Transcript Thrombocytopenia and Sepsis

Nephrolithiasis and
Urinary infections
Dr. Justin Hourmozdi, EM/IM-2
Henry Ford Hospital Emergency Medicine Grand Rounds
November 13th 2014
Overview
 Diagnosis and acute management of nephrolithiasis
 Urinary tract infections
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Uncomplicated UTI
Complicated UTI
Catheter Associated UTI
Asymptomatic Bacteriruia
UTI in Pregnancy
Basic anatomy
Kidney stones: Epidemiology
• Prevalence: 13% North America
• Incidence: 7-12 cases per 10,000 persons
• 70-90% form calcium stones (primarily calcium oxalate).
Others are uric acid, struvite and cystine stones.
Kidney stones: Risk factors
History of previous kidney stones, obesity, HTN, DM,
female, family history, metabolic disorders,
myleoproliferative disorders, gastric bypass, high protein
diet, dehydration
Kidney stones: Presentation
 Flank or upper abdominal pain stones moving from renal
pelvis to upper ureter
 Lower abdominal or groin pain lower ureter
 “colic”, peristalsis of ureter against stone and smooth muscle
spasms, also temporary obstruction and distention of renal
capsule
 Hematuria (usually microscopic), dysuria, N/V, gravel urine
 In a retrospective study of over 450 patients with CTdocumented acute nephrolithiasis, hematuria was present in
95% on day one and 65-68% on days three and four
Kidney stones: DDx
Remember to explore a thorough differential even with a
classic presentation, especially if the patient is older or no
previous history of kidney stones
 Vascular (acute renal artery occlusion or venous
thrombosis, mesenteric ischemia, aortic syndromes),
infectious (pyelonephritis, diverticulitis), GI (SBO,
pancreatitis, gallbladder disease, appy), GU (ectopic,
torsion, PID)
Kidney stones: CT vs US
 Multicenter RCT of 2759 patients visiting an ED with
symptoms suggestive of nephrolithiasis, and in whom a
serious alternative diagnosis was considered unlikely. Patients
were randomly assigned to initial imaging with a CT, US
performed by a radiologist, or bedside US by an EP. After the
initial imaging test was complete, subsequent evaluation and
care was at the discretion of the EP.
 US 54% sensitive (EP) vs 57% (radiologist) vs CT 88%. CT was
eventually performed in 41% of those who initially had US
performed.
 The rate of important missed diagnoses that resulted in
complications (pyelonephritis or diverticular abscess) was
similar and not statistically different between the groups
(US=0.5% vs CT=0.3%), ages 18-76.
Kidney stones: Diagnosis
 Labs: UA, urine preg, basic metabolic panel
 Imaging: ultrasound and non-contrast CT
 CT more sensitive than ultrasound but increased cost
and radiation (low-dose renal protocol). The sensitivity
and specificity of CT is 96-99%. Ureteral dilation on
imaging without a stone could signify recent passage of
stone
Kidney stones: Acute management
 Pain management: NSAIDs>opioids, better in
combination for severe pain, check Cr prior to NSAID
prescription
 Fluids: IVFs if N/V, dehydrated, otherwise aggressive
hydration does not improve pain or passage of stone
 Stone passage: <4mm most will spontaneously pass,
>4mm PCP referral for trial a-blocker vs CCB, >9mm
Urology referral for possible intervention (SWL vs
ureteroscopy)
Kidney stones: Complications
 Urgent urologic consultation is warranted in patients
with obstruction, urosepsis, significant acute renal
failure, anuria
 Admission for those with unyielding pain, N/V and
inability to take PO medications
Approach?
 Relatively young or healthy person with appropriate
history and PE, previous history of kidney stones, serious
alternative diagnosis unlikely  US, UA, Upreg, lytes
(+US and +hematuria vs –US and +hematuria vs both -)
 Older, comorbidities, no history of previous kidney
stones, considering alternative diagnoses CT, UA, lytes
Urinary tract infections
•Most common bacterial infection
•7 million office visits, 1 million ED
visit, 100,000 hospitalizations
•1/3 women have 1 episode of UTI
requiring antibiotics by 24 yo
•Annual cost of community
acquired UTI: $1.6 billion
•Catheter associated UTI is most
common nosocomial infection
UTI: Microbiology
• E. Coli- 75-95%
• Staphylococcus saprophyticus- 5-15%
• Young, sexually active females
• Proteus, Pseudomonas, Klebsiella and Eneterobacter
• More predominant in those with structural abnormalities,
hospital acquired and nursing home patients
• Corynebacterium urealyticum
• Immunosuppressed and renal transplant patients
• Highly antimicrobial resistant but usually sensitive to Vanco
• Fungal (usually Candida)
• Indwelling catheter, bladder stasis, immunosuppressed
UTI: Labs
Laboratory Test
Sensitivity
Specificity
Any coliforms
1.00
0.71
More than 100 coliforms per
mL of urine
0.95
0.85
More than 8 WBC/mm3
0.91
0.50
More than 20 WBC/mm3
0.50
0.95
LE dipstick
0.75-0.90
0.95
Nitrite dipstick
0.35-0.85
0.95
UTI: Uncomplicated Cystitis
 Premenopausal, nonpregnant women with no urological
abnormalities or comorbidities
 Absence of flank pain, fever, other signs of pyelonephritis
Can one of the recommended antimicrobials below be used considering:
Availability, Allergies, Tolerance, Local Resistance Patterns, Cost (if no
then Cipro x3d or B-lactam except amoxicillin/amp x5-7d)
1) Macrobid 100 mg BID x 5 days (avoid if early pyelo is suspected,
contraindicated for CrCl<60)
2) Bactrim 160/800 mg (one DS tab) BID x 3 days (avoid if resistance
prevalence is known to exceed 20% or if used for UTI in previous 3
months)
3) Fosfomycin 3 gm single dose (avoid if early pyelo is suspected)
*If mild case of cystitis caused by ESBL: Macrobid or Fosfomycin
UTI: Uncomplicated Pyelonephritis
 Premenopausal, nonpregnant women with no urological
abnormalities or comorbidities.
 Presence of flank pain, fever, other signs of pyelonephritis
1) Cipro 500 mg BID x 7 days *avoid if >10% resistance pattern, if
>10%, an initial IV dose ceftriaxone or 24-h dose of an
aminoglycoside is recommended (Level B)
2) Bactrim 160/800 mg BID x 10-14 days *if known prior
susceptibility, if empiric, an initial IV dose of ceftriaxone or 24h dose aminoglycoside is recommended (Level B)
Hospitalized, 7-14 day tx: Cipro, Ceftriaxone, Cefepime, Zosyn,
Aminoglycoside, Carbapenem depending on susceptibilities or
suspicion
UTI: Uncomplicated Pyelonephritis
Who do I image?
 Generally a clinical diagnosis, but scan if suspicion for complication
(abscess, renal stone, obstruction),
immunosuppressed/comorbidities, failure to respond to appropriate
antibx after 48-72 hours, or other possible significant diagnoses
considered. Ultrasound or MRI if unable to have IV contrast.
 Always scan men.
UTI: Complicated Cystitis and
Pyelonephritis
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Extremes of age, pregnant, or male (consider STIs or prostatitis)
Anatomic or functional abnormalities of urinary tract, obstruction
Concurrent kidney stone, foreign body (catheter, stents)
Immunosuppressed, comorbid medical conditions
Recent instrumentation, hospital acquired, h/o MDR organisms
Pyelonephritis was complication (abscess, papillary necrosis)
Severe sepsis, septic shock
1-2 week treatment course: Ceftriaxone, Cipro OR Cefepime, Zosyn,
Aminoglycoside, Carbapenem depending on susceptibilities or
suspicion
 Aminoglycoside: consider adding initial dose if severe
sepsis/shock
 Vancomycin or Ampicillin: consider adding if suspect MRSA or
enterococcus (NH/hospital acquired, indwelling catheter, elderly
men/BPH, recent instrumentation or renal transplant)
UTI: Elderly
 May be afebrile or have only a low grade temp; may also
present with altered mental status, lethargy, or have
generalized weakness. 20% of elderly patients with acute
pyelonephritis have no fevers, predominant symptoms are
generalized, GI or pulmonary
UTI:
atheter Associated
• Most common healthcare associated infection worldwide
• Approximately 20% of hospital-acquired bacteremias
arise from the urinary tract, and the mortality
associated with this condition is about 10%
• Risk factors: females, diabetes, age, duration of use,
UTI in past 12 months, non-sterile technique, underlying
neurological disease
• E Coli still most common, but increased rates of
Pseudomonas, Proteus, Enterococcus, Staphylococcus
and antibiotic resistance.
UTI: Catheter Associated
 UTI symptoms: new onset or worsening of fever (most
common symptom), SIRS, altered mental status,
malaise, or lethargy with no other identified cause;
flank pain or CVA tenderness; acute hematuria; pelvic
discomfort. In those whose catheters have been
removed, dysuria, urgent or frequent urination, or
suprapubic pain. In patients with spinal cord injury,
increased spasticity, autonomic dysreflexia, or sense of
unease are also compatible with CA-UTI
 Culture: >/=103 cfu/mL of a single bacterial species in
a single catheter urine specimen or urine specimen
from a patient whose catheter has been removed
within the previous 48 hrs
UTI: Catheter Associated
 In the catheterized patient, pyuria is not diagnostic of
CA-bacteriuria or CA-UTI, however it’s absence suggests
an alternative diagnosis. Also the presence or absence of
odorous or cloudy urine alone should not be used to
differentiate CA-ASB from CA-UTI or as an indication for
urine culture or antibiotics.
 “Purple urine bag syndrome”: color is due to blue and red
metabolic products of biochemical reactions formed by
bacterial enzymes in the urine, specifically Klebsiella,
Proteus, and Proviencia spp
 If an indwelling catheter has been in place for >2 weeks
at the onset of CA-UTI and is still indicated, the catheter
should be replaced. The urine culture should be obtained
from the freshly placed catheter and not the old catheter
or the urine bag to avoid culturing bacteria present in the
biofilm of the catheter but not in the bladder.
Asymptomatic bacteriuria: Definition
 Women: bacteriuria is defined as 2 consecutive voided
urine specimens with isolation of the same bacterial
strain with >/=105 cfu/mL
 Men: A single voided urine specimen with 1 bacterial
species isolated with >/=105 cfu/mL
 Both: A single catheterized urine specimen with 1
bacterial species isolated with >/= 102 cfu/mL
Asymptomatic bacteriuria: Treatment
 Asymptomatic bacteriuria + pyuria = no treatment
 Asymptomatic bacteriruia in diabetics, nonpregnant
women, elderly, neurogenic bladder, foley patients = no
treatment
 Asymptomatic bacteriuria in pregnancy = treat (Macrobid
x5d)
UTI: The Pregnant Patient
• 30-40% of untreated bacteriuria early in gestation develop
symptomatic acute UTI including pyelonephritis
• Bacteriuria in pregnancy is associated with premature birth, low
birth weight, preeclampsia, perinatal mortality
• Treatment for asymptomatic bacteriuria is usually started in
women with ≥105 cfu/mL from a good clean-catch specimen
• Treat asymptomatic bacteriuria: Macrobid x5d, Keflex or
Augmentin x 5-7 days, Fosfomycin 3g single dose
• Acute pyelonephritis: always admit; Ceftriaxone, Augmentin,
Cefpodoxime x 10-14 days
• Low threshold for renal ultrasound
Please feel free to email for complete references
Thank you!