00:01
All right.
00:02
Are you ready to talk about the
dreaded urinary tract infection?
We’re going to cover some
epidemiology and some microbiology,
but mostly discuss some pearls that, I think,
will really help you in practice
regarding diagnosis and management.
00:15
Let’s go.
00:17
So, in terms of epidemiology,
definitely more females than
males get urinary tract infections.
00:24
In fact, over a lifetime,
about half of all women experience
a urinary tract infection.
00:30
And of course, E. coli cause most cases of UTI,
but certainly have to think
about other less common organisms,
Staph saprophyticus, Klebsiella, Enterobacter.
00:42
And the symptoms,
I think you know, they're fairly classic,
dysuria being the most common,
frequency of urination.
00:49
And just those two symptoms alone,
without any vaginal symptoms,
such as vaginal discharge or burning,
has a 90% positive predictive value
in identifying urinary tract infections.
01:03
And this is something that I've actually learned
that I didn’t necessarily know because
I usually want patients to
come in and get checked out.
01:10
But if a – particularly a female patient
calls in and complains of dysuria,
along with increased frequency,
no vaginal symptoms,
they actually did a study and found that only 5% of cases
of urinalyses were negative in a study of telephone management.
01:26
So, these cases actually can be managed over the phone
and might be a good indication to give
antibiotics just right there on the spot
to help treat the UTI.
01:35
Because physical examination is fairly limited
for identifying urinary tract infection.
01:41
Classic is suprapubic tenderness to palpation,
but only one in five women at most actually have
significant suprapubic tenderness to palpation.
01:49
Always check for costovertebral angle tenderness because
of the risk for ascending infection and pyelonephritis.
01:55
But I do think that one pearl I've
learned in managing patients
with suspected UTI is that there's a difference
between costovertebral angle tenderness
that’s mild where it’s like,
yes, that kind of hurts.
02:08
If it’s pyelonephritis or a perinephric abscess
or some more severe infection,
touching that back,
just even a gentle touch or a light touch like that,
will really make the patient
jump. It really hurts.
02:23
So, if it’s just a mild kind of soreness,
that doesn’t necessarily qualify as
costovertebral angle tenderness,
because once I chart CVAT,
I have to treat like I'm treating pyelonephritis,
and that's different from most UTIs.
02:38
Patients, of course, get a urinalysis.
02:41
Urine culture isn't necessary for every case,
and this may come up on your examination,
but certainly for more complicated cases.
02:48
Recurrent UTIs, women who are pregnant,
immunocompromised or immunocompromising
conditions and diabetes,
all those patients get routine cultures,
but a healthy younger woman
doesn't need routine culture.
03:04
And they found that, even with
the classic symptoms present,
that even as low as 100 colony-forming units per milliliter,
can be suggestive and diagnostic for
UTI among otherwise healthy patients.
03:18
Kind of remarkable.
03:19
Much lower threshold than there was in the past when
it had to be 105 CFU per milliliter in order to diagnose UTI.
03:28
In terms of management, we reach to antibiotics.
03:30
And I can tell you there is not one that's perfect.
03:32
First line is still considered trimethoprim sulfamethoxazole
or co-trimoxazole,
but usually three days is acceptable.
03:43
Try to think about what your rates of resistance
are when you're getting cultures back.
03:47
If your rates of resistance to TMP-SMX exceed 20%,
in my practice, they probably see 30 to 40%,
it’s probably better to reach for another drug.
04:00
The one I usually reach for, nitrofurantoin,
it's an older drug, but associated
with lower rate of resistance.
04:06
Unfortunately, multiple times per day dosing
and you have to take it for five days,
but generally well tolerated and more effective.
04:13
And then fosfomycin is also an option,
and that's just one dose for a very
convenient type of dosing schedule.
04:20
Second line agents include
fluoroquinolones which are effective,
but we are trying to practice stewardship
and avoid overuse of fluoroquinolones
and avoid the spread of fluoroquinolone resistance.
04:34
So, let’s talk about UTI in kids because
this is an issue that comes up in practice,
but also very much will come
up on your examination.
04:41
So, first of all, abnormal urinalysis,
so with white cells or nitrite,
leukocyte esterase, plus at least
50,000 colony-forming units per milliliter.
04:52
Now, for kids, it's a special case.
04:55
You want to look for congenital abnormalities
of the renal and bladder system.
05:00
So, therefore, doing an ultrasound on those organs is important
even after a first UTI between 2 and 24 months of age.
05:08
However,
what was also recommended in the past
was avoiding cystourethrogram.
05:14
That's no longer recommended.
05:16
So, I think that might be the exam
question you get is, what is indicated.
05:20
So, culture would be indicated.
05:21
Urinalysis would be indicated.
Ultrasound would be indicated.
05:24
VCUG would not be indicated for first UTI
in cases of between 2 and 24 months.
05:30
Second UTI, yes, it would be.
05:32
Checking for reflux.
05:34
So, in terms of management of
UTI among young children,
oral antibiotics are acceptable.
05:41
They don’t have to be put in the hospital.
05:43
Previously, everybody required parenteral antibiotics.
05:46
So, IV only if they're really sick,
but it is a longer duration of treatment.
05:50
It’s between 7 to 14 days, depends on the practitioner.
05:53
But it’s not – no three or five-day
options are available for children.
05:59
So, that's a brief overview of urinary tract infection.
06:02
A common diagnosis.
06:03
We may kind of take for granted,
but hopefully you’ve gained a few pearls
there in terms of clinical wisdom that
it may be able to be manage on
the phone in those classic cases.
06:14
You got some insight into antibiotics.
06:16
And particularly the workup in kids.
06:18
Those are all good things to know for
your exam and for your clinical practice as well.
06:24
Thanks very much.