4 urinary tract infection


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4 urinary tract infection

  2. 2. DefinitionsUTI : Inflammatory response of urothelium tobacterial invasion associated with bacteriuria&Pyuria.Bacteriuria: Presence of bacteria in urinewhich is normally free of bacteria.It may bedue to contamination.Pyuria: Presence of WBCs in urine.Bacteriuria without pyuria: Colonization with noinfection.Pyuria without bacteriuria: T.B, stones, cancer.
  3. 3. Uncomplicated UTI: Inf. in normal U.T bothstructurally & functionally.Complicated UTI: U.T is functionally orstructurallyabnormal, host is compromised, increasedvirule-nce of bacteria (pregnancy, elderly, DM,instrume-ntation).First or isolated: Never had inf. before or sincealong time.Unresolved inf.: not responded to
  4. 4. Incidence & Epidemiology-UTIs are the most common bacterial inf.-1.2% of office visits by females & 0.6% bymales.-50% of females will experience UTI during life.-Once a pt. has inf., is likely to developsubseque-nt infections.
  5. 5. Pathogenesis:Routes of infection:1-Ascending route:-Bowel reservoir----urethra----bladdere.g: perineum soiled with faeces.indwelling catheter-Cystitis may ascend to kidney by VUR.2-Haematogenous route:-Renal infection with staph. From a septic focus.3-Lymphatic route:-Not common.-From adjacent organs (severe bowel inf. – RPabscess).
  6. 6. Urinary Pathogens:E. Coli : 85% of community acquired50% of hospital acquiredProteus, klebsiella, gm +ve (E. faecalis):remain.Bacterial adherence:Bacterial adhesins:-UP expresses a number of adhesins that allowitto attach to U.T tissues.
  7. 7. Natural defenses of U.T:1- Periurethral & urethral region:- Normal flora of introitus & urethra contain orga-- nisms as lactobacilli & streptococci forming a- barrier against UP.- - Flow of urine.2- Urine:- Organisms normally colonizing the urethra donot multiply in urine.- Bacterial growth is inh. by dilute urine or high orhigh osmolality assoc. with low Ph.- Tamm-Horsfall ptn. (1000ng/ml) block bacterialbinding to urothelial receptors.3- bladder emptying.4- General immunity.
  8. 8. Diagnosis- -Urine & U.T are normally free of bacteria &infl.Urine collection:-Mid stream.-How to collect ?voided or catheterizedSuprapubic aspiration: highly accurate,useful in newbornpts who can not void-Non circumcised: prepuce retracted, glanswashed-In females: spread labia, wash introitus, mid
  9. 9. Urine analysis:5-10 ml centrifuged for 5 min. at 2000 rpm.Bacteriuria found in 90% of infs. with counts>100000 CFU/ml.2 WBCs/HPF in centrifuged specimen= 10 in anunspined specimen & both correlates with bacte-ruria.Imaging techniques:-Not required in most cases.-Indications: fever- failure to respond to treatmentrecurrent infs.- D.M- history of stones or surgery.-Plain, IVU, VCUG, U/S, CT.
  10. 10. Principles of antimicrobial treatment:-Efficacy is dependent on drug level in urine &duration this level remains above MIC of inf.organism.-Concentration in blood is not important as inurine, except in septicemia or bacterimia.-Patients with renal failure:Dose modification are necessary for drugcleared only by kidneys.Conc. power is impaired ---difficult eradicationofinfection.
  11. 11. Bladder infectionsUncomplicated cystitis:-Most caes in females.-25% between 20-40 yrs.Risk factors:-Weak urine flow.-Promote colonization: sexual activity.-Facilitate ascent: catheter, fecal incontinence.Clinical presentation:-Dysuria, frequency, urgency, S.P pain.-Haematuria, foul smelling urine.-Fever & chills usually absent (superficial mucosalinfection).Causative organism: E. coli 80-90%
  12. 12. Lab diagnosis:-urine analysis: pyuria, bacteriuria, hematuria.-urine culture: often not necessary.Treatment:-TMP-SMX, quinolones, floroquinolones-Duration: 3 days.Complicated cystitis:-Occur in compromised U.T or by resistant org.-mild cystitis----life threatening renal inf. &urosepsis.-Urine culture is mandatory.-treatment of cause.
  13. 13.  Kidney InfectionsAcute Pyelonephritis:-Inflammation of both renal parenchyma &pelvis.Causative organism:-E. coli (80%), proteus, klebsiella,pseudomonas-Rarely, gm +ve.Pathology:-Renal enlargement, capsule strips easily,smallyellowish white cortical abscesses withparench-
  14. 14. Clinical picture:-Chills, fever (100F or >), flank pain.-LUTS (dysuria, urgency, frequency).-GIT symptoms.Lab diagnosis:-CBC: leucocytosis with predominance ofneutrophils, inc.ESR & C- reactive ptn.U.A: WBCs in clumps, bacterial rods.WBC castsSpecific casts (bacteria in ptn matrix).U.C:Blood culture:
  15. 15. Radiology:IVU: renal enlargement (1.5 cm greater inlength).focal ― (focal bacterial nephritis)disappear with treatment.calyceal & ureteral dilatation (endotoxins)U/S & CT: to diagnose complicated PNto reevaluate pts not respondingafter72 hours treatment.Treatment: Antibiotics for 7 days.Bed rest – antipyretics.
  16. 16. Emphysematous PN:-Acute necrotising parenchymal & perirenal infn.caused by gas forming UP.-Organism cause fermentation of glucose ----CO2.-However, not common in diabetics.Should be considered compl. of severe PN.-Mortality rate 20-40%Causative organism:-E. coli (commonest), klebsiella, proteus.Clinical picture:-Triad of fever, vomiting, flank pain.-Pneumaturia, when infn. involves collectingsystem.
  17. 17. Imaging:-Plain KUB: crescentic gas shaddow (in renalspace) & loculated ― ― (inparench.)-IVU: rare of value (NF or poorly functioning K.)U/S: gas.CT: procedure of choice.Treatment: surgical emergency-Fluid resuscitation & broad spectrumantibiotics.-Nephrectomy if no improvement after fewdays.
  18. 18. Renal Abscess:-Collection of purulent material confined to renalparenchyma.-Usually due to VUR in an obstructed kidney.-Causative organism: g +Ve or –Ve.Clinical picture:-Triad------cystitis-History of g +Ve source of inf.(1-8 weeks) beforeonset of symptoms. e.g: skin carbuncle.Lab diagnosis:-Leucocytosis, pyuria, bacteriuria (if communicat).-Urine culture: no or different organism (bldborne).
  19. 19. Radiology:-Renal enlargement & distortion of renal contour.-Renal fixation on insp. & exp. films.-Obliteration of psoas shadow & scoliosis.-CT is the procedure of choiceRenal enlargement & area of low attenuation.Thickening of perinephric fascia.Treatment:-PC or open drainage (DD. Renal tumor).-I.V antibiotics & observation, if <3cm.-----goodresponse.-Follow up with U/S or CT till complete resolution.
  20. 20. Infected Hydronephrosis & Pyonephrosis:Infected HN: bacterial inf. in a hydronephrotic k.Pyonephrosis:inf. HN associated with suppurationof renal parenchyma----partial or total loss ofrenal function.Differentiation not always easy.Clinical picture:-Triad.-Bacteria may not be present if ureter completelyobstructed.Radiology: internal ecchoes in dilated P.Csystem.Treatment: drainage &antibiotics.
  21. 21. Perinephric abscess:Etiology:-Rupture of a cortical abscess into perinephricsp.-Infected perirenal hematoma or urinoma.-Spread of osteomyelitis from T.B lumbarspine.When it rupture through renal fascia ---paraneph.abscess.Clinical picture: insidious onset, 1/3 afebrile.Local signs of infl. (hotness, redness, oedema,loin mass may be pointing)
  22. 22. Radiology:-Absent psoas shaddow, elevated or immobilediaphram.-U/S & CT: ecchogenic collection.Treatment:-Surgical drainage (if large)-PC ― (if small)
  23. 23. PROSTATITISEtiology:1- G –Ve: E. coli (80%), kleb.,pseudomonas,….2- G +Ve: staph aureus (5-10%)3- Chlamydia & U. urealyticum: minor role.Risk factors:1- Intra-prostatic ductal reflux.2- Immunologic alteration inside prostate.3- Acute epididymitis, indwelling catheter,TURP
  24. 24. Pathology:-Increase no. of infl. cells within parenchyma.-Lymphocytic infil. in stroma adjacent to acini(most common pattern).-Corpora amylacea (deposition of pr. secretionaround a sloughed epithelial cell) may obstructpr. gland.Classification: “Traditional classificationsystem”Type s. of UTI bacteria infl.cells1-ABP: severe + +2-CBP: mild + +3-NBP: ----- - +4-Prostatodynia: ----- - -
  25. 25. Clinical picture:1- ABP: fever, severe irritative & obstructiveC/O.5%------- CBP2- CBP: asymptomaticirritative & obstructive C/O3- NBP: pain (predominant C/O) inperineum,S.P,penis, testis, low back.4- Prostatodynia: painful ejaculation (50%)symptoms tend to wane & wax over
  26. 26. Diagnosis:1- Physical examination:-Important but not helpful for diagnosis orclassificatABP: prostate is hot, boggy, very tenderOther types: prostate is normal.2- Cytology & culture:- Stamey 4 glass urine collectionTreatment:1- Antibiotics: for ABP & CBP.2- Alpha adr. blockers: for NBP & prostatodyniawith poor relaxation of B.N -----increase ur. flow&decrease IPR.
  27. 27. 3- Anti-inflammatory:NSAIDs- cortisone.4- Ms. relaxants:NBP & prostatodynia may be due to smooth &skeletal ms dysregulation of pelvis& perineum.5- Phytotherapy:Some plant extracts show 5 alpha- reductaseactivity, alpha blocker, anti- inflammatory.6- Allopurinol:IPR---inc. metabolites containing purine &pyrimidine in pr. ducts-----inflammation.
  28. 28. Orchitis:Definition:-Inflammation of testis, & also describe testicularpain without evidence of infl.Etiology:-Isolated orchitis is relatively rare & usually viraldue to blood spread.-Orchitis of bacterial origin usually occur due tolocal spread from ipsi. epididymis (E. coli, pseud.,Staph, strept.,N. gonorrhea).Presentation:-Pain- fever- nausea & vomiting- tenderness-secondary hydrocele.
  29. 29. Diagnosis:Urine analysis- urethral swabU/S: to rule out malignancy & torsionTreatment:- Rest- scrotal support- hydration- antipyretics-AI- Antibiotics.Chronic orchitis:-Inflammation & pain in testis, without swellingfor >6 weeks.-Self limited & may take years to resolve.
  30. 30. Epididymitis:-Acute : sudden pain, infl., swelling.-Chronic: pain & infl. with no swelling >6 weeks.may be due to inadequate treatment.-Spread from bladder, urethra & prostate.-Starts in tail-----body-----head.-Testis is involved in most cases-----epididymo-orchitis.Treatment:-antibiotics for 4-6 weeks.-Chronic: self-limiting taking long duration.-Epididymectomy: with treatment failure & to curepain.
  31. 31. Tuberculosis (T.B)-Always considered in a pt. with vague longstanding urinary C/O with no obvious cause.-Age: 20-40 yrs, uncommon in children.When to suspect?-Following presentation without obviousetiology.Frequency—recurrent cystitis not respondingtotreatment---gross or microscopic hematuria---sterile pyuria.
  32. 32. T.B of kidney:-Organism settle in blood v. close to glomeruli.-Caseating granulomas develop & consist of giantcells (Langhans) surrounded by lymphocytes &fibroblasts.-Caseous material open through calyces---cavitiesof moth-eaten appearance.-Course depends on virulence & resistance.-If pathology progress + obst.---autonephrectomy.-If healing occur---fibrosis & calcification---stricturein calyces or PUJ.-Mycobacterium may remain viable in calcificlesions.
  33. 33. T.B of ureter:-T.B ureteritis---fibrosis---str. usually at UVJ-Whole ureter may be affected---multiple levelsureteric str.T.B of bladder:-Starts around U.O---infl. & edema---T.Bgranuloma-T.B ulcers is rare, occasionally whole bladderiscovered by infl. velvety granulation---bladderfibr-
  34. 34. T.B of epididymis & testis:-Painful & infl. scrotal swelling. D.D: ep.orchitis.-Globus minor affected alone in 40%.-Testicular affection without ep. is very rare.-Scrotal sinus.T.B of penis----superficial glanular ulcer.D.D:Tr.T.B of urethra ---urethral stricture.
  35. 35. Diagnosis:1-Tuberculin test:-M.T.B complex (M.T.B—M. bovis—M.microti—M. africanum).-Intradermal inj. of a PPD of tuberculin.-Infl. condition reaching max.between 48-72hrs.-Central indurated zone surrounded byerythema.-+Ve reaction =inf., but not indication of activeT.B or C/O due to T.B.2-Urine examination:
  36. 36. 3-Urine culture:-Lowenstein-Jensen.-Takes 6-8 weeks (slowly growing).-3-5 consequetive early morning samples(org. is intermittently excreted).4-Imaging:-Plain KUB:-Calcification in kidney, ureter, bladder, seminalvesicle.-Plain chest & spine.-IVU:-Fibrosed & occluded calyx (lost calyx).-Moth-eaten cavities, HUN, contracted bladder.
  37. 37. TreatmentFirst line drugs:1-Isoniazid (INH): hepatotoxicity, peripheralneuritis.5 mg/kg maximum 300 mg2-Rifampicin: hepatotoxicity10 mg/kg max. 600 mg3-Pyrazinamide: hepatotoxicity20-25 mg/kg4-Streptomycin: ototoxicity5-Ethambutol: retrobulbar neuritis15-25 mg/kg
  38. 38. Cornerstone is multidrug treatment to decreaseduration of treatment & drug resistant developm-ent.Second line drugs:-kanamycin—amikacin—ciprofloxacin……Guidelines:-Short course 6 months regimen.-All drugs given in a single dose.-Followup with urine culture at 3, 6, 12 monthsafter treatment finished.Surgery: delayed until medical treatment adminis-tered for 4-6 weeks.
  39. 39. Parasitic diseasesUrinary schistosomiasis:Caused by S. haematobium.Pathology & pathogenesis:-Worms in pelvic v. plexus----eggs in lower UT.-Granulomas formed in response to egg Ag------large,bulky, hyperemic polypoid masses. As egglaying ceases, eggs are destroyed or calcified &infl. wanes & replaced by f.t. (inactive form).Acute& chronic bladder ulcers-Obstructive uropathy occur due to chronic dis.Usually bilateral asymmetrical (JV & lower ureter)-Bladder cancer is a sequalae:early, sq.c.c (60-
  40. 40. Presentation:Acute:‖ Katayama fever‖-fever, lymphadenopathy, splenomegaly, urticaria-occur 3-9 weeks after inf.-terminal hematuria & dysuria.Chronic:-HUN—contracted bladderDiagnosis:1-Presence of eggs with terminal spikes is diagn-ostic of & only possible during active inf.2-Serologic tests: do not diff. between acute & chinf.3-Plain & IVU.
  41. 41. Treatment:Medical:Praziquentel: drug of choicecure rate 80-100%dose:2 oral doses of 40mg/kg in 24 hrsNo serious side effects.Surgical: nephrectomy—ureteric implantation
  42. 42. FilariasisLymphatic filariasis:-Causative organism: W. bancrofti-Cycle proceeds from human---mosquito---human.-Acute lymphatic infiltration----fever, lymphangitis& lymphadenitis---chronic lymphatic obstruction& dilation----hydrocele, elephantiasis of limbs &chyluria.-Diagnosis: C.p & Giemsa stain for blood.-Treatment:Diethylcarbamazine (DEC), ivermectin,albendazole.
  43. 43. Nonlymphatic Filariasis:-Transmitted by black flies (Simulum species).-Adult worms inhibit S.C tissues----f. nodules inwhich it is encapsulated.-Microfilaria travel through dermis & eye ----------blindness.-Diagnosis:Microscopic exam. of skin snips under normalsaline or Giemsa stain.Treatment:-Ivermectin. DEC not used due to severeallergic