Thursday, July 4, 2013

An Infection Way Too Common in Women

I walked into the exam room to see a patient I was familiar with.  I had taken care of her kids many times before when they had strep throat, upper respiratory infections and when she had problems with her sinus allergies. 
“Hi, Liz, what brings you in?”
“Oh, Sharon, I think I’ve got one of my bladder infections back again.  I woke up yesterday morning with that initial feeling that I knew something was wrong.  It burned to urinate.  So I started drinking my cranberry juice yesterday and that helped some, but my symptoms are worse today.  I had to get up and go use the restroom several times during the night, even though I had very little urine to get rid of.”
“Well, Liz, I have yet to come across a woman who didn’t know that she had an urinary tract infection.  Women are very good about picking up these types of infections.  So did you give the medical assistant a sample of your urine before you came in this room?”
“Yeah, she had me leave a sample in the lab.”
“Great.  Have you had any back pain, fevers, nausea or vomiting?”
“Well this morning it began to hurt on my left side of my back.  Nothing else.”
“Okay.  What antibiotic do you typically take that works for your urinary tract infection?”
“I think it’s called Cipro, I know it’s a white pill I take twice a day, and it works real well for me.”
“Well, Cipro is one of the antibiotics we use, that’s for sure.  How frequently do you get these infections?”
“Maybe once a year, no more than that.”
“Okay, well then you don’t need a prescription for antibiotics to use at home when you’re symptoms start up.  We usually give patients their own antibiotic prescriptions to use if they have a history of having numerous urinary tract infections  (UTI) during the past year.   I note you don’t have any drug allergies and besides problems with seasonal allergies you don’t have any other problems.  Are you taking your Allegra right now?”
“Yeah, I started taking it about a week ago  when the trees started blooming.”
“Ok, well  then let me take a look at you by listening to your chest, heart and feel your abdomen.  Then I’ll go find out what your urine sample shows.”
“Okay.”
Liz’s physical exam was normal except for mild tenderness over  her lower abdomen in the midline (corresponds to where her bladder is located) and she did have some costovertebral tenderness on the left side (back pain which corresponds to urinary tract infections).

Risk factors

female > male
urinary tract malformation
hospitalized patients (especially those who have foley catheters in)
presence of renal stones
immunocompromised patient (kidney transplant)
diabetic patient
sicke cell disease
polycystic kidney disease

Signs/Symptoms

lower midline pelvic discomfort/pain (over bladder)
pain over lateral posterior back (either right or left, or both sides)
urgency
frequency
burning with urination
blood in urine
nausea/vomiting
fevers
protein in urine
bacteria +
leucocyte esterase + (on urinalysis), this shows the presence of white blood cells

“Liz, I’ll be right back, I’m going to go see what your urine results are.”
I left the exam room  and walked over to the lab station.  The tech gave me her urinalysis results which showed what I expected a typical UTI to show, she had positive nitrates, leucocyte esterase, bacteria and a small amount of protein.    I walked back into the exam room and advised Liz of her results. 
“Liz, I’m going to give you Cipro to take for the next 7 days twice a day to make sure the infection is totally cleared up.  I’ll send off your urine to have a culture done on it just to make sure that you’re not infected with an unusual  bacteria or that the bacteria is not resistent to the Cipro.  Go ahead and acidify your urine by drinking lots of cranberry juice, and you can pick up some ‘Azo’ over the counter which will help with your urge to urinate and well as address your burning sensation. It will turn your urine orange so don’t be concerned about that. You should only need to take the ‘Azo’ for 2  days or so, then stop it.”
With that I handed her a prescription for her antibiotics. 
“Thanks,  for your help.”
“No problem.  Now I hope you enjoy your weekend.
“I will.”

Diagnosis/Treatment

urinalysis shows bacteria, leucocyte esterase, +nitrates, ? protein, ?blood
Culture (if done) will reveal 80-85% E. coli, a gram negative bacteria
Treatment consists of antibiotics for 3-10 days.  The length of time is decided upon by the clinician and the extent of symptoms the patient has.  Many women can be treated for 3 days if the clinician believes it is an uncomplicated infection (i.e. bladder infection only).  If the clinician believes the bacteria has gone up into the kidneys then the patient needs to be treated for 7-10 days. 
Kidney involvement can be suspected if the patient has positive pain over their back sides on the lateral aspects, nauea/vomiting and/or fevers.
Typical antibiotics can include: Macrobid, Cipro, Bactrim DS, or a Cephalosporin. 

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