1.Urinary Tract InfectionsUrinary Tract Infections DR.TARIK ELDARATDR.TARIK ELDARAT MD UROLOGISTMD UROLOGIST Friday, September 27, 2013

2. Todays GoalsTodays Goals Be able to define the various types of UTIsBe able to define the various types of UTIs Describe the classic signs of pyelonephritisDescribe the classic signs of pyelonephritis Be able to determine if a urine culture is positiveBe able to determine if a urine culture is positive Know the types of imaging needed and who needsKnow the types of imaging needed and who needs imagingimaging Explain why we care so much about early diagnosis andExplain why we care so much about early diagnosis and prompt treatmentprompt treatment Friday, September 27, 2013 3. DefinitionsDefinitions UTIinflammatory response of the urothelium toUTIinflammatory response of the urothelium to bacterial invasion.bacterial invasion. UncomplicatedHealthy patient with normal urinaryUncomplicatedHealthy patient with normal urinary tract.tract. Complicatedcompromised patient or one with aComplicatedcompromised patient or one with a functional or structural abnormality.functional or structural abnormality. RecurrentRecurrent Reinfectioninfection from different bacteria outside the urinaryReinfectioninfection from different bacteria outside the urinary tract.tract. Persistentfocus from within the urinary tract that is neverPersistentfocus from within the urinary tract that is never eradicated.eradicated. Friday, September 27, 2013 4. Bacteriuria: the presence of bacteria in the urine Significant bacteriuria: 105 organism or more per milliliter Pyuria: the presence of white blood cells in urine Pyuria with 5 or more cells per microscopic high-power field: reliable indicator of UTI The absence of such pyuria does not reliably exclude UTI Friday, September 27, 2013 5. Pyuria alone=inflammationPyuria alone=inflammation Bacteriuria without pyuria=colonizationBacteriuria without pyuria=colonization Epithelial cells=contaminationEpithelial cells=contamination 6. The normal urinary tract is sterile for many reasons: Eradication of bacteria by urinary and mucous flow: secretory peptides target cytoplasm of bacteria Urothelial bactericidal activity Urinary secretory IgA Blood group antigens in secretion alter bacterial adhesion Friday, September 27, 2013 7. DefensesDefenses Primary DefensePrimary Defense Flow of UrineFlow of Urine VoidingVoiding Secondary DefenseSecondary Defense LactoferrinLactoferrin pHpH IgAIgA IL-6IL-6 IL-8IL-8 Tamm-HorsfallTamm-Horsfall Friday, September 27, 2013 8. ClassificationClassification Isolatedfirst infections or those isolated by 6 months(30-Isolatedfirst infections or those isolated by 6 months(30- 40% of women).40% of women). Unresolvedinsufficient treatmentUnresolvedinsufficient treatment ResistanceResistance Development of resistanceDevelopment of resistance Two species one is resistantTwo species one is resistant Rapid reinfection before completion of therapy onRapid reinfection before completion of therapy on initial organisminitial organism Azotemia(poor concentration of drug)Azotemia(poor concentration of drug) Papillary necrosis + azotemiaPapillary necrosis + azotemia Staghorn Calculi(mass and concentration of bacteriaStaghorn Calculi(mass and concentration of bacteria too great)too great)Friday, September 27, 2013 9. Friday, September 27, 2013 10. Friday, September 27, 2013 11. EpidemiologyEpidemiology 7 million office visits annually(1.2% female, 0.6% male)7 million office visits annually(1.2% female, 0.6% male) Prevalence increases with hospitalization, disease, numberPrevalence increases with hospitalization, disease, number of infections,of infections, Susceptible females2 infections in 6 months = 66%Susceptible females2 infections in 6 months = 66% chance of developing infection in the next 6 months.chance of developing infection in the next 6 months. Prophylaxis changes the time to recurrence not the chanceProphylaxis changes the time to recurrence not the chance of recurrence.of recurrence. Pregnancy increases the clinical acuity of infections.Pregnancy increases the clinical acuity of infections. Friday, September 27, 2013 12. PathogenesisPathogenesis Ascendingpredominant routeAscendingpredominant route Impairment of peristalsis enhancesImpairment of peristalsis enhances infection(endotoxin from G- Bacteria,infection(endotoxin from G- Bacteria, pregnancy, obstruction)pregnancy, obstruction) Pelvic Pressure enhancesPelvic Pressure enhances infection(obstruction, VUR)infection(obstruction, VUR) HematogenousrareHematogenousrare Lymphaticvery rare(RP abscess)Lymphaticvery rare(RP abscess)Friday, September 27, 2013 13. PathogensPathogens NosocomialNosocomial E. Coli50%E. Coli50% KlebsiellaKlebsiella EnterobacterEnterobacter CitrobacterCitrobacter SerratiaSerratia PseudomonasPseudomonas S. epidermitisS. epidermitis Community-AcquiredCommunity-Acquired E. Coli85%E. Coli85% ProteusProteus KlebsiellaKlebsiella E. faecalisE. faecalis Staph.Staph. Saprophyticus(10%Saprophyticus(10% of young sexuallyof young sexually active females)active females) Friday, September 27, 2013 14. Community-Acquired UTICommunity-Acquired UTI E.coli K.pneumoniae Proteus S.saprophyticus S.epi & gm - enterics Enterococcus Friday, September 27, 2013 15. Nosocomial UTINosocomial UTI catheter associatedcatheter associated Short Term Long Term E.coli E.coli Pseudomonas Pseudomonas Proteus Proteus Enterobacter Candida Providencia Morganella S.aureus Enterococcus Friday, September 27, 2013 16. Friday, September 27, 2013 17. Causative organismsCausative organisms Gram +ve: Enterococci, StaphylococcusGram +ve: Enterococci, Staphylococcus saprophyticus.saprophyticus. Gram ve:Gram ve: Escherichia coliEscherichia coli,, ProteusProteus species,species, Pseudomonas aeruginosaPseudomonas aeruginosa,, KlebsiellaKlebsiella strains.strains. Also: Mycobacterium tuberculosisAlso: Mycobacterium tuberculosis Friday, September 27, 2013 18. Escherichia coliEscherichia coli E. coli (serotypes: 02, O4, O6) which areE. coli (serotypes: 02, O4, O6) which are fimbrinated strains adhering to uro-fimbrinated strains adhering to uro- epithelial cells, leading to colonization andepithelial cells, leading to colonization and infection is the commonest cause of urinaryinfection is the commonest cause of urinary tract infections.tract infections. Friday, September 27, 2013 19. Gram negative bacilliGram negative bacilli Pseudomonas, Proteus, and KlebsiellaPseudomonas, Proteus, and Klebsiella infections often follow catheterization andinfections often follow catheterization and gynecological surgery (nosocomialgynecological surgery (nosocomial pathogen).pathogen). Infection with proteus may be complicatedInfection with proteus may be complicated by phosphate stone formation as it is ureaby phosphate stone formation as it is urea leads to alkaline pH.leads to alkaline pH. Friday, September 27, 2013 20. S. saprophyticusS. saprophyticus Infection more common in young women.Infection more common in young women. Friday, September 27, 2013 21. What parts of the urinary tract can get infected? Urethra - Urethritis Urinary bladder Cystitis Ureters Ureteritis Kidneys - Pyelonephritis Friday, September 27, 2013 22. Cystitis 23. IncidenceIncidence 1-3% of all GP consultations1-3% of all GP consultations 5% of women each year with symptoms. Up5% of women each year with symptoms. Up to 50% of women will suffer from ato 50% of women will suffer from a symptomatic UTI during their lifetime.symptomatic UTI during their lifetime. UTI in men is much rarerUTI in men is much rarer A proportion of patients may beA proportion of patients may be symptomatic in the absence of infection -symptomatic in the absence of infection - called 'urethral syndrome'called 'urethral syndrome' 24. What are the signs and symptoms of UTI? Cystitis Frequency Urgency Dysuria painful voiding Pain or discomfort in suprapubic or perineal area or lower back Cloudy or foul-smelling urine Friday, September 27, 2013 25. CausesCauses The most common cause is bacterial infectionThe most common cause is bacterial infection Eschericia coli is the pathogen in 70% ofEschericia coli is the pathogen in 70% of uncomplicated case of lower urinary tract infections.uncomplicated case of lower urinary tract infections. Other organisms include Proteus mirabilis, KlebsiellaOther organisms include Proteus mirabilis, Klebsiella pneumoniae, Staphylococcus saprophyticus,pneumoniae, Staphylococcus saprophyticus, Staphylococcus aureus and Pseudomonas species.Staphylococcus aureus and Pseudomonas species. Urethral Syndrome -not associated with anyUrethral Syndrome -not associated with any infectioninfection Rarely kidney or bladder stones, prostatism,Rarely kidney or bladder stones, prostatism, diabetesdiabetes 26. PreventionPrevention Drinking plenty of fluids helps preventDrinking plenty of fluids helps prevent cystitis in the first place.cystitis in the first place. If cystitis follows sexual intercourse, someIf cystitis follows sexual intercourse, some advise passing urine soon after to try andadvise passing urine soon after to try and prevent it.prevent it. There is no evidence to suggest a linkThere is no evidence to suggest a link between lower urinary tract infection andbetween lower urinary tract infection and use of bath preparationsuse of bath preparations 27. Beware!Beware! PregnantPregnant Under age 12Under age 12 MalesMales Systemically ill (fever, sickness, backache)Systemically ill (fever, sickness, backache) Catheterised patientsCatheterised patients Kidney or bladder stonesKidney or bladder stones 28. InvestigationInvestigation Urine dipstickUrine dipstick can be done in the surgery and will be positive for nitrates andcan be done in the surgery and will be positive for nitrates and leucocytes (leukocyte esterase test). This helps to differentiateleucocytes (leukocyte esterase test). This helps to differentiate those with UTI from the 50% with urethral syndrome.those with UTI from the 50% with urethral syndrome. Urine microscopy and culture reveals significant bacteruriaUrine microscopy and culture reveals significant bacteruria (usually >105 /ml).(usually >105 /ml). Asymptomatic bacteruriaAsymptomatic bacteruria is present in 12-20% of women aged 65-70 years and does notis present in 12-20% of women aged 65-70 years and does not impair renal function or shorten life so no treatmentimpair renal function or shorten life so no treatment in 4-7% of pregnant women and associated with prematurein 4-7% of pregnant women and associated with premature delivery and low birth weight and always requires treatment.delivery and low birth weight and always requires treatment. 29. Differential DiagnosisDifferential Diagnosis Urethral syndromeUrethral syndrome Bladder lesion e.g. calculi, tumour.Bladder lesion e.g. calculi, tumour. Candidal infectionCandidal infection Chlamydia or other sexually transmitted disease.Chlamydia or other sexually transmitted disease. UrethritisUrethritis Drug induced cystitis (e.g. withDrug induced cystitis (e.g. with cyclophosphamide, allopurinol, danazol,cyclophosphamide, allopurinol, danazol, tiaprofenic acid and possibly other NSAIDs)tiaprofenic acid and possibly other NSAIDs) 30. Complications and PrognosisComplications and Prognosis Ascending infection can occur, leading to development ofAscending infection can occur, leading to development of pyelonephritis, renal failure and sepsis.pyelonephritis, renal failure and sepsis. In children, the combination of vesicoureteric reflux andIn children, the combination of vesicoureteric reflux and urinary tract infection can lead to permanent renalurinary tract infection can lead to permanent renal scarring, which may ultimately lead to the development ofscarring, which may ultimately lead to the development of hypertension or renal failure. 12-20% of children alreadyhypertension or renal failure. 12-20% of children already have radiological evidence of scarring on their firsthave radiological evidence of scarring on their first investigation for UTI.investigation for UTI. Urinary tract infection during pregnancy is associated withUrinary tract infection during pregnancy is associated with prematurity, low birth weight of the baby and a highprematurity, low birth weight of the baby and a high incidence of pyelonephritis in women.incidence of pyelonephritis in women. Recurrent infection occurs in up to 20% of young womenRecurrent infection occurs in up to 20% of young women with acute cystitis.with acute cystitis. 31. Management Issues - GeneralManagement Issues - General 50% will resolve in 3 days without50% will resolve in 3 days without treatmenttreatment No evidence to support drink plentyNo evidence to support drink plenty It is reasonable to start treatment withoutIt is reasonable to start treatment without culture if the dipstick is positive for nitratesculture if the dipstick is positive for nitrates or leucocytes.or leucocytes. MSU if dipstick negative but suspicionMSU if dipstick negative but suspicion 32. Management Issues - GeneralManagement Issues - General Culture is always indicated inCulture is always indicated in MenMen Pregnant womenPregnant women ChildrenChildren Those with failure of empirical treatmentThose with failure of empirical treatment Those with complicated infectionThose with complicated infection 33. Self careSelf care Drink slightly acid drinks such as cranberryDrink slightly acid drinks such as cranberry juice, lemon squash or pure orange juicejuice, lemon squash or pure orange juice (poor trial evidence for this)(poor trial evidence for this) Try a mixture of potassium citrate availableTry a mixture of potassium citrate available from your pharmacist (little evidence butfrom your pharmacist (little evidence but widely recommended)widely recommended) 34. AntibioticsAntibiotics Trimethoprim is an effective first line treatment.Trimethoprim is an effective first line treatment. Cephalosporins are as effective as trimethoprimCephalosporins are as effective as trimethoprim but more expensive and more likely to disrupt gutbut more expensive and more likely to disrupt gut flora.flora. Nitrofurantoin is as effective as trimethoprim butNitrofurantoin is as effective as trimethoprim but more expensive and frequently causes nausea andmore expensive and frequently causes nausea and vomitingvomiting The 4-quinolones (ciprofloxacin, norfloxacin,The 4-quinolones (ciprofloxacin, norfloxacin, ofloxacin) are effective in the treatment of cystitis.ofloxacin) are effective in the treatment of cystitis. To preserve their efficacy, they should not usuallyTo preserve their efficacy, they should not usually be used as first line therapybe used as first line therapy 35. AntibioticsAntibiotics 3 days of antibiotic is as effective as 5 or 7 days3 days of antibiotic is as effective as 5 or 7 days Single dose antibiotic results in lower cure ratesSingle dose antibiotic results in lower cure rates and more recurrences overall than longer courses.and more recurrences overall than longer courses. In relapse of infection (i.e. reinfection with theIn relapse of infection (i.e. reinfection with the same bacteria), treatment with antibiotic for up tosame bacteria), treatment with antibiotic for up to 6 weeks is recommended.6 weeks is recommended. 36. Urinary Tract InfectionsUrinary Tract Infections T r e a t m e n t o f R e c u r r e n t C y s t i t i s T r e a t l o n g e r ( 2 - 6 w e e k s ) R e l a p s e S e e k o c c u l t s o u r c e o f i n f e c t o n U r o l o g i c e v a l u a t i o n D a i l y o r t h r i c e w e e k l y p r o p h y l a x i s N o r e l a t i o n t o c o i t u s P o s t c o i t a l p r o p h y l a x i s T e m p o r a l l y r e l a t e d t o c o i t u s 3 U T I / y r P a t i e n t i n i t i a t e d t h e r a p y 2 U T I / y r U r o l o g i c e v a l u a t i o n n o t r o u t i n e l y i n d i c a t e d R e i n f e c t i o n D i a p h r a g m a n d s p e r m i c i d e C o n s i d e r c h a n g i n g c o n t r a c e p t i v e m e t h o d R e c u r r e n t C y s t i t i s 37. Antibiotics for UTI in PregnancyAntibiotics for UTI in Pregnancy Cephalosporins and penicillins are recommendedCephalosporins and penicillins are recommended in pregnancy because of their long term safetyin pregnancy because of their long term safety recordrecord Nitrofurantoin is also likely to be safe duringNitrofurantoin is also likely to be safe during pregnancypregnancy Quinolones, Trimethoprim and Tetracyclines areQuinolones, Trimethoprim and Tetracyclines are not recommended for use during pregnancynot recommended for use during pregnancy Seven days of treatment is required.Seven days of treatment is required. Urine should be tested regularly throughoutUrine should be tested regularly throughout pregnancy following initial infection.pregnancy following initial infection. 38. Fever Nausea and vomiting More pronounced malaise Pain in the back (+) CVA tenderness Acute pyelonephritis Friday, September 27, 2013 39. Acute PyelonephritisAcute Pyelonephritis 40. Clinical ManifestationsClinical Manifestations Classic signs of cystitisClassic signs of cystitis EnuresisEnuresis FrequencyFrequency DysuriaDysuria HesitancyHesitancy Suprapubic discomfortSuprapubic discomfort Classic signs of pyelonephritisClassic signs of pyelonephritis +/- UTI signs+/- UTI signs ChillsChills NauseaNausea Flank painFlank pain In older children and adults Friday, September 27, 2013 41. But In InfantsBut In Infants Fever! Fever!!Fever! Fever!! Fever!!!Fever!!! Lack classic signsLack classic signs IrritabiltyIrritabilty Poor feedingPoor feeding VomitingVomiting DiarrheaDiarrhea Present in 5,000 colonies/mm abnormal 2 tube approach2 tube approach 81. Acute bacterial prostatitisAcute bacterial prostatitis HistoryHistory Lower urinary tract obstruction, perineal pain,Lower urinary tract obstruction, perineal pain, dysuria, and feverdysuria, and fever Systemic symptomsSystemic symptoms PhysicalPhysical Tender, warm, boggy, swollen prostateTender, warm, boggy, swollen prostate Massage isMassage is NOTNOT indicated in acute prostatitisindicated in acute prostatitis 82. Acute bacterial prostatitisAcute bacterial prostatitis ManagementManagement Outpatient therapyOutpatient therapy Bactrim, ampicillin, or quinolone for 4 6 weeksBactrim, ampicillin, or quinolone for 4 6 weeks Bedrest, analgesics, antipyretics, stool softenersBedrest, analgesics, antipyretics, stool softeners Inpatient therapyInpatient therapy Parental antibiotics: ampicillin and gentamycinParental antibiotics: ampicillin and gentamycin Avoid urethral catheterization for retentionAvoid urethral catheterization for retention Urology consultUrology consult 83. Chronic bacterial prostatitisChronic bacterial prostatitis HistoryHistory Bladder outflow obstructionBladder outflow obstruction Dysuria; perineal, low back, or testicular painDysuria; perineal, low back, or testicular pain Hematuria, hematospermia, painful ejaculationHematuria, hematospermia, painful ejaculation Physical examinationPhysical examination Variable prostate examVariable prostate exam Relapsing UTI in men is the hallmark of chronicRelapsing UTI in men is the hallmark of chronic bacterial prostatitisbacterial prostatitis GNR most common; alsoGNR most common; also Enterococcus and S. saprophyticusEnterococcus and S. saprophyticus 84. Chronic bacterial prostatitisChronic bacterial prostatitis ManagementManagement Difficult to eradicate given poor penetration ofDifficult to eradicate given poor penetration of antibiotic into the non-inflamed prostateantibiotic into the non-inflamed prostate Bactrim and fluoroquinolonesBactrim and fluoroquinolones Doxycycline and macrolides second-lineDoxycycline and macrolides second-line Prolonged treatment requiredProlonged treatment required Recheck prostatic fluid after treatmentRecheck prostatic fluid after treatment Alpha-blockers to reduce symptomsAlpha-blockers to reduce symptoms Suppressive therapySuppressive therapy 85. Prostatitis: complicationsProstatitis: complications Renal parenchymal infectionRenal parenchymal infection BacteremiaBacteremia Prostate abscessProstate abscess ImmunocompromisedImmunocompromised FB; obstructionFB; obstruction Prostatic stonesProstatic stones Nidus for persistentNidus for persistent infectioninfection 86. ProstatodyniaProstatodynia HistoryHistory Persistent pelvic, suprapubic, infrapubic, scrotal,Persistent pelvic, suprapubic, infrapubic, scrotal, inguinal, or perineal paininguinal, or perineal pain Lower tract obstruction and dysuriaLower tract obstruction and dysuria Absence of systemic symptomsAbsence of systemic symptoms Physical exam usually unremarkablePhysical exam usually unremarkable No bacteria identified and no evidence ofNo bacteria identified and no evidence of inflammation presentinflammation present Limited course of antibiotics, alpha blockadeLimited course of antibiotics, alpha blockade