UTI Incontinence Urosepsis

Question 1

Incontinence

• definition
• MC in what age and gender
• dx
• What is DIAPPERS?
• tx

Answer 1

Definition
-involuntary leakage of urine in sufficient volume or frequency so as to cause hygienic or social problems (can cause quality of life problems!)

MC in women older than 60

Dx

• Exam for pelvic atrophy, prolapse, masses
• neuro exam
• stress test
• rectal for sphincter tone, impaction, prostate
• UA/UC, sensitivity
• BUN, creatinine, glucose, calcium, electrolytes

DIAPPERS
Delirium
Infection
Atrophy
Pharmaceuticals (anticholingerics, alpha agonists, alpha antagosist, diuretics, calcium channel blockers, any CNS depressant)
Psychologic
Endocrine or excess urine output
Restricted mobility
Stool impaction

Tx

• Behavioral Approaches
• -reduce caffeine/liquids, timed voiding, bladder training
• biofeedback, electrical stimulation
• pessiary, kegals, decrease prostate size
• anticholinergics (oxybutinin, tolterodine)

Question 2

UTI

• MC age
• risk factors
• Cause
• What is the biggest risk factor for asymptomatic bacteriuria?

Answer 2

MC in men and women over 65

Risk Factors

• Advanced age
• fecal incontinence/impaction
• neurogenic bladder
• vaginal atrophy/estrogen deficiency
• pelvic prolapse/ cystocele
• insufficient fluid intake/dehydration
• indwelling foley catheter or instrument procedure
• BPH
• DM

Cause

• E. Coli (30%)
• Proteus species (GI tract)(30%)

Asymptomatic bacteriuria: nearly 100% of people with chronic catheters have this!

Question 3

UTI in women over 65 is defined by at least two of the following…

Answer 3

• fever (over 38 C)
• frequency, urgency, dysuria, suprapubic tenderness or CVA tenderness
• positive urine culture of at least 10 to the 5th colony-forming units/mL with no more than 2 species of microorganisms
• pyuria

*Urine cultures in infected elderly patients may have lower colony counts: 10 to 2nd or 3rd

Question 4

UTIs in the elderly

• When the dx of UTI is in doubt, what should you do?
• signs and sx
• Dx
• Tx

Answer 4

In the elderly, when the dx is in doubt, withhold abx for 1 week and follow-up (outpatients)

Signs and sx

• nocturia, incontinence
• confusion
• lethargy
• anorexia
• fever or hypothermia
• FTT
• pain/dysuria
• behavioral changes

Dx

• UA (greater than 100,000/ml is indicative of infection)
• rapid tests for bacteria: nitrite dipstick and leukocyte esterase test
• gram stain of urine
• Urine culture and sensitivity
• WBC with diff (left shift=bacterial)

Tx

• based on location of infection and likely causative agent
• treat women with macrobid or bactrim
• UTIs in older men: high risk and should have longer courses of therapy (cipro or bactrim)

Question 5

What is the leading cause of secondary nosocomial bacteremia?

What is the issue with this?

Dx of this?

How to reduce this?

Answer 5

UTIs associated with urinary catheters

The problem is that patients with indwelling catheters often do not experience typical signs of UTI

Dx
-blood and urine cultures when pt develops fever or other unexplained signs of an infection

Most effective strategies to reduce UTIs are avoidance of unnecessary catheterization and catheter removal when the catheter is no longer indicated

Question 6

Sepsis/Urosepsis

• definition
• risk factors of urosepsis
• signs and sx
• dx
• tx

Answer 6

Definition

• active multiplication of bacteria in the bloodstream that results in an overwhelming infection
• cytokines (impaired pulmonary, hepatic, or renal function)
• death by multi-system organ failure

Risk factors of urosepsis

• BPH
• DM
• SLE
• Alcohol
• taking steroids

Signs and sx

• hypotension
• tachycardia
• tachypnea
• rales
• resp distress
• anorexia, nausea, vomiting

Dx

• kidney functions, CBC, Chem 8
• UA/UC
• CT/MRI/US
• Catheterization (to follow output in case their kidneys shut down)

Tx

• immediate hospitalization
• treat for shock??
• fluids
• broad spectrum abx
• -imipenem
• -meropenem
• -piperacillin-tazobactam
• -sulbactam-ampicillin