(3/23) Schriever C Lecture: Urinary Tract Infections & Prostatitis Urinary Tract Infection (UTI) Classifications and Definitions

- Anatomical Site o Lower: Most common, including cystitis urethritis, and prostatitis o Upper: More severe, such as pyelonephritis

- Complication Status o Uncomplicated: UTI occurring in healthy women aged 15-45yo o Complicated: Everyone else

- Recurrence o Reinfection (Different bug) o Relapse (same bug)

- The Vice Versas o Asymptomatic bacteriuria o Symptomatic abacteriuria

Host Defense Mechanisms - Urinary Flow: The concentration of urea, pH, osmolality, and flow turbulence help to prevent infection - Bladder Spasms: Ascending bacteria can be sensed by the bladder, which will stimulate urination - Surface: Anti-adherence mechanisms to prevent bacterial attachment to the bladder

Epidemiology and Etiology - Prevalence of UTI varies primarily by age, gender, and comorbidities. A classic representation of the most

commonly affected is ‘the old, the young, and those with baggage (diabetes~)’. Additionally – mostly females - Pathophysiology: Infection is commonly associated with a breached host defense mechanism. The route of

infection is ascending o Structural abnormalities: Obstruction of urinary flow may be compromised due to prostatic hypertrophy

(enlarged prostate) and renal stones/calculi o Vesicoureteral reflux: Urinary backflow into the kidneys o Additional predisposing factors: Catheters, pregnancy, neurologic malfunction (stroke, DM) o Contributing Elements of pathogenicity:

§ Size of inoculum (how many bacteria threaten us at a time) § Virulence of the organism (such as fimbriae to adhere to the urinary anatomy) § Impaired host defense mechanisms (see above)

- Common pathogens: The majority of UTIs are caused by a single organism o Uncomplicated UTI ~ ‘Community-Acquired’

§ E. coli (>85%), Staphylococcus saprophyticus (5-15%), and other gram(-) and gut bacteria, such as Enterococcus faecalis and enterics

o Complicated ~ ‘Nosocomial’ § E. coli (50%) is still most common, but must also heavily consider other gram(-)s as well,

Enterococcus (30%), and Staphylococci o Atypical

§ S. epidermis: Generally a contaminant § S. aureus: Often bacteremia first, then shows in the urine § Candida: More common in the critically ill

Lower Tract Infections - This is the most commonly seen UTI, it is uncomplicated and may present with the following symptoms:

o Dysuria (pain), gross hematuria (blood in urine), nocturia, suprapubic heaviness or pain Upper Tract Infections

- When bacteria ascend outside of the bladder to the ureters and kidneys, symptoms become more systemic: o Fever, flank pain, costovertebral tenderness (this is the kidney pain in the back), abdominal pain o Elderly patients often present with mental status changes and altered appetite

Diagnosis of Urinary Tract Infections -Is it contamination, or an infection- - Urine is subjected to testing. It can be collected by:

o Midstream clean catch: Represents the urine that is in the bladder. Void, stop, then collect the mid-stream o Catheterization: Collecting a sample using a catheter may be more accurate though it is invasive o Suprapubic bladder aspiration: Very rarely done, only when suspecting very specific rare infections

- à Urinalysis o Dipstick: LE and Nitrate test are most important, but we can also evaluate pH, glucose, protein, ketones

§ Leukocyte Esterase (LE) test – it is a byproduct of WBC, which if present we can associate with inflammation and infection

§ Nitrate Reduction Test: If present, bacteria (gram(-)) in the urine will reduce nitrate to nitrite o Microscopic Exam is rarely done due to inconclusive and nonspecific results. Though can see WBC

- à Urine Culture: Can be used to quantify and assess susceptibility o Inoculating loop is calibrated to dip into urine, streak on agar plate, and do susceptibility tests

Basis of Treating UTIs - Specific Treatment: When deciding treatment options, it is important to identify the infection as lower/upper,

complicated/uncomplicated so that the correct antibiotic and duration of therapy can be chosen. o Most often, uncomplicated UTI in women are treated empirically based on the signs and symptoms, and

monitoring is focused on symptom relief o Empiric therapy has changed over the years, due to resistance. Collect urine cultures before dosing

- Non-Specific Treatment: So-called “Nuts-n-Twigs,” ingesting cranberries and cranberry juice have been shown to be efficacious in reducing infection and treatment severity. The mechanism is unknown, though it is predicted to be related to inducing anti-adhesive properties.

o If the patient likes cranberries à suggest cranberries. If they don’t, there’s no need to push them Acute Uncomplicated Cystitis

- Most common UTI presentation, patient will not be in clinical distress. Prior to treating, collect urine cultures n Short-Course Therapy – Nitrofurantoin 100mg PO q12º x5days -OR- Bactrim 800/160mg PO q12 x3days

o Cipro is no longer favored due to overuse and rising resistance rates. It is a 3rd option, after Nitro and Bactrim. Cipro is associated with “collateral damage”

Acute Urethral Syndrome also known as Symptomatic abacteriuria - Feels like a UTI (dysuria & pyuria), but no bacteria are found in culture. It is critical to use risk factors to

determine the need for treatment and alternative diagnoses. It could be an atypical bacteria n Short-Course Therapy – Nitrofurantoin 100mg PO q12º x5days -OR- Bactrim 800/160mg PO q12 x3days n Suspecting chlamydia – Doxycycline -OR- Azithromycin

Asymptomatic Bacteriuria - Although there are no symptoms, large quantities of bacteria are found in the urine. Typically, this infection is not

treated, albeit a few exceptions o Children: We do not want their urinary tracts scarred o Pregnant: Without treatment, bacterial infections may retard growth and lead to low birth-weights o Pt with Instrumentation: Prior to undergoing a urologic procedure, prophylactic abx should be used to

knock down whatever bug is present so we do not push the bacteria to bad places Acute Pyelonephritis [Complicated]

- Patients with acute pyelonephritis will be presenting quite sick. They will require extended treatment regimens - If no response in 3-4 days, further diagnostic work-up may be required and a change in therapy Mild-Moderate S/Sx n Fluoroquinolones for 2 weeks (Ciprofloxacin and Levofloxacin) This is effective against E. coli and Enterics

o 2nd-line: Bactrim 800/160mg PO q12 for 2 weeks o if enterococci are identified, narrow the spectrum of treatment: Ampicillin or Amoxicillin

Severely-Ill patients presenting with severe infections should be hospitalized and start broad-spectrum IV abx n AG + Beta Lactam -OR- FQ ± Beta Lactam

o Patients in nursing homes, already hospitalized, or with an indwelling catheter should be considered for MDR organisms such as Pseudomonas

Recurrent Infections - Reinfection (Different bug, 80%)

o If infrequent (< 3x year): Short-course therapy as usual o If recurrent (³ 3x year): Short-course therapy is still preferred. Long-term therapy has been associated

with negative outcomes

§ If the infection is related to a renal calculi, then treatment will not help – must be removed - Relapse (Same bug, 20%)

UTIs in Males [Complicated] - Causative factors include: Catheterization, Instrumentation, or Stones - Risk factors include: Older men more frequently are obstructed due to enlarged prostate or prostatitis n Initial Infection 10-14 days of treatment

o Collect follow-up cultures 4-6 weeks post-therapy n Recurrent Infection: 6 weeks or longer

UTIs in special populations - Pregnancy: Untreated, there is a major concern for slowed growth of the developing fetus, regardless of the size of

the inoculum. We must treat with fetal-friendly abx, such as Cephalosporins and PCN, but NOT FQ - Catheterized Patients: If a patient has a catheter, bacteriuria is frequent and expected. Some patients have lifelong

catheters, as a result they will need to be treated based on their symptoms (Temperature is the most common) o Consider doing a short-course and check for response, -Yes this would be complicated and would require

2 weeks, but checking first is critical Prostatitis

- Inflammation of the prostate and the surrounding tissue. As the inflamed area enlarges, urinary flow is impaired. Although the pathogenesis is not well-elucidated, reflux of infected urine into prostatic ducts is likely

o Prostatic Antibacterial Factor (PAF): An endogenous agent that is bactericidal to UTI pathogens that is decreased in cases or prostatitis and the elderly

o pH Environment: Normally the prostatic secretions are 6.6-7.6, in both prostatitis populations and in the elderly the pH is often measured 7-9

- Epidemiology: Far more common in men. 50-70% of men will develop prostatitis o Bug = E. coli (>75%) and other gram(-) enterics (klebsiella, proteus, pseudomonas, Enterobacter) o Acute Prostatitis: Severe illness + fever + urinary and constitutional symptoms o Chronic Prostatitis: A relapse o Nonbacterial Prostatitis: Presenting the S/Sx of infection, but no bugs isolated. Expect Chlamydia,

Ureaplasma, Trichomonas - Treatment: Due to high failure rates, a very long treatment period is required, ranging at minimum 4-6 weeks

Acute Bacterial Prostatitis: Systemic infection with localized pain, high fever, and chills - Dx: Digital palpitation of the prostate (will find it swollen, tender, warm, indurated). Overall, dx is based on

clinical presentation and presence of significant bacteriuria n IV AG + Beta Lactam for 4-6w at minimum

o Once afebrile/less symptomatic, can switch IV à PO if responding to 5-7 days of IV abx Chronic Bacterial Prostatitis: Far more difficult to diagnose AND treat. The prostate gland is often normal, but recurrent UTIs and vague symptoms such as a dribbling stream continually occur

- Dx: A midstream culture following a prostatic massage can help identify the infective agent and diagnosis n FQ for at least 6 weeks: Ciprofloxacin 500mg PO q12º -OR- Levofloxacin 500mg PO Qdaily

o If it is the patient’s first bout of Chronic Prostatitis, Bactrim DS q12 x4-6w can be a safe option o Moxifloxacin is not indicated as it is a respiratory quinolone and Nitro localizes only to urinary tract

(4/2) Schriever Lecture: Management of Gynecological Infections Vaginal Normal Flora (that may be infectious)

- Aerobes: B-streptococci, E. coli - Anaerobes: Peptostreptococcus, Prevotella, Bacteroides, G. vaginalis Atypical: Mycoplasma

Polymicrobial Infections of the Female Pelvis: Infections of the female pelvis, unless definitely diagnosed, should be treated as polymicrobial infections consisting of both aerobic and anaerobic pathogens

- Pregnancy: Intrapartum, Postpartum, Post-abortal - Post-surgical infections - Pelvic Inflammatory Disease (PID)

Infections related to Pregnancy - Intrapartum

o Intra-amniotic infectious syndrome (IAIS), also known as chorioamnionitis, occurs when amniotic fluid/fetal membranes become infected due to vaginal organisms ascending into the intrauterine cavity after membrane rupture. This event is usually preterm (<37w) and may cause dysfunctional labor resulting in preterm birth