UTI Case Presentation

Pain in the throneCristal Ann Laquindanum

TMC ER Rotation

M.R.31 FSingleFrom Pasig

Chief complaint:

Painful urination

Histo

ry o

f Pre

sent

Illness

• Few hours PTC,

• Dysuria

• Urgency

• Frequency

• Low back pain

• No hematuria

• No hypogastric pain

• No suprapubic pain

• No fever

• No consult

• No medications

Revie

w o

f Syste

ms

• No vaginal discharge

• No vaginal irritation

• No cough/ cold

• No fever

• No loose stools

• No chest pain

• No dizziness

• No palpitations

Past M

ed

ical

Histo

ry

• UTI (early this year)

• Treated, resolved

• No past surgeries and hospitalizations

• No hypertension, diabetes, asthma

• Allergies to Amoxicillin

Fam

ily H

istory

• Unremarkable family history

Perso

nal S

ocia

l H

istory

• Non-smoker, non-alcohol drinker

• Housewife

OB

-Gyn

e H

istory

• LMP: Feb 11 (day 5 of menstruation)

• 3-5 day duration, 28-30 day interval of menstruation

• G0

PHYSICAL EXAMINATION

64.5 kg 168 cm (BMI: 22.9, normal weight)BP: 110/70PR: 60 beats/minRR: 18 breaths/minTemp: 36.8 C

Vitals

Anicteric scleraePink conjunctivaeNo TPC, No CLADNeck veins not dilatedDry lips, moist buccal mucosaNonhyperemic pharynx

HEENNT

Symmetrical chest expansionResonant on percussionEqual tactile and vocal fremitiNo retractionsNo ralesNo wheezes

Chest/Lungs

Adynamic precordiumNo heaves or thrillsApex beat is at 5th ICS MCLNormal rate, regular rhythmNo murmurs

Heart

Flat, soft abdomenNo tendernessNo organomegalyNo massesNormoactive bowel sounds

Abdomen

No CVA tenderness

Urinary

Full pulsesNo edema, no cyanosisGood turgorNo rashes, no lesionsEqually distributed hairNo clubbingCRT <2sec

Extremities

Salient Features

• 31 female• Painful urination• Acute presentation of:• Dysuria• Urgency• Frequency• Low back pain• No hematuria• No hypogastric pain• No suprapubic pain• No fever

• Previous history of UTI

• Afebrile• Soft, non-tender

abdomen• No CVA tenderness

• Sexual history?

CLINICAL IMPRESSIONUrinary Tract Infection

Acute uncomplicated cystitis

• Clinically, acute uncomplicated cystitis is suspected in non-pregnant women, 18-64 years old, presenting with dysuria, frequency, or gross hematuria, with or without back pain. Risk factors for complicated urinary tract infection must be absent.

The Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults, 2004

Etiology

• The most common agents are the gram-negative bacilli.

• Escherichia coli• Proteus • Klebsiella • Enterobacter• Serratia• Pseudomonas

Etiology

• Gram-positive cocci play a lesser role in UTIs.

• Staphylococcus saprophyticus

• Enterococci• Staphylococcus

aureus

Pathogenesis

• urinary tract should be viewed as a single anatomic unit • bacteria gain access to the bladder via the urethra• alteration of the normal vaginal flora by antibiotics, other

genital infections, or contraceptives (especially spermicide)

• Loss of the normally dominant H2O2-producing lactobacilli in the vaginal flora facilitate colonization by E. coli.

Pathogenesis

• Why females? • proximity to the anus, its short length (~4 cm), and its

termination beneath the labia• Found in 2-8% of pregnant women• decreased ureteral tone, decreased ureteral peristalsis, and

temporary incompetence of the vesicoureteral valves

• How about males?• Uncommon; entertain a possibility of heterosexual or

homosexual rectal intercourse• urethral obstruction due to prostatic hypertrophy

Pathogenesis

• Obstruction?• Any impediment to the free flow of urine (tumor, stricture,

stone, or prostatic hypertrophy) results in hydronephrosis

• Dysfunction?• Interference with bladder enervation, as in spinal cord injury,

tabes dorsalis, multiple sclerosis, diabetes, and other diseases

• Reflux?• common among children with anatomic abnormalities of the

urinary tract as well as among children with anatomically normal but infected urinary tracts

Clinical Presentation

Cystitis PyelonephritisHistory dysuria, frequency,

urgency, and suprapubic pain

Generally develop rapidlyfever, shaking chills, nausea, vomiting, and diarrheasymptoms of cystitis may or may not be presentHematuria in acute phase

PE tenderness of the urethra or the suprapubic areagrossly cloudy and malodorous urine; bloody in ~30% of cases

Tachycardia, muscle tenderness, CVA tenderness

Laboratory White cells and bacteria can be detected (102 to 104 bacteria per milliliter of urine – no bacteria seen)

pyuria (> 5 wbc/hpf of centrifuged urine) on urinalysis and bacteriuria with counts of > 10,000 cfu of a uropathogen/ml on urine culture

Clinical Presentation

• Urethritis• 30% of women with acute dysuria, frequency, and pyuria

have midstream urine cultures that show either no growth or insignificant bacterial growth

• Distinguish between sexually-transmitted pathogens and low count E.coli or staphylococcal infection

Chlamydial or gonococcal infection E.coli UTI

Gradual, >7 days of symptomsno hematuriano suprapubic pain

abrupt onset, <3 days of symptomsgross hematuriasuprapubic painhistory of UTIs

Differential diagnosis

Infectious

• Cervicitis• Urethretis• Vulvovaginitis

Physical

• Urethral strictures• Tumor

Diagnostics

• In women who present with additional symptoms such as vaginal discharge or vaginal irritation, either a standard urine microscopy or dipstick for LE and nitrites can be done to confirm the diagnosis

• Pre-treatment urine culture and sensitivity is not recommended

• Standard urine microscopy and dipstick leukocyte esterase (LE) and nitrite tests are not prerequisites for treatment


What was done?

• Urinalysis

• Light yellow• Turbid• pH 7.0• SG 1.015• RBC +3 (39/hpf)• Protein +1 • WBC +3 (260/hpf)• Epithelial 3/hpf• Casts 0/hpf• Bacteria 251/hpf


Therapy

ANTIBIOTICS THAT CAN BE USED FOR ACUTE UNCOMPLICATED CYSTITIS


What was given?

• Levofloxacin 500mg OD x 7 days• Etoricoxib (Arcoxia) 12 mg PRN


• Ampicillin and amoxicillin should not be used

• Three-day therapy is the recommended duration of treatment except for nitrofurantoin, which must be given for 7 days.

• Post-treatment urine culture not recommended


It didn’t work! Now what?

• Patients whose symptoms worsen or do not improve after 3 days should have a urine culture and the antibiotic should be empirically changed, pending result of sensitivity testing

• Patients whose symptoms fail to resolve after the 7- day treatment should be managed as a complicated urinary tract infection


Prognosis

• In patients with uncomplicated cystitis or pyelonephritis, treatment ordinarily results in complete resolution of symptoms

• It rarely progresses to renal functional impairment and chronic renal disease. Repeated upper tract infections often represent relapse rather than reinfection

• Repeated symptomatic UTIs in children and in adults with obstructive uropathy, neurogenic bladder, structural renal disease, or diabetes progress to chronic renal disease with unusual frequency

Who needs prophylaxis?

• Women who experience frequent symptomatic UTIs (>3 per year on average) are candidates for long-term administration of low-dose antibiotics• Daily or thrice-weekly administration of a single dose of

TMP-SMX (80/400 mg), TMP alone (100 mg), or nitrofurantoin (50 mg)

• Norfloxacin and other fluoroquinolones

• Men with chronic prostatitis; patients undergoing prostatectomy, both during the operation and in the postoperative period; and pregnant women with asymptomatic bacteriuria

PUBLIC HEALTH

References

• The Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults, 2004

• Harrison’s Principles of Internal Medicine, 16th ed

Pain in the throneCristal Ann Laquindanum

TMC ER Rotation

UTI Case Presentation

Education

Transcript of UTI Case Presentation