmentforthreedaysisthenorm,deemedless
likely to induce antibiotic resistance likelytoinduceantibioticresistance
Sulfonamides andTrimethoprimarecommonlyused,butTrimethoprimis
theusualchoiceforinitialtreatment
1040%oforganismsareresistanttoTrimethoprim
Nitrofurantoin ,quinoloneslikeCiprofloxacinandNorfloxacin,aswellas
Cefalexin are generally effective Cefalexin aregenerallyeffective
OnlyuseCoamoxiclav orAmoxicillinwhenorganismisknowntobe
sensitive
24/06/2013 BerylNavti,ClinicalPharmacist,SEPT
T t t f UTI TreatmentofUTIs
24/06/2013 BerylNavti,ClinicalPharmacist,SEPT
TreatmentofUTIs:Algorithm
YES
ComplicatedUTI?
Pregnancy
Obtain urine culture

NO
g y
Elderlypatient
Underlyingmedicalcondition
Abnormalityofurinarytract
Obtainurineculture
Tailortreatmenttocultureresult

YES

Pyelonephritis?
Fever
Flankpain
Symptoms>7days
Treatforuncomplicated
pyelonephritis

NO
YES
NO
Acuteuncomplicatedcystitis/urethritis? Treataccordingly
NO

YES
Riskfactorsforantibioticresistance?
CurrentorrecentuseofTrimethoprim
Recenthospitalisation
Usealternativeagentsuchas
aquinoloneforthreedaysor
f f d

NO
RecentUTI(inthepastyear?)
Trimethoprimtablets
nitrofurantoinfor7days
24/06/2013 BerylNavti,ClinicalPharmacist,SEPT
200mgtwiceadayforthreedays
TreatmentofUTIsAntibioticdoses
l h l h l LowerUrinary Tract
Infection
AcutePyelonephritis BacterialProstatitis Prophylactic
therapy
Trimethoprim 200mg twiceadayfor
threedays
200mgtwiceadayfor
714days
200mgtwiceadayfor
46weeks
100mgatnight
Nitrofurantoin 50mgfourtimesaday
forthreedays
50mgfourtimesdaily
for714days
50100mgatnight
Coamoxiclav 375mg8hourly for
three days
375mg8hourlyfor
714days

threedays 7 14days
Ciprofloxacin(adjust
dosein renal
impairment)
100mg12hourlyfor
threedays
250mg500mg every
12hoursfor714days
250mg12hourlyfor
46weeks

Norfloxacin (adjust
doseifrenalfunction
impaired)
400mg12hourlyfor
threedays
400mg12hourlyfor
714days
400mg12hourlyfor
46weeks

Cefuroxime (adjust 250mg12hourly or ( j
doseifrenalfunction
impaired)
125mg 12hourlyfor
threedays
g y
750mg68hourlyIV
inseriouslyillpatient,
for714days

Cefalexin 500mg12hourlyfor 500mg12hourlyfor 125mgatnight
threedays threedays
24/06/2013 BerylNavti,ClinicalPharmacist,SEPT
Specialconsideration:Olderadults
PrevalenceofUTIriseswithageespeciallyamongst
theoldandfrailininstitutionalcare(40%inwomen)
Contributingfactorsincludeincreasedprevalenceof
d l i l b li i l d fi i i underlyingstructuralabnormalities,postmenopausaloestrogendeficiencyin
women,prostatichypertrophyinmen,amongstothers
Theurinarytractisthemostfrequentsourceofbacteraemiainolder y q
patientsadmittedtohospital
Symptomsmaynotfollowclassicpatternsseeninyoungeradultsand
fever might not occur fevermightnotoccur
Patientswithunderlyingconditionssuchasdementiamayfinditdifficult
toexplainsymptoms
Agitation,changeinmentalstateorotherbehaviouralchangesmaybethe
onlysignofUTIinelderlymenandwomen
Left untreated UTI can lead to delirium or even death in an elderly Leftuntreated,UTIcanleadtodeliriumorevendeathinanelderly
patient
24/06/2013 BerylNavti,ClinicalPharmacist,SEPT
SpecialConsideration:RecurrentUTIs
Failureoftreatment,withpersistenceofcausativeorganismonrepeat
lt t d l i di i ti ti d culturemaysuggestunderlyingcauseneedinginvestigationand
treatment
Reinfectionwithadifferentorganismorwiththesameorganismafteran g g
intervalmayalsooccur
Recurrentinfectionsarecommon,sofurtherinvestigationisonlyjustified
if infections exceed three to four times a year ifinfectionsexceedthreetofourtimesayear
Ifunderlyingcausecannotbeidentifiedorremoved,prophylactic
antibiotictherapycanbeusedtopreventrecurrence
Thisistoreduceriskofsepticaemiaandrenaldamage
RecurrentUTIs,particularlywherethereareunderlyingcauses(e.g
catheterisation) can result in permanent kidney damage catheterisation)canresultinpermanentkidneydamage
24/06/2013 BerylNavti,ClinicalPharmacist,SEPT
Measures to prevent UTIs MeasurestopreventUTIs
Keeppatientshydrated(Fluidintakeofatleast2litresperday) p p y ( p y)
Encourageregularcompleteemptyingofthebladder
Goodpersonalhygiene p yg
Forwomen,avoidfemininehygienesprays
Encouragefronttobackcleansing cou age o t to bac c ea s g
Showerspreferabletobaths
Cranberry juice maybe effective Cranberryjuicemaybeeffective
Frequentlychangethosewhouseincontinencepads
Set reminders/timers for those who are memoryimpaired to Setreminders/timersforthosewhoarememory impairedto
usethebathroom
24/06/2013 BerylNavti,ClinicalPharmacist,SEPT
CaseStudy
Ann is an 80 year old widow admitted to an elderly mentally ill (EMI) acute Annisan80yearoldwidowadmittedtoanelderlymentallyill(EMI)acute
unitdiagnosedwithdepression
Shehasbeenstableforafewweeksandisbeingconsideredfordischarge
Shewakesupthismorningirritableandagitatedandrefusesherbreakfast
Asnursestrytocalmher,shebecomesaggressive,shoutingthatshe
wants to go home as her husband is waiting for her for his tea wantstogohomeasherhusbandiswaitingforherforhistea.
Shebargesintothewarddoctorsoffice,sitsdownandsaysshesnot
leavinguntilthedoctorsaysshecangohome
Anursecomesinandtalkscalmlytoherandpersuadeshertoleavethe
office.AsAnngetsup,sheswoonsandhastobesteadied,whilethe
doctornoticesthatshewetherselfwhilesittingdown g
Shehasneverwetherselfbeforeanddoesntnormallyneedhelpwith
toileting
A i bbi ll bl Annisnowsobbinguncontrollably
24/06/2013 BerylNavti,ClinicalPharmacist,SEPT
Questions from case study Questionsfromcasestudy
Pleasereadthesequestionsandtrytoanswerthem.
Theanswersareonthenextslide.
1.Whatactionshouldbetakenbythewarddoctor?
2.Whatarethepresentingfeatures,signsandsymptomsofUTI
inolderadults?
3.Howdothesedifferfromyoungeradults
4.WhatorganismsusuallycauseUTI?
5.WhatarethemanagementrecommendationsforUTIinolder
adults?
6 Wh l b k d i id f UTI i 6.WhatgeneralstepscanbetakentoreduceincidenceofUTIsin
hospitalwards?
24/06/2013 BerylNavti,ClinicalPharmacist,SEPT
Answers to the case study questions Answerstothecasestudyquestions
1. Urine dipstick of MSU sample
2. Agitation, confusion, urinary incontinence, can lead to
delirium
3 Y d lt t ith i d i 3. Younger adults present with urinary urgency, dysuria,
frequency of urination, abdominal pain
4 Most common organismis Escherichia Coli tho gh 4. Most common organism is Escherichia Coli, though
Klebsiella and some streptococci are also seen in
hospital hospital
5. Antibiotic therapy
6 Keeping patients hydrated helping patients maintain 6. Keeping patients hydrated, helping patients maintain
good personal hygiene and encouraging bladder
emptying, general cleanliness on wards etc
24/06/2013 BerylNavti,ClinicalPharmacist,SEPT