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UTI Case Presentation

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  • Esch- erichia coli causes 􏰚80% of acute infections in patients without cath- eters, urologic abnormalities, or calculi.
  • Serratiaand Pseudomonas, assume increasing im- portance in recurrent infections and in infections associated with uro- logic manipulation, calculi, or obstruction
  • normally colonized by diphtheroids, streptococcal species, lactobacilli, and staphylococcal species
  • Dysfunction use of catheters for bladder drainage and is favored by the prolonged stasis of urine in the bladder.
  • Transcript

    • 1. Pain in the throne
      Cristal Ann Laquindanum
      TMC ER Rotation
    • 2. M.R.
      31 F
      Single
      From Pasig
      Chief complaint:
      Painful urination
    • 3. Few hours PTC,
      Dysuria
      Urgency
      Frequency
      Low back pain
      No hematuria
      No hypogastric pain
      No suprapubic pain
      No fever
      No consult
      No medications
      History of Present Illness
    • 4. No vaginal discharge
      No vaginal irritation
      No cough/ cold
      No fever
      No loose stools
      No chest pain
      No dizziness
      No palpitations
      Review of Systems
    • 5. UTI (early this year)
      Treated, resolved
      No past surgeries and hospitalizations
      No hypertension, diabetes, asthma
      Allergies to Amoxicillin
      Past Medical History
    • 6. Unremarkable family history
      Family History
    • 7. Non-smoker, non-alcohol drinker
      Housewife
      Personal Social History
    • 8. LMP: Feb 11 (day 5 of menstruation)
      3-5 day duration, 28-30 day interval of menstruation
      G0
      OB-Gyne History
    • 9. Physical Examination
    • 10. Vitals
      64.5 kg 168 cm
      (BMI: 22.9, normal weight)
      BP: 110/70
      PR: 60 beats/min
      RR: 18 breaths/min
      Temp: 36.8 C
    • 11. HEENNT
      Anictericsclerae
      Pink conjunctivae
      No TPC, No CLAD
      Neck veins not dilated
      Dry lips, moist buccal mucosa
      Nonhyperemic pharynx
    • 12. Chest/Lungs
      Symmetrical chest expansion
      Resonant on percussion
      Equal tactile and vocal fremiti
      No retractions
      No rales
      No wheezes
    • 13. Heart
      Adynamic precordium
      No heaves or thrills
      Apex beat is at 5th ICS MCL
      Normal rate, regular rhythm
      No murmurs
    • 14. Abdomen
      Flat, soft abdomen
      No tenderness
      No organomegaly
      No masses
      Normoactive bowel sounds
    • 15. Urinary
      No CVA tenderness
    • 16. Extremities
      Full pulses
      No edema, no cyanosis
      Good turgor
      No rashes, no lesions
      Equally distributed hair
      No clubbing
      CRT <2sec
    • 17. 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?
    • 18. Clinical impression
      Urinary Tract Infection
    • 19. 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.
      Acute uncomplicated cystitis
      The Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults, 2004
    • 20. Etiology
      The most common agents are the gram-negative bacilli.
      Escherichia coli
      Proteus
      Klebsiella
      Enterobacter
      Serratia
      Pseudomonas
    • 21. Etiology
      Gram-positive cocciplay a lesser role in UTIs.
      Staphylococcus saprophyticus
      Enterococci
      Staphylococcus aureus
    • 22. 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.
    • 23. 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
    • 24. 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, tabesdorsalis, 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
    • 25. Clinical Presentation
    • 26. 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
    • 27. Differential diagnosis
      Infectious
      Cervicitis
      Urethretis
      Vulvovaginitis
      Physical
      Urethral strictures
      Tumor
    • 28. 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 notrecommended
      Standard urine microscopy and dipstick leukocyte esterase (LE) and nitrite tests are not prerequisites for treatment
      The Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults, 2004
    • 29. 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
      The Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults, 2004
    • 30. Therapy
      ANTIBIOTICS THAT CAN BE USED FOR ACUTE UNCOMPLICATED CYSTITIS
      The Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults, 2004
    • 31. What was given?
      Levofloxacin 500mg OD x 7 days
      Etoricoxib (Arcoxia) 12 mg PRN
      The Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults, 2004
    • 32. 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
      The Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults, 2004
    • 33. 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
      The Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults, 2004
    • 34. 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
    • 35. 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
    • 36. Public health
    • 37.
    • 38. References
      The Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults, 2004
      Harrison’s Principles of Internal Medicine, 16thed
    • 39. Pain in the throne
      Cristal Ann Laquindanum
      TMC ER Rotation