Urinary tract infection , Clinical Based learning

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Urinary tract Infection,Clinical Based Learning

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  • I also wanna mention that it took me 10 days to know that I am sick,2 weeks of having the Bacteria developing in my body through weird feelings that I am just not me, losing appetite, you just witness that u are being different then 3 to 4 days of chills-fever ( Most fuked up time) then the real UTI of frequent washroom visits and fever for no reason. In short. It was the most fuked 2 weeks I ever had in my life and thx God I was back on track with my Dr. prescription to Cipro Xl 500mg and advised me using ADULT DIAPERS . Thanks!
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Urinary tract infection , Clinical Based learning

  1. 1. Urinary Tract Infection Clinical Based Learning Dr.T.V.Rao MD Dr.T.V.Rao MD 1
  2. 2. Clinical Presentation• A 30 years female patient presented with frequencency and urgency in Urination with raise of body temperature since 3 days.• She also presented with lower abdominal pain since 4 days• What can be your Provisional Clinical Diagnosis ? Dr.T.V.Rao MD 2
  3. 3. Signs and Symptoms of Urinary Tract Infection• Elevated temperature—(vital signs) Elderly require > time to present with fever, may not have any increase in temperature → may even be hypothermic Elderly at ↑’d risk for masked or absent fever response due to antipyretics, corticosteroids, chemo Rx, alcoholism, hypothyroidism, malnutrition and renal insufficiency Studies indicate fever is a marker for serious infection & most important clinical indicator for antibiotic treatment Other studies, fevers can resolve without treatment; antibiotics did not improve outcomes in elderly Not always due to UTI—consider differential diagnoses: pulmonary or skin infections Lack of fever may delay diagnosis Dr.T.V.Rao MD 3
  4. 4. • The provisional diagnosis can be a Urinary tract infection (UTI )• Define Urinary Tract Infection ? What are the possible etiological agents ? Dr.T.V.Rao MD 4
  5. 5. Organs Involved in UTI The following organs are infected• Kidney• Bladder• Ureters• Do not include Urethra, Infections of Urethra is called as Urethritis, dealt under different clinical syndromes Dr.T.V.Rao MD 5
  6. 6. What is a Urinary Tract Infection• An infection of one or more structures in the urinary system. Most UTIs are caused by gram- negative bacteria, most commonly Escherichia coli or species of Klebsiella, Proteus, Pseudomonas, or Enterobacter, although other strains, such as Staphylococcus and Serratia, are emerging Dr.T.V.Rao MD 6
  7. 7. Notes on pathogens* Escherichia coli : the commonest urinary pathogen causing 60-90 % of urinary infections* Pseudomonas, Proteus, Klebsiella and S. aureus are associated with hospital acquired infections because their resistance to antibiotics favor their selection in hospital patients (catheterization, gynaecological surgery)* Proteus infections are associated with renal stones Proteus produce a potent urease which act on ammonia, rendering the urine alkaline* S. saprohyticus infections are found in sexually active young women Dr.T.V.Rao MD 7
  8. 8. Rare Microbes causing UTI• Streptococcus agalactiae• Streptococcus milleri• Other Streptococci• Anaerobic Streptococci• Gardernella vaginalis Dr.T.V.Rao MD 8
  9. 9. Notes on pathogens* Candida urinary infection is usually found in diabetic patients and immunosuppression* Infection of the anterior urinary tract (urethritis) is mainly caused by N. gonorrhea, staphylococci, streptococci and chlamydia* M. tuberculosis is carried in blood to kidney from another site of infection (e.g. respiratory T.B.) Dr.T.V.Rao MD 9
  10. 10. What is the Basis of Diagnosis of Urinary Tract Infection ? Dr.T.V.Rao MD 10
  11. 11. Diagnostic CriteriaPyuria• A host response to infecting bacteria causing an increase of white blood cells or pus in the urine• Associated with presence of both symptomatic and asymptomatic UTI’s in elderly• Level of pyuria is ↑ when infected with a gram negative organism• Most research finds this is so common that it has questionable value in UTI detection and as an indicator for Rx in the absence of clinical symptoms Dr.T.V.Rao MD 11
  12. 12. Collecting the Urine• There are several different methods for collection of a urine sample. The most common is the midstream clean-catch technique. Hands should be washed before beginning. For females, the external genitalia (sex organs) are washed two or three times with a cleansing agent and rinsed with water. In males, the external head of the penis is similarly cleansed and rinsed. The patient is then instructed to begin to urinate, and the urine is collected midstream into a sterile Dr.T.V.Rao MD 12 container.
  13. 13. Collected in wide mouthed container • The urine collected in a wide mouthed container from patients • A mid stream specimen is the most ideal for processing • Female patients passes urine with a labia separated and mid stream sample is collected Dr.T.V.Rao MD 13
  14. 14. Early inoculation a Priority• Urine collected in sterile specimen container must be processed within 2 hours, or refrigerated and processed within 24 hours• Urine collected in sterile specimen container with borate preservative should be processed within 24 hours (no refrigeration required) Dr.T.V.Rao MD 14
  15. 15. Collection of UrineCatheterized Patients • Another method is the catheterized urine specimen in which a lubricated catheter (thin rubber tube) is inserted through the urethra (tube-like structure in which urine is expelled from the bladder) into the bladder. This avoids contamination from the urethra or external genitalia. Dr.T.V.Rao MD 15
  16. 16. Suprapubic aspiration• On rare occasions, the health care provider may collect a urine sample by inserting a needle directly into the bladder (suprapubic tap) and draining the urine; this method is used only when a sample is needed quickly and technically competent staff are available Dr.T.V.Rao MD 16
  17. 17. Specimen collected in Infants and Children• Non invasive methods are safe and ideal• Follow the Broomhall et al method By tapping just above the pubis with two fingers place on suprapubic region after 1 hour of feed, tapping on at the rate of 1 tap/second for period of 1 minute, if not successful tapping is repated once again.The child spontaneously pass the Urine and to be collected in a sterile container Dr.T.V.Rao MD 17
  18. 18. Transport of Urine for Culturing Urine• All collected specimens of urine to be transported to laboratory with out delay• Delay of 1 – 2 hour deter the quality of diagnostic evaluations.• If the delay is anticipated the specimens are at preserved at 40c• In field conditions Boric acid can be added at a concentration of 1.8 % Dr.T.V.Rao MD 18
  19. 19. Wet Film examination of Urine• All wet films to be examined with high power ( x 40 ) objective.• Prepare the drop of urine after mixing the urine without centrifugation• Transfer 0.05 ml on the middle of the microscope slide and cover slip is applied.• The prepared specimen show a small excess of fluid along the edges of the cover slip.• A approximate finding of 1 leukocyte / 7 high power fields corresponds to presence of pyuria. Dr.T.V.Rao MD 19
  20. 20. Selection of Loop for Semi quantitative Method Dr.T.V.Rao MD 20
  21. 21. Culturing of urine for Isolation of Bacterial pathogens• Semi quantitative culture Select the Media For common isolates MacConkey agar helps in differentiation of Lactose fermenting organisms from non lactose fermenting pathogens Dr.T.V.Rao MD 21
  22. 22. Culture Media for Isolation• Blood agar helps in isolation of fastidious, extracting strains May extended incubation for isolation of pathogens for more than 48 hours with added atmosphere of 5 – 10 % co2 Dr.T.V.Rao MD 22
  23. 23. What you understand by Significant bacteriuria ? • Significant bacteriuria in an asymptomatic patient is 100,000 or more colonies per milliliter of urine from a midstream, clean-catch specimen; Dr.T.V.Rao MD 23
  24. 24. Mac Conkey’s agar showing Proteus and E.Coli Dr.T.V.Rao MD 24
  25. 25. How you interpret counts ?• Up to 104/ml considered normal i.e. Insignificant• 105/ml and above considered to be Significant• Concept valid only for voided specimen of urine• Exceptions - slow growing organisms, patient on antibiotic therapy, diuretic therapy Dr.T.V.Rao MD 25
  26. 26. Most important point in Interpretation• Yet many theories on Significant bactenuria are controversial.• The reporting of results should be mainly based on clinical history.• Even a true infection may contain only 103• In such circumstances tests to be reported as probably or possibly significant• A good coordination between a Microbiologist and Physician is the best solution to patients with Urinary tract infections. Dr.T.V.Rao MD 26
  27. 27. What are different Biochemical tests you perform different isolates ? • Catalase test • Oxidase test • Nitrite reduction test • Indole test • Methyl red test • V P test • Citrate test • Decarboxylation tests Lysine, ornithine, Arginine tests Dr.T.V.Rao MD 27
  28. 28. Antibiotic Sensitivity• Always use a pure growth of the isolates.• Perform testing for antibiotic sensitivity with inoculum which is comparable to defined McFarland standards. Dr.T.V.Rao MD 28
  29. 29. How you perform Antibiotic Sensitivity Testing ?• All the isolated bacteria identified as pathogenic to be tested for Antibiotic Sensitivity/Resistance pattern by disk diffusion methods Dr.T.V.Rao MD 29
  30. 30. Issues on Urinary Tract infection Dr.T.V.Rao MD 30
  31. 31. Causative Pathogens and other implicationUTI in Women• Escherichia coli—gram (-) etiologic agent in ~ = 80% of all UTI’s• Research indicates primary source of microbial invasion is retrograde colonization by intestinal pathogens• Other factors influencing colonization: vaginal pH, urethral length, capacity of bacteria to adhere to urothelium Osborne, 2004 Dr.T.V.Rao MD 31
  32. 32. Urinary Tract Infection Why it is Important Urinary tract infection—most common source of bacteremia, a dangerous systemic infection in long- term care facilities Bacteremia—40 times more likely to occur in catheterized than non-catheterized residents Bacteremia leads to significant morbidity and mortality in the vulnerable elderly Dr.T.V.Rao MD 32
  33. 33. Clinical Problems manifesting as Urinary tract Infections• An infection of the Genitourinary tract where the Microbes do not grow on selected media as in Mycobacterium tuberculosis Gonococcus Nutritionally exacting or anaerobic bacteria Dr.T.V.Rao MD 33
  34. 34. What is Polymicromial bacteriuria • Contamination most frequent cause of multiple microorganisms • 25-33% in LTCF’s may be polymicrobic due to fistulas, urinary retention, infected stones, or catheters Dr.T.V.Rao MD 34
  35. 35. Non Specific Urethritis• Several conditions mimic Urinary tract infection which are associated with organism other than routinely isolated in simple and few selective media, they can be Can be urethral or Bladder infections with Chlamydia Ureplasma Trichomonas, Few viruses Dr.T.V.Rao MD 35
  36. 36. Serious Infections associated with UTI• Acute pyelitis• Pyelonephritis• May lead to Bacteremias detected by Blood culture• A prominent infection with Staphylococcus aureus can cause above manifestations.• Be prompt to diagnose Urinary Tract Infections Dr.T.V.Rao MD 36
  37. 37. • Created by Dr.T.V.Rao MD for Microbiology Students in Developing World • Email • doctortvrao@gmail.com Dr.T.V.Rao MD 37

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