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.
  • UTI Case Presentation

    1. 1. Pain in the throne<br />Cristal Ann Laquindanum<br />TMC ER Rotation<br />
    2. 2. M.R.<br />31 F<br />Single<br />From Pasig<br />Chief complaint: <br />Painful urination<br />
    3. 3. Few hours PTC, <br />Dysuria<br />Urgency<br />Frequency<br />Low back pain<br />No hematuria<br />No hypogastric pain<br />No suprapubic pain<br />No fever<br />No consult<br />No medications<br />History of Present Illness<br />
    4. 4. No vaginal discharge<br />No vaginal irritation<br />No cough/ cold<br />No fever<br />No loose stools <br />No chest pain <br />No dizziness<br />No palpitations<br />Review of Systems<br />
    5. 5. UTI (early this year)<br />Treated, resolved<br />No past surgeries and hospitalizations<br />No hypertension, diabetes, asthma<br />Allergies to Amoxicillin<br />Past Medical History<br />
    6. 6. Unremarkable family history<br />Family History<br />
    7. 7. Non-smoker, non-alcohol drinker<br />Housewife <br />Personal Social History<br />
    8. 8. LMP: Feb 11 (day 5 of menstruation)<br />3-5 day duration, 28-30 day interval of menstruation<br />G0<br />OB-Gyne History<br />
    9. 9. Physical Examination<br />
    10. 10. Vitals<br />64.5 kg 168 cm <br />(BMI: 22.9, normal weight)<br />BP: 110/70<br />PR: 60 beats/min<br />RR: 18 breaths/min<br />Temp: 36.8 C<br />
    11. 11. HEENNT<br />Anictericsclerae<br />Pink conjunctivae<br />No TPC, No CLAD<br />Neck veins not dilated<br />Dry lips, moist buccal mucosa<br />Nonhyperemic pharynx<br />
    12. 12. Chest/Lungs<br />Symmetrical chest expansion<br />Resonant on percussion<br />Equal tactile and vocal fremiti<br />No retractions<br />No rales<br />No wheezes<br />
    13. 13. Heart<br />Adynamic precordium<br />No heaves or thrills<br />Apex beat is at 5th ICS MCL<br />Normal rate, regular rhythm<br />No murmurs<br />
    14. 14. Abdomen<br />Flat, soft abdomen<br />No tenderness<br />No organomegaly<br />No masses<br />Normoactive bowel sounds<br />
    15. 15. Urinary<br />No CVA tenderness<br />
    16. 16. Extremities<br />Full pulses<br />No edema, no cyanosis<br />Good turgor<br />No rashes, no lesions<br />Equally distributed hair<br />No clubbing<br />CRT <2sec <br />
    17. 17. Salient Features<br />31 female<br />Painful urination<br />Acute presentation of:<br />Dysuria<br />Urgency<br />Frequency<br />Low back pain<br />No hematuria<br />No hypogastric pain<br />No suprapubic pain<br />No fever<br />Previous history of UTI<br />Afebrile<br />Soft, non-tender abdomen<br />No CVA tenderness<br />Sexual history?<br />
    18. 18. Clinical impression<br />Urinary Tract Infection<br />
    19. 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.<br />Acute uncomplicated cystitis<br />The Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults, 2004<br />
    20. 20. Etiology<br />The most common agents are the gram-negative bacilli. <br />Escherichia coli<br />Proteus <br />Klebsiella<br />Enterobacter<br />Serratia<br />Pseudomonas<br />
    21. 21. Etiology<br />Gram-positive cocciplay a lesser role in UTIs. <br />Staphylococcus saprophyticus<br />Enterococci<br />Staphylococcus aureus<br />
    22. 22. Pathogenesis<br />urinary tract should be viewed as a single anatomic unit <br />bacteria gain access to the bladder via the urethra<br />alteration of the normal vaginal flora by antibiotics, other genital infections, or contraceptives (especially spermicide)<br />Loss of the normally dominant H2O2-producing lactobacilli in the vaginal flora facilitate colonization by E. coli.<br />
    23. 23. Pathogenesis<br />Why females? <br />proximity to the anus, its short length (~4 cm), and its termination beneath the labia<br />Found in 2-8% of pregnant women<br />decreased ureteral tone, decreased ureteral peristalsis, and temporary incompetence of the vesicoureteral valves<br />How about males?<br />Uncommon; entertain a possibility of heterosexual or homosexual rectal intercourse<br />urethral obstruction due to prostatic hypertrophy<br />
    24. 24. Pathogenesis<br />Obstruction?<br />Any impediment to the free flow of urine (tumor, stricture, stone, or prostatic hypertrophy) results in hydronephrosis<br />Dysfunction?<br />Interference with bladder enervation, as in spinal cord injury, tabesdorsalis, multiple sclerosis, diabetes, and other diseases<br />Reflux?<br />common among children with anatomic abnormalities of the urinary tract as well as among children with anatomically normal but infected urinary tracts<br />
    25. 25. Clinical Presentation<br />
    26. 26. Clinical Presentation<br />Urethritis<br />30% of women with acute dysuria, frequency, and pyuria have midstream urine cultures that show either no growth or insignificant bacterial growth<br />Distinguish between sexually-transmitted pathogens and low count E.coli or staphylococcal infection<br />
    27. 27. Differential diagnosis<br />Infectious<br />Cervicitis<br />Urethretis<br />Vulvovaginitis<br />Physical<br />Urethral strictures<br />Tumor<br />
    28. 28. Diagnostics<br />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<br />Pre-treatment urine culture and sensitivity is notrecommended<br />Standard urine microscopy and dipstick leukocyte esterase (LE) and nitrite tests are not prerequisites for treatment <br />The Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults, 2004<br />
    29. 29. What was done?<br />Urinalysis<br />Light yellow<br />Turbid<br />pH 7.0<br />SG 1.015<br />RBC +3 (39/hpf)<br />Protein +1 <br />WBC +3 (260/hpf)<br />Epithelial 3/hpf<br />Casts 0/hpf<br />Bacteria 251/hpf<br />The Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults, 2004<br />
    30. 30. Therapy<br />ANTIBIOTICS THAT CAN BE USED FOR ACUTE UNCOMPLICATED CYSTITIS<br />The Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults, 2004<br />
    31. 31. What was given?<br />Levofloxacin 500mg OD x 7 days<br />Etoricoxib (Arcoxia) 12 mg PRN<br />The Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults, 2004<br />
    32. 32. Ampicillin and amoxicillin should not be used<br />Three-day therapy is the recommended duration of treatment except for nitrofurantoin, which must be given for 7 days.<br />Post-treatment urine culture not recommended<br />The Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults, 2004<br />
    33. 33. It didn’t work! Now what?<br />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<br />Patients whose symptoms fail to resolve after the 7- day treatment should be managed as a complicated urinary tract infection<br />The Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults, 2004<br />
    34. 34. Prognosis<br />In patients with uncomplicated cystitis or pyelonephritis, treatment ordinarily results in complete resolution of symptoms<br />It rarely progresses to renal functional impairment and chronic renal disease. Repeated upper tract infections often represent relapse rather than reinfection<br />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<br />
    35. 35. Who needs prophylaxis?<br />Women who experience frequent symptomatic UTIs (>3 per year on average) are candidates for long-term administration of low-dose antibiotics<br />Daily or thrice-weekly administration of a single dose of TMP-SMX (80/400 mg), TMP alone (100 mg), or nitrofurantoin (50 mg)<br />Norfloxacin and other fluoroquinolones<br />Men with chronic prostatitis; patients undergoing prostatectomy, both during the operation and in the postoperative period; and pregnant women with asymptomatic bacteriuria<br />
    36. 36. Public health<br />
    37. 37.
    38. 38. References<br />The Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults, 2004<br />Harrison’s Principles of Internal Medicine, 16thed<br />
    39. 39. Pain in the throne<br />Cristal Ann Laquindanum<br />TMC ER Rotation<br />

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