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APPROACH TO URINARY INFECTION IN PRIMARY CARE
ASSOC PROF HÜLYA AKAN,MD
DEPARTMENT OF FAMILY MEDICINE
Objectives
• At the end of this lesson students should be able to explain approach to
- Acute uncomplicated lower tract infection in women
- Recurrent lower tract infection in women- Acute upper tract infection (pyelonephritis) in
women- UTIs in men- UTI s in children
• The urinary tract is comprised of the kidneys, ureters, bladder, and urethra
• A urinary tract infection (UTI) is an infection caused by pathogenic organisms (for example, bacteria, fungi, or parasites) in any of the structures that comprise the urinary tract.
• Dysuria is the most prominent symptom and accounts for 3% of primary care office visits
• Approach to urinary infection differs according to age, sex and underlying diseases
• Acute uncomplicated lower tract infection in women
• Recurrent lower tract infection in women
• Acute upper tract infection (pyelonephritis) in women
• UTIs in men, children and geriatric population
• The most common causes of UTI infections (about 80% to 90%) are Escherichia coli bacterial strains that usually inhabit the colon.
• Klebsiella, Pseudomonas, Enterobacter, Proteus, Staphylococcus, Mycoplasma, Chlamydia, Serratia and Neisseria
• Some parasites (Trichomonas, Schistosoma) also may cause UTIs
Differential Diagnosis
• Vaginal atrophy
• Vaginitis
• Urethritis
• Interstitial cystitis
• Prostatitis
• Urethritis
Risk factors
• %10-20% of women have epithelium makes easy adherence of m.o.
• Colonization of vagina – use of contaceptive cream-jelly, nonoxynol-9
• Barrier use• Shorter distance between urethra and anus-
sexual intercourse• Fecal incontinence• Stasis of baldder
Risk factors of pyelonephritis
• Recurrent urinary tract infection
• Diabetes mellitus
• Recent incontinence
• New sexual partners
• Use of spermicide
• Mother with history of UTI
History
• Urinary frequency
• Dysuria
• Nocturia
• Suprapubic discomfort
• Urgency
• Malodorous urine
Probability of symptoms
•Dysuria+nocturia: %65
•Malodorus urine and nocturia or urgency or recurrence of symptoms fallowing UTI: 90%
•Vaginal complaints, external dysuria: STI /vaginitis
Physical Examination
• Vital signs
• Palpation of mid and lower abdomen
• Percussion of flanks
• Genital examination (prostatitis, vaginitis)
Red Flags for a complicated Infection
• Male gender• Infant or geriatric age• Symptoms more than 7 days• Immunosuppressive condition• Diabetes mellitus• Episode of acute pyelonephritis within the past
year• Known anatomic abnormality• Fever• Flank pain or tenderness
Laboratory Tests: Collecting specimen
• Midstream urine: First few seconds of urine is not collected
• Catheterization in infants and very young
• Plastic bag collection
Urinanalysis
Dry reagent test strip (dipstick)• Leukocyte esterase: Detects presence of
esterase from WBC. False positive: chlamydial infection, high urine pH, high levels of urine glucose, certain drugs
• Nitrite: Dietary nitrates are excreted into the urine and converted to nitrit by bacteria
False negative: Gram positive ones and Pseudomonas don’t convert nitrate to nitrite, E. Coli need sometime to convert and vegeterians
• Leucocyte esterase + nitrite: both positive and both negative is better predictor of infection presence or absence
• Blood:Peroxidase like activity
False positive: Myoglobin, peroxidase producing bacteria
Direct microscopy:• Centrifuge 10 ml freshly
voided urine, decanting the urine than resuspending the sediment
• Leukocyte:High-power field (x 400) 5 or more
• Bacteria: 10 or more ; if no bacteria rule out
• White cell casts
Urine Culture• Not cost-effective in routine care• Do it:- Children, men, geriatric population- Patients with red flags
- Younger women: Risk of upper tract infection
- Infection with bacteria not likely respond firt line antibiotics
Management: Acute uncomplicated lower tract infection in women
• Telephone directed• Ampiric antibiotic treatment: 3 days or 7 days
regimen
- Trimethoprim/sufamethoxazole
- Nitrafurantoin (7 days)
- Fluoroquinolone (e.g.ciprofloxacine)• Occult pyelonephritis: 7 days regimen• Phenazopyridine analgesia for severe dysuria
Management: Acute uncomplicated lower tract infection in women
• Recurrent infection: Urine culture and treat in the same way
• Prevention: • Patient initiated treatment• Unsweetened cranberry juice• Increasing fluid intake• 3 or more a year related STI: single dose
antibiotic after intercourse• Behavioral advices( not using pantyhose, wiping
font to back, postcoital voiding) have not been proven effective.
Acute Pyelonephritis inYounger Women
• Women who are medically stable and maintaining hydration with oral intake: Can be treated as outpatients
• Women who, because of severity of infection or underlying disability, are not medically stable or unable to take oral fluids or medications: Refer for hospitilization
• Women who have been infection complicated by abcess or obstruction, regardless of ability to take fluids by mouth
Adult Men with UTIs
• Differentiate lower or upper UTIs
• Differentiate prostatitis and urethritis
• Treat as complicated UTIs: - Order urine culture
pretreatment - First line usually
floroquinalone 14 days• After second infection or first
episode of pyelonephritis: Imaging for anatomic abnormality or nephrolithiazis
UTIs in Older Adults
• Atypic symptoms: Mental status change, tachpnea, tachycardia, fever, gait instability, or falls
• Pretreatment urine culture• 3 days regimen acceptable but 7-14 days are
prefered• Frequent relapses: Search for nephrolithiazis or
urinary retention• Elder women: Local estrogen decrease
repeating gram negative organisms
UTIs in Children
• Girls: 5-8 %• Boys: 1-2 %• Noncircumsized v
circumsized• Young children:
perineal colonization• Older children: stasis• Vesicoureteral reflux:
30-50 %
• First year of life: unexplained fever consider UTIs
• Neonates: Late-onset jaundice, Poor weight gain, Irritability, Hypothermia
• Infants: Diarrrhea , vomiting, failure to thrive
• School children: Back pain, abdominal pain, incontinence
• Urinanalysis has limited sensitivity in young children; Urine culture routinely
• Older children dipstick and urine microscopy have similar sensitivity and specifity as in adults
• Older than 3 mo: 3 days antibiotic regimen if no systemic signs
TMP/SMXAmoxicillin/clavunateNitrafurantoinThird generation cephalosporins• Younger than 3 mo: refer for hospitilization;
treated with parenteral antibiotics• Urine culture after cpmpletion of treatment to
confirm successful treatment