INTRODUCTION• NCUTI among the most prevalent NCI• Nosocomial bacteriuria develops in up to 25% ofpatients requiring a urinary catheter for > 7 days• The prevalence of hospital-acquired UTIs in the PEPstudy was 10% and urosepsis accounted for 12% of allepisodes.
MICROBIOLOGICAL DATA• Gram-negative bacilli E.COLI account for majority of the caseswhile Gram-positive organisms are involved less frequently,• with E. coli being the commonest bacterium isolated in bothcatheterized and non-catheterized patients• Organisms isolated from patients with complicated urinaryinfection and urosepsis tend to be more resistant
RISK FACTORS Of NCUTI elderly patients diabetics immuno-suppressed patients. Structural and functional abnormalities of the genitourinary tract Indwelling urinary catheters
Classification of UTIUncomplicatedUTI >>>healthyindividualComplicated UTI >>> functional orstrucutional u t abnormalityUrosepsisSpecial male genitourinary tractinfection eg epidedymitis
EVALUATION• History is crucial in the evaluation of any UTI Itshould includeany previous history of infections,antibiotic use,timeline of symptoms. If possible,any laboratory results associated with previousinfections, including culture results should beobtained.
• The physician should promptly look for evidenceof sepsis in sever form of UTI• A thorough physical examination (including apelvic examination and digital rectalexamination to exclude acute prostatitis) shouldalso be performed.
INVISTIGATIONURINE FOR dipstick , R/E&CULTURE ISCRUCIALROUTINE BLOOD TEST +CRPBLOOD CUTURELOCALIZING UNDERLYING URINARY TRACTABNORMALITY ULTRA SOUND CT&MRI Urine sample should be taken from sample port not from drainage bagurine should be transported to lab &processed within 10minutepresence or high acount of pyuria not indicate diagnosis if culture shows less than10 3 cfu/mlgram stain of centrifuged urine is reliable in detection of infectedorganism
Diagnosis• CA-UTI in patients with indwelling urethral,indwelling suprapubic, or intermittentcatheterization is defined by– the presence of symptoms or signs compatible with UTI– no other identified source of infection– >103colony forming units (cfu)/mL of 1 bacterial speciesin a single catheter urine specimen or in a midstreamvoided urine specimen from a patient whose urethral,suprapubic, or condom catheter has been removedwithin the previous 48 h
Diagnosis• CA-ASB in patients with indwelling urethral,indwelling suprapubic, or intermittentcatheterization is defined– >105cfu/mL of 1 bacterial species in a single catheter urinespecimen– patient without symptoms compatible with UTI• CA-ASB in a man with a condom catheter isdefined– >105cfu/mL of 1 bacterial species in a single urinespecimen from a freshly applied condom catheter– patient without symptoms compatible with UTI
Diagnosis• In the catheterized patient, pyuria is notdiagnostic of CA-bacteriuria or CA-UTI– The presence, absence, or degree of pyuria shouldnot be used to differentiate CA-ASB from CA-UTI– Pyuria accompanying CA-ASB should not beinterpreted as an indication for antimicrobialtreatment
TREATMENT GENERALSUPPORTIVE MANAGEMENT• ANTIMICROBIAL THERAPY Antimicrobial Selection shouldbe depend on:.Local(hospital /ward) pattern of microorganism isolation andantibiotic resistanceWherever possible, antimicrobial therapy should be delayedpending results of urine culture and organism susceptibility,unless sever form or impeding sepsis indicated empiricalregimes.Where empirical therapy is initiated, the antimicrobial choiceshould be reassessed once culture results become available,usually within 48 h to 72hr
Antibiotic regime for NCUTIUrinary tract infections Possible antibioticuncomplicated cystitis- Nitrofurntion 100mg orally for 3daysBactrim DS orally twice daily for 3 dayCiprofloxacin 250mg orally twice daily for 3 daysor Levofloxacin 250mg orally once daily for 3 daysor augamantineuncomplicatepyelonephritisIcomplicated cystitis orpyelonephritisl,Ciprofloxacin 200-400mg IV every 12 hour orLevofloxacin250 to 500mg IV onceor aminoglycosideas 2line amikacinor gentamicin,intravenous regimen such as a fluoroquinolone, aminoglycoside (with or without an extended-spectrumcephalosporin, an extended-spectrum penicillin, or acarbapenem for7-14d
hospital-acquired urosepsisregime Doseantipseudomonal third-generationcephalosporincefepime,ceftazidime1–2g every 8–12 h2g every 8 hOr piperacillin/beta- lactamase inhibitorimipenem or meropenem(tazocine(or carbamide merepnem.4 5g every 6 h500mg every 6 hplusaminoglycoside (amikacin,(gentamicinا7mg/kg per d†Amikacin 20 mg/kg per dt
community-acquired primary urosepsisregime doseOr3rdgeneration cephalosporin eg:Ceftriaxone 1to2g daily+pipracillin)beta-l actamase inhibitor (tazocin.4 5g every 6 horafluoroquinolonelevofloxcine,ciproflaxcine750mg every d400mg every 8 hA combination therapy with an aminoglycoside or a carbapenem maybe essential in areas with high rate of fluoroquinolone resistance.
IMPORTANT NOTESMost patients require treatment for about 14-21 daysSuccessful antimicrobial therapy will usually amelioratesymptoms promptly,Patients who fail to respond in this time frame should bereassessed to excludeurinary obstruction or abscess (which may requiredrainage),to exclude resistance of the infecting organismconsider an alternate diagnosisCatheters should be replaced before initiatingantimicrobial therapy for the treatment of a symptomatic
REFRENCES•Nottingham Antimicrobial Guidelines Committee April 2011 Review April 2012•European Prevalence of Infection in Intensive care Study. EPIC International Advisory Committee•European Society of Infections in Urology. Hospital acquired urinary tract infections in and use ofantibiotics. Data from the PEP and PEAP-studies.•SENTRY Antimicrobial Surveillance Program (2000 Diagn Microbiol Infect((.•The European and Asian guidelines on management and prevention of catheter- urinary tractinfections associated•Surviving Sepsis Guidelines•TMC infectious control
always consider local pattrenof microrganisms resistence,avilblity of antibiotic ,host factoralways consider delyed anti bioticas much as patient clinical satuationtolarate to direct antibiotic accordingto result of culture& sensitvity