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Urinary Tract Infections
I would like to tell you something…Will you listen to me…?
Overview of UTI
7 million office visits yearly 1 million hospitalizations About 2/3rds of patients are women
◦ 40% to 50% of women have UTI at some point during their lives
Important complications of pregnancy, diabetes mellitus, polycystic disease, renal transplantation, conditions that impede urine flow (structural and neurologic)
Terms
Urinary tract infection Significant bacteriuria Asymptomatic bacteriuria Acute pyelonephritis Chronic pyelonephritis Chronic interstisial nephritis Pyuria Urethral syndrome
UTI: the finding of microorganisms in bladder urine with or without clinical symptoms and with or without renal disease Women: Presence of at least 100,000 colony-forming units (cfu)/mL in a pure culture of voided clean-catch urine.
Men: Presence of just 1,000 cfu/mL
Significant bacteriuria: the number of bacteria in the voided urine exceeds the number that can be expected from contamination (i.e. ≥ 10⁵ cfu/ml)
Asymptomatic bacteriuria: Significant bacteriuria (>105 cfu/ml) without clinical symptoms.
Acute bacterial pyelonephritis: a clinical syndrome of fever, flank pain, and / or tenderness
Chronic bacterial pyelonephritis: Long-standing infection associated with active bacterial growth in the kidney; or the residum of lesions caused by such infection in the past
Chronic interstitial nephritis: renal disease with histologic findings resembling chronic bacterial pyelonephritis but without evidence of infection
Pyuria: the presence of pus (WBC’s) in urine, which may or may not be caused by UTI. The preferred method for quantification is enumeration in unspun urine. The leukocyte esterase nitrite test has a sensitivity of between 70% and 90% for symptomatic UTI
Urethral syndrome: characterized by frequency, dysuria, and suprapubic discomfort without demonstrable infection
Some Classifications of
UTI
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Presentation of UTIs Urethritis
o The inflammation and infection is limited to the urethrao It is usually a sexually transmitted disease.o Present in men and women
Cystitiso Irritation of the lower urinary tract mucosa (i.e. bladder)o Dysuria (painful urination)o Urgency & frequency but smallo Suprapubic tendernesso Pyuria
Haemorrhagic cystitiso Large quantities of visible blood in the urineo Caused by an infection (bacterial or viral)o Irritation when voiding
Pyelonephritiso Kidney infection from lower UTI infectiono Complications – Sepsis, septic shock and death
Uncomplicated vs Complicated UTI
Uncomplicated UTI: infection that occurs in a structurally and neurologically normal urinary tract
Females > Males
Complicated UTI: infection in a urinary tract with functional or structural abnormalities (including indwelling catheters and renal calculi)
Females = Males In elderly men are always considered complicated In women are complicated when:
Hx of recurrent UTI Secondary to structural abnormalities Catheters Stones Urinary retention Abscess formation or urosepsis
Primary Vs. Recurrent
Primary UTI Infection that occurs in the urinary
tract for the first time. No previous episodes of infections.
Recurrent UTI Presence of past history of urinary
tract infection
RecurrentRelapse Vs. Reinfection
Relapse Recurrence within 2 weeks of
treatment and mainly due to treatment failure, the initial organism is not totally cleared.
The Same Organism
Occurs in case of:• Acute Upper UTI.• Presence of obstruction like stone
disease.
ReinfectionRecurrence within several weeks after
the antibiotic therapy has cleared up the initial episode.
Different Organisms
Lower Urinary Tract Infection(Urethritis and Cystitis)
Vs
Upper Urinary tract Infection(Pyelonephritis)
Acute Uncomplicated Cystitis Acute bacterial cystitis is usually
characterized by sudden onset, multiple urinary symptoms, pyuria, and sometimes hematuria
Acute dysuria in young women usually indicates: acute bacterial cystitis; the urethral syndrome; or vaginitis
Although most patients have lower urinary symptoms only, 30% to 50% may have subclinical renal involvement
Causes: E. coli (80%), S. saprophyticus (10% to 15%), and occasionally Klebsiella, Proteus mirabilis, and other microorganisms.
Acute Uncomplicated Pyelonephritis Largely a clinical diagnosis Pyuria is usually present; about 20%
have positive blood cultures; causative organisms the same as with cystitis
Predisposing factors: structural abnormalities; strains of E. coli with unique markers; genetically-determined carbohydrate receptors on uroepithelial cells
Highly significant! Presence of WBC casts suggests pyelonephritis
Physiologic changes with aging in the urinary tractAge-Related Changes Men WomenDecreased bladder capacity and increased urine production (especially at night)
Decreased voided volume
Decreased estrogen w/menopause leads to thinning of vaginal & urethral mucosa
Decreased lower urinary tract sensory threshold
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√Palmer, 2004
Urinary Tract InfectionPhysiologic Changes
Physiologic changes with aging in the urinary tract
Age-Related Changes Men Women
Problems of urinary storage & emptying
↑incidence of overflow incontinence from urethral obstruction or stricture
Decreased estrogen levels leads to pH changes in vagina, favoring colonization of E. coli, ↑risk of UTI
Prostatic enlargement can lead to urinary obstruction, increased residual urine & infection
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Palmer, 2004
Risk Factors Organisms Rout of Infection Symptoms - History Signs – Physical Exam Differential Diagnosis Investigation Treatment Complications
Urinary Tract Infections
Risk Factors
??????
Risk Factors
General Conditions Diabetes Previous urinary tract infection Kidney Problems Immunosuppression Sickle Cell Disease Functional or mental impairment Urinary Stone Disease Urinary Tract Anomalies Neurogenic Bladde
Urologic instrumentation or surgery Urethral catheterization Renal transplantation spinal injury
Risk Factors
Specific for Females
Structure of Urinary Tract. Sexual Behavior. It is not STD Contraception. Pregnancy Menopause
Risk Factors
Specific for Males
Benign Prostatic Hypertrophy
Prostatitis
Risk Factors
Specific for Children
Uncircumcised Males
Vesicoureteral Reflux Disease.
Frequency distribution of symptomatic UTI and prevalence of asymptomatic bacteriuria by age and sex
)Male – shaded area; Female – line(
Organisms
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OrganismsGram Negative Organisms
E.Coli In Acidic Urine (most common)
Proteus In Alkali Urine
Klebsiella
Citrobacter
Pseudomonas
OrganismsGram Positive Organisms
Staphylococcus Aureus
Staphylococcus Epidermidis
Streptococcus Feacalis
OrganismsFungal Infections
Mainly in Diabetic Patients.
Candida Species
Rout of Infection
??????
Rout of Infection
Ascending Infection.◦ The common route of nearly all forms of urinary
tract infection (bacteria initially colonize periurethral tissues)
◦ Common in females than in males because of shorter urethra
◦ Single bladder catheterization can result in UTI in 1% of the ambulatory population
Lymphatic Spread. Increase bladder pressure can cause lymphatic flow
to be directed toward the kidney
Local Spread.
Rout of Infection
Hematogenous Spread.• Frequently seen with Staphylococcus aureus
bacteremia or endocarditis• Also seen to occur in experimental models with
Candida• Infections with gram negative bacilli rarely occurs
by this route Descending From the Kidneys Local Spread.
Symptoms - History
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Symptoms - History
Lower Urinary Tract Infection
Frank Hematurea.
Painful Micturation.
Discomfort in the lower abdomen.
Urinary Frequency.
Urinary Urgency.
Symptoms - History
Upper Urinary Tract Infection
High Grade Fever, chills and rigor.
Flank Pain.
Nausea and Vomiting
Lower UTI Symptoms.
Signs – Physical Exam
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Signs – Physical Exam
Vital Signs
Suprapubic Tenderness
Flank Tenderness
Based on the symptoms both
a clinical diagnosis of a UTI and a differentiation between lower (cystitis) or upper (pyelonephritis) UTI should be made
Differential Diagnosis
??????
Differential Diagnosis
Lower UTI
Stones.
Vaginitis and STD
Interstitial Cystitis.
Menopausal Changes.
Prostate Disease.
Differential Diagnosis
Upper UTI
Pneumonia.
Cholecystitis.
Appendicitis.
Kidney Stones.
Investigation
??????
Investigation
Dipstick Test
Nitrites Test
Leukocyte Esterase Test.
Blood.
Proteins.
Investigation
Microscopic Examination
WBC’s Count.
RBC’s Count.
Cellular and Hyaline Casts.
Investigation
Clinical Symptoms
Plus
Suggestive Dipstick
Plus
Suggestive Microscopic ExamEqual
Urinary Tract Infection (75%)
Investigation
Gram Stain and Urine Culture
Urine culture is gold standard.
Used in every positive dipstick and urinalysis.
Used in negative dipstick and urinalysis if:
- Age less than 2 Years.
- UTI symptoms (25%).
Investigation
Helpful Laboratory Tests
CBC
Serum Electrolytes
KFT
Blood Culture.
Investigation
Imaging Studies
Recurrent cases of pyelonephritis
Structural abnormalities are suspected.
No response to treatment.
Suspicion of obstruction.
Children: age 2 - 24 months
Investigation
Ultrasound
Screening for hydronephrosis.
Kidney Stones.
Kidney Abscess.
Investigation
Nuclear Scan
Kidney Scar.
InvestigationX-rays
Stones. Structural Abnormalities. Urethral Narrowing. Incomplete Bladder Emptying. Examples:
- MCUG- IVP and KUB
Symptomaticpatient
Uncomplicated cystitisin a woman,
no risk factorsnot a relapse
Typical symptoms, < 2 infections / year,
patient familiar withher illness
Bacterial culture,"on the spot" testingto confirm diagnosis
Starttreatmentbased onresults
Antibiotictherapy
Yes
No
No
Yes
TreatmentUpper UTI
Good Hydration.
Oral TMP-SMX or Quinolones for 2 weeks.
Oral amoxicillin and clavulanic acid for 2 weeks.
TreatmentLower UTI
Good Hydration.
Oral TMP-SMX or Quinolones for 1 week.
Relapses are best treated with the same AB, long period.
Treatment
Reinfections
Long term AB prophylaxis.
Surgical reimplantation of the ureters >>> VUR disease
Treatment
Failure of Treatment
Compliance and AB Dose. Bacterial Resistance. Polymicrobial UTI. Azotemia. Papillary Necrosis. Staghorn Calculi.
Prophylaxis of recurrent cystitis with antimicrobial agents
prophylaxis should be considered when more than 3 infections per year
prophylaxis to continue for 6 months if infections recur after prophylactic
treatment, the prophylaxis is re-commenced for 6 – 12 months
Drugs of choice in UTI prophylaxis
First choice: trimethoprim 100 mg in the evenings nitrofurantoin 50 - 75 mg in the eveningsSecond choice: methenamine hippurate 1 g twice daily norfloxacin 200 mg daily or on 3 evenings per week nitrofurantoin (not if serum creatinine is above 150 μmol/l) quinolones (in cases where there is no response with other
prophylactic medication or tolerance to other medications is poor)
During pregnancy: nitrofurantoin 50 mg daily or methenamine hippurate 1 g daily for the rest of the
pregnancy particularly if recurrent bacteriuria is diagnosed in early
pregnancy
Complications
??????
Complications
Spread of Infection
- Sepsis.- Prostatitis.- Epididymitis.
Persistence of Infection
- Perinephric Abscess.- Chronic Infection.
Complications
Obstruction.
Kidney Scar.
Kidney Stones
That will be all … thanks for not falling asleep ;)Bye Bye