UTI Case Presentation

1. Pain in the throne Cristal Ann Laquindanum TMC ER Rotation

2. M.R. 31 F Single From Pasig Chief complaint: Painful urination

3. History of Present Illness Few hours PTC, Dysuria Urgency Frequency Low back pain No hematuria No hypogastric pain No suprapubic pain No fever No consult No medications

4. Review of Systems No vaginal discharge No vaginal irritation No cough/ cold No fever No loose stools No chest pain No dizziness No palpitations

5. Past Medical History UTI (early this year) Treated, resolved No past surgeries and hospitalizations No hypertension, diabetes, asthma Allergies to Amoxicillin

6. Family History Unremarkable family history

7. Personal Social History Non-smoker, non-alcohol drinker Housewife

8. OB- Gyne History LMP: Feb 11 (day 5 of menstruation) 3-5 day duration, 28-30 day interval of menstruation G0

9. Physical Examination

10. 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 Vitals

11. Anicteric sclerae Pink conjunctivae No TPC, No CLAD Neck veins not dilated Dry lips, moist buccal mucosa Nonhyperemic pharynx HEENNT

12. Symmetrical chest expansion Resonant on percussion Equal tactile and vocal fremiti No retractions No rales No wheezes Chest/Lungs

13. Adynamic precordium No heaves or thrills Apex beat is at 5 th ICS MCL Normal rate, regular rhythm No murmurs Heart

14. Flat, soft abdomen No tenderness No organomegaly No masses Normoactive bowel sounds Abdomen

15. No CVA tenderness Urinary

16. Full pulses No edema, no cyanosis Good turgor No rashes, no lesions Equally distributed hair No clubbing CRT <2sec Extremities

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. 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

20. Etiology The most common agents are the gram-negative bacilli . Escherichia coli Proteus Klebsiella Enterobacter Serratia Pseudomonas

21. Etiology Gram-positive cocci play 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 H 2 O 2 -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, 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

25. Clinical Presentation Cystitis Pyelonephritis History dysuria, frequency, urgency, and suprapubic pain Generally develop rapidly fever, shaking chills, nausea, vomiting, and diarrhea symptoms of cystitis may or may not be present Hematuria in acute phase PE tenderness of the urethra or the suprapubic area grossly cloudy and malodorous urine; bloody in ~30% of cases Tachycardia, muscle tenderness, CVA tenderness Laboratory White cells and bacteria can be detected (10 2 to 10 4 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

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 Chlamydial or gonococcal infection E.coli UTI Gradual, >7 days of symptoms no hematuria no suprapubic pain abrupt onset, <3 days of symptoms gross hematuria suprapubic pain history of UTIs

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 not recommended 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. References The Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults, 2004 Harrison’s Principles of Internal Medicine, 16 th ed

38. Pain in the throne Cristal Ann Laquindanum TMC ER Rotation