UTI is an infection involving the urothelium.

Pyelonephritis (kidney)

Cystitis (bladder infection),

prostatitis (prostate infection),

urethritis.

 

 

 

 

 

Urinary incontinence is not sufficient reason for continued use of an indwelling catheter. In male patients, incontinence can be managed with a carefully applied condom catheter. Care must be taken to inspect the penis frequently for signs of skin maceration or pressure. In female patients, diapering and frequent linen changes are necessary.

Restoring bladder function to achieve adequate reflex voiding or a balanced bladder may require the use of an intermittent catheterization program. The basis of a balanced bladder program is that the volume of residual urine not exceed a third of the volume of voided urine. In general, an intermittent catheterization program is initiated if the residual volume is greater than 100 mL or if the voided volume exceeds 400 mL. The patient is catheterized every 4 hours initially and then every 6 hours for 24 hours, and the patient is reassessed. Good records are necessary throughout the program.

 

 

 

 

Escherichia coli is the most common organism in all patient groups, but Klebsiella, Pseudomonas, Proteus, and other organisms are more common in patients with certain risk factors for complicated urinary tract infections.(Like what?)

Urinary tract infections: Thirty to forty percent of nosocomial infections are UTIs, contributing ~15% to prolongation of hospital stay with an attributable cost of ~$1300.

  • – Most nosocomial UTIs are associated with prior instrumentation or indwelling bladder catheterization. The 3–7% risk of infection for each day a catheter remains in place is due to the ascent of bacteria from the periurethral area or via intraluminal contamination of the catheter.

  • – In men, condom catheters may lessen the risk of UTI.

  • – The most common pathogens are Escherichia coli, nosocomial gram-negative bacilli, enterococci, and (particularly for pts in the ICU) Candida.

  • – For suspected infection in the setting of chronic catheterization, the catheter should be replaced and a freshly voided urine specimen obtained for culture to confirm actual infection as opposed to simple colonization of the catheter.

  • – As with all nosocomial infections, it is useful to repeat the culture to confirm the persistence of infection at the time therapy is initiated.

 

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Antibiotics

 

Levaquin (levofloxacin), Cipro, Proquin (ciprofloxacin), Keflex (cephalexin), ZotrimBactrim (trimethoprim/sulfamethoxazole), MacrobidFuradantin (nitrofurantoin), Monurol (fosfomycin), Hiprex (methenamine hippurate), Trimpex, Proloprim, Primsol (trimethoprim), and NegGram (nalidixic acid).

Cystitis may also be treated with pain relievers such as Pyridium (phenazopyridine).

 

 

For Sepsis

After administration of 2100 ml of crystalloid fluid (30 ml per kilogram of body weight), the patient’s jugular venous pressure is 8 cm of water, but her systemic arterial pressure has decreased to 80/50 mm Hg (mean arterial pressure, 60 mm Hg).

During the 3 hours that she has been in the emergency department, she has produced 20 ml of urine, as measured through a Foley catheter that was placed on her arrival.

You place a central venous catheter and initiate a norepinephrine infusion, which you adjust with a goal of raising her mean arterial pressure to 65 to 70 mm Hg. She is transferred to the intensive care unit (ICU); on arrival in the ICU, her mean arterial pressure is 65 mm Hg while she is receiving 40 μg of norepinephrine per minute, and her heart rate is 100 beats per minute.

A chest radiograph shows early evidence of acute lung injury and good central catheter placement.

Her arterial oxygen saturation is 100% while she is receiving 4 liters of oxygen through a nasal cannula.

You are aware that there are two main approaches to the management of septic shock in a patient such as Ms. Jones. One approach involves serial measurement of central venous pressure, central venous oxygen saturation (Scvo2), and hemoglobin, and following the early, goal-directed therapy (EGDT) protocol, in which specified targets are used for the initiation of inotropic agents or transfusion of red cells.1 For example, if the central venous pressure is less than 8 mm Hg, additional fluid resuscitation is administered; if the Scvo2 is less than 70%, the patient receives a transfusion of red cells until a hematocrit goal of at least 30% is reached, and if the Scvo2 remains less than 70%, inotropic support is initiated.

The second approach involves continuing intravenous administration of antibiotics and vasopressors, guided by clinical signs including blood pressure and urine output, without serial central venous pressure monitoring, serial Scvo2 monitoring, transfusion of red cells, or administration of inotropic agents. You are undecided about which of these approaches would maximize the chance of survival for your patient with septic shock.

 

 

 

 

 

 

Women with recurrent symptomatic urinary tract infections can be treated with continuous or postcoital prophylactic antibiotics;

[other treatment options include self-started antibiotics, cranberry products, and behavioral modification.]

Patients at risk of complicated urinary tract infections are best managed with broad-spectrum antibiotics initially, urine culture to guide subsequent therapy, and renal imaging studies if structural abnormalities are suspected.

Continuous and postcoital antimicrobial prophylaxis reduces the risk of recurrent UTIs.(A)

A

19

Cranberry products may reduce the incidence of recurrent symptomatic UTIs.

B

2325

Use of topical estrogen may reduce the incidence of recurrent UTIs in postmenopausal women.

B

2627

Treatment of complicated UTIs should begin with broad-spectrum antibiotic coverage, with adjustment of antimicrobial coverage guided by culture results.

C

11

Prophylactic antimicrobial therapy to prevent recurrent UTIs is not recommended for patients with complicated UTIs.

C

6


UTI = urinary tract infection.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limitedquality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml.

Women with recurrent symptomatic urinary tract infections can be treated with continuous or postcoital prophylactic antibiotics; other treatment options include self-started antibiotics, cranberry products, and behavioral modification. Patients at risk of complicated urinary tract infections are best managed with broad-spectrum antibiotics initially, urine culture to guide subsequent therapy, and renal imaging studies if structural abnormalities are suspected.

– As with all nosocomial infections, it is useful to repeat the culture to confirm the persistence of infection at the time therapy is initiated.

+++++++++++++++

 

Urinary tract infections (UTIs) are among the most common bacterial infections encountered in medicine. Urinary tract infections are a common source of sepsis and prolonged illness.

Frequency of sexual intercourse is the strongest predictor of recurrent urinary tract infections.

Thirty to forty percent of nosocomial infections are UTIs, contributing

  • – Most nosocomial UTIs are associated with prior instrumentation or indwelling bladder catheterization. The 3–7% risk of infection for each day a catheter remains in place is due to the ascent of bacteria from the periurethral area or via intraluminal contamination of the catheter.

  • – In men, condom catheters may lessen the risk of UTI.

  • – The most common pathogens are Escherichia coli, nosocomial gram-negative bacilli, enterococci, and (particularly for pts in the ICU) Candida.

  • – For suspected infection in the setting of chronic catheterization, the catheter should be replaced and a freshly voided urine specimen obtained for culture to confirm actual infection as opposed to simple colonization of the catheter.

 

An indwelling catheter is the most frequent source. In an acutely ill or multiply injured patient, an indwelling catheter may be necessary for medical reasons but should be removed as soon as possible.

 

In those who have comorbid conditions, recurrent complicated urinary tract infections represent a risk for ascending infection or urosepsis. 

Content 3

Content 11

 

A 22-year-old woman presents to the clinic for a recurrent urinary tract infection. She is prescribed trimethoprim/sulfamethoxazole. What is the mechanism of action of this antimicrobial drug?
A- Inhibition of bacterial wall synthesis
B- Inhibition of folic acid synthesis
C- Inhibition of bacterial protein synthesis
D- Inhibition of mycolic acid synthesis
E- Inactivation of bacterial toxins

 

Answer

The correct answer is B.

Sulfonamides act as antimicrobial agents through inhibition of folic acid synthesis, which leads to inhibition of bacterial nucleic acid synthesis. Penicillin and cephalosporin are involved in inhibition of bacterial cell wall synthesis. Inhibition of bacterial protein synthesis is the mechanism of action of aminoglycosides while inhibition of mycolic acid synthesis is the main action of isoniazid. Sulfonamides have no role in inactivation of bacterial toxins.

 

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