• Like
Urinary tract infections
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

Urinary tract infections

  • 2,933 views
Published

 

Published in Health & Medicine , Technology
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
No Downloads

Views

Total Views
2,933
On SlideShare
0
From Embeds
0
Number of Embeds
0

Actions

Shares
Downloads
266
Comments
0
Likes
5

Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide
  • Prostatis will affect 50% of men at some time in their life; 2 million visits a year
    Fungal infections (ie Aspergillus) seen more often in immunocompromised patients
  • Most pts with dx of prostatitis are adults with perineal, lower back pn, lower abd pain, or ejaculatory complaints.
    Most don’t have bacteriuria and thus there is little bacterial evidence of infection
    Inflammatory response: in expressed prostatic secretions, semen, post massage urine, or prostate tissue
  • First 2 tubes should be sterile or have a colony count smaller by an order of magnitude
    The diagnosis of prostatitis requires VB3 to have 10 fold increase in colonies over VB1
    3 tube approach gives us sample of urethra (1), bladder (2), and prostate
    2 tube approach: obtain urine before and after massage– if WBC appear, prostatitis can be inferred
  • NOT A SUBTLE DIAGNOSIS
    Systemic symptoms include malaise, myalgias, or occasional toxic appearance
    Prostate massage may cause bacteremia or vas infection.
    Urine culture will generally reveal the pathogen.
  • These antibiotics will penetrate the prostate well under circumstances of inflammation
  • Bladder outflow obstruction: frequency, dribbling, diminished stream, hesitancy, and urgency
    Usually seen in older men
    Dysuria etc more often seen in younger men
    Prostate may be enlarged, asymmetrical, boggy, or tender
  • Prostate fluid has high pH and makes it difficult for antibiotics to penetrate
    Bactrim is the main choice as it diffuses into and concentrates into prostatic fluid
    May sometimes take up to 8 –12 weeks
    Alpha blockers may be of benefit in acute prostatitis as well
    Suppressive therapy includes daily Bactrim, prostate reduction procedures
    **** 1/3 have symptomatic and bacteriologic cure; 1/3 have symptomatic cure; 1/3 have no improvement****
  • Prostate abscess: immunocompromised, diabetes, indaquate initial therapy, foreign bodies, gu obstruction.
    Imaging may be necessary to document the abscess (might be felt on physical examination)
  • 1. Empiric course of abx in case of occult infection though there is no data to support this

Transcript

  • 1. Urinary Tract Infections DR.TARIK ELDARAT MD UROLOGIST Friday, October 18, 2013
  • 2. Today’s Goals      Be able to define the various types of UTIs Describe the classic signs of pyelonephritis Be able to determine if a urine culture is positive Know the types of imaging needed and who needs imaging Explain why we care so much about early diagnosis and prompt treatment Friday, October 18, 2013
  • 3. Definitions     UTI—inflammatory response of the urothelium to bacterial invasion. Uncomplicated—Healthy patient with normal urinary tract. Complicated—compromised patient or one with a functional or structural abnormality. Recurrent – Reinfection—infection from different bacteria outside the urinary tract. – Persistent—focus from within the urinary tract that is never eradicated. Friday, October 18, 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, October 18, 2013
  • 5. Pyuria alone=inflammation  Bacteriuria without pyuria=colonization  Epithelial 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, October 18, 2013
  • 7. Defenses  Primary Defense – Flow of Urine – Voiding  Secondary Defense – – – – – Lactoferrin pH IgA IL-6 IL-8 – Tamm-Horsfall Friday, October 18, 2013
  • 8. Classification Isolated—first infections or those isolated by 6 months(3040% of women).  Unresolved—insufficient treatment – Resistance – Development of resistance – Two species one is resistant – Rapid reinfection before completion of therapy on initial organism – Azotemia(poor concentration of drug) – Papillary necrosis + azotemia – Staghorn Calculi(mass and concentration of bacteria Friday, October 18, 2013 too great) 
  • 9. Friday, October 18, 2013
  • 10. Friday, October 18, 2013
  • 11. Epidemiology      7 million office visits annually(1.2% female, 0.6% male) Prevalence increases with hospitalization, disease, number of infections, Susceptible females—2 infections in 6 months = 66% chance of developing infection in the next 6 months. Prophylaxis changes the time to recurrence not the chance of recurrence. Pregnancy increases the clinical acuity of infections. Friday, October 18, 2013
  • 12. Pathogenesis  Ascending—predominant route – Impairment of peristalsis enhances infection(endotoxin from G- Bacteria, pregnancy, obstruction) – Pelvic Pressure enhances infection(obstruction, VUR) Hematogenous—rare  Lymphatic—very rare(RP abscess) Friday, October 18, 2013 
  • 13. Pathogens  Nosocomial – E. Coli—50% – Klebsiella – Enterobacter – Citrobacter – Serratia – Pseudomonas – S. epidermitis Friday, October 18, 2013  Community-Acquired – E. Coli—85% – Proteus – Klebsiella – E. faecalis – Staph. Saprophyticus(10% of young sexually active females)
  • 14. Community-Acquired UTI E.coli S.epi & gm - enterics Enterococcus Proteus K.pneumoniae S.saprophyticus Friday, October 18, 2013
  • 15. Nosocomial UTI catheter associated Short Term Long Term E.coli Enterococcus Enterobacter E.coli Proteus Candida Proteus Providencia Morganella S.aureus Pseudomonas Friday, October 18, 2013 Pseudomonas
  • 16. Friday, October 18, 2013
  • 17. Causative organisms Gram +ve: Enterococci, Staphylococcus saprophyticus.  Gram –ve: Escherichia coli, Proteus species, Pseudomonas aeruginosa, Klebsiella strains.  Also: Mycobacterium tuberculosis  Friday, October 18, 2013
  • 18. Escherichia coli  E. coli (serotypes: 02, O4, O6) which are fimbrinated strains adhering to uroepithelial cells, leading to colonization and infection is the commonest cause of urinary tract infections. Friday, October 18, 2013
  • 19. Gram negative bacilli Pseudomonas, Proteus, and Klebsiella infections often follow catheterization and gynecological surgery (nosocomial pathogen).  Infection with proteus may be complicated by phosphate stone formation as it is urea leads to alkaline pH.  Friday, October 18, 2013
  • 20. S. saprophyticus  Infection more common in young women. Friday, October 18, 2013
  • 21. What parts of the urinary tract can get infected? Urethra - Urethritis Urinary bladder – Cystitis Ureters – Ureteritis Kidneys - Pyelonephritis Friday, October 18, 2013
  • 22. Cystitis
  • 23. Incidence 1-3% of all GP consultations  5% of women each year with symptoms. Up to 50% of women will suffer from a symptomatic UTI during their lifetime.  UTI in men is much rarer  A proportion of patients may be symptomatic in the absence of infection 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, October 18, 2013
  • 25. Causes  The most common cause is bacterial infection – Eschericia coli is the pathogen in 70% of uncomplicated case of lower urinary tract infections. – Other organisms include Proteus mirabilis, Klebsiella pneumoniae, Staphylococcus saprophyticus, Staphylococcus aureus and Pseudomonas species.   Urethral Syndrome -not associated with any infection Rarely kidney or bladder stones, prostatism, diabetes
  • 26. Prevention Drinking plenty of fluids helps prevent cystitis in the first place.  If cystitis follows sexual intercourse, some advise passing urine soon after to try and prevent it.  There is no evidence to suggest a link between lower urinary tract infection and use of bath preparations 
  • 27. Beware! Pregnant  Under age 12  Males  Systemically ill (fever, sickness, backache)  Catheterised patients  Kidney or bladder stones 
  • 28. Investigation  Urine dipstick – can be done in the surgery and will be positive for nitrates and leucocytes (leukocyte esterase test). This helps to differentiate those with UTI from the 50% with urethral syndrome.   Urine microscopy and culture reveals significant bacteruria (usually >105 /ml). Asymptomatic bacteruria – is present in 12-20% of women aged 65-70 years and does not impair renal function or shorten life so no treatment – in 4-7% of pregnant women and associated with premature delivery and low birth weight and always requires treatment.
  • 29. Differential Diagnosis       Urethral syndrome Bladder lesion e.g. calculi, tumour. Candidal infection Chlamydia or other sexually transmitted disease. Urethritis Drug induced cystitis (e.g. with cyclophosphamide, allopurinol, danazol, tiaprofenic acid and possibly other NSAIDs)
  • 30. Complications and Prognosis     Ascending infection can occur, leading to development of pyelonephritis, renal failure and sepsis. In children, the combination of vesicoureteric reflux and urinary tract infection can lead to permanent renal scarring, which may ultimately lead to the development of hypertension or renal failure. 12-20% of children already have radiological evidence of scarring on their first investigation for UTI. Urinary tract infection during pregnancy is associated with prematurity, low birth weight of the baby and a high incidence of pyelonephritis in women. Recurrent infection occurs in up to 20% of young women with acute cystitis.
  • 31. Management Issues - General 50% will resolve in 3 days without treatment  No evidence to support “drink plenty”  It is reasonable to start treatment without culture if the dipstick is positive for nitrates or leucocytes. 
  • 32. Management Issues - General  Culture is always indicated in – – – – – Men Pregnant women Children Those with failure of empirical treatment Those with complicated infection
  • 33. Self care  Drink slightly acid drinks such as cranberry juice, lemon squash or pure orange juice (poor trial evidence for this)  Try a mixture of potassium citrate available from your pharmacist (little evidence but widely recommended)
  • 34. Principles of Antimicrobial Therapy Treatment of UTI should result in sterile urine.  Antimicrobial levels in urine.  Resistant clones present 5-10% of cases with empiric treatment.  Friday, October 18, 2013
  • 35. Antibiotics     Trimethoprim is an effective first line treatment. Cephalosporins are as effective as trimethoprim but more expensive and more likely to disrupt gut flora. Nitrofurantoin is as effective as trimethoprim but more expensive and frequently causes nausea and vomiting The 4-quinolones (ciprofloxacin, norfloxacin, ofloxacin) are effective in the treatment of cystitis. To preserve their efficacy, they should not usually be used as first line therapy
  • 36. Antibiotics    3 days of antibiotic is as effective as 5 or 7 days Single dose antibiotic results in lower cure rates and more recurrences overall than longer courses. In relapse of infection (i.e. reinfection with the same bacteria), treatment with antibiotic for up to 6 weeks is recommended.
  • 37. Urinary Tract Infections T re a tm e n t o f R e c u rre n t C y s titis R e c u r r e n t C y s t it is R e la p s e S e e k o c c u lt s o u r c e o f in f e c t o n U r o lo g ic e v a lu a t io n R e in fe D ia p h r a g m a n C o n s id e r c h a n g in m e th T r e a t lo n g e r ( 2 - 6 w e e k s ) c t io n d s p e r m ic id e g c o n tr a c e p t iv e o d U r o lo g ic e v a lu a t io n n o t r o u t in e ly in d ic a t e d ³ 3 U T I/y r ³ 2 U T I/y r N o r e la t io n t o c o it u s T e m p o r a lly r e la t e d t o c o it u s D a ily o r t h r ic e w e e k ly p r o p h y la x is P o s t c o it a l p r o p h y la x is P a t ie n t in it ia t e d t h e r a p y
  • 38. Antibiotics for UTI in Pregnancy      Cephalosporins and penicillins are recommended in pregnancy because of their long term safety record Nitrofurantoin is also likely to be safe during pregnancy Quinolones, Trimethoprim and Tetracyclines are not recommended for use during pregnancy Seven days of treatment is required. Urine should be tested regularly throughout pregnancy following initial infection.
  • 39. Acute pyelonephritis Fever Nausea and vomiting More pronounced malaise Pain in the back (+) CVA tenderness Friday, October 18, 2013
  • 40. Acute Pyelonephritis
  • 41. Clinical Manifestations  Classic signs of cystitis – – – – – – – – –  Enuresis Frequency Dysuria Hesitancy Suprapubic discomfort +/- UTI signs Chills Nausea Flank pain Classic signs of pyelonephritis Friday, October 18, 2013 In older children and adults
  • 42. But… In Infants       Fever! Fever!! Fever!!! Lack classic signs Irritabilty Poor feeding Vomiting Diarrhea Friday, October 18, 2013 Present in <1/2 of infants with UTIs
  • 43. Risk factors  Female (30%:10%) – – – Shorter urethral length Urethral opening close to the anus Exposure to spermicide » Has antimicrobial activity, disrupt the periurethral flora content Friday, October 18, 2013
  • 44. Risk Factors: continued  Factors that prohibit complete emptying of the bladder – Constipation – cystocele, rectocele, uterine prolapse, urinary calculi, BPH    Estrogen deficiency Oral antimicrobials Immobility Friday, October 18, 2013       Poor hygiene Poor toileting habits Fecal incontinence Catheterization Diabetes mellitus Dehydration
  • 45. Diagnosis  Urine Collection – Suprapubic Aspiration – Catheterized specimen – Voided specimen Friday, October 18, 2013  Urinalysis – Sensitive to colonies of 30K/ml or less – Bacteria seen on microscopy with no growth may be vaginal flora
  • 46. Specimen collection Samples should be collected before the start of antibiotics.  Transport within 2 h. if delay is suspected then refrigeration at 4C or boric acid.  Mid stream urine.  Adhesive bags; in infants.  Friday, October 18, 2013
  • 47. The Positive Culture  Suprapubic – Any number of pathogens – Should be completely sterile  Transurethral – 103 colony forming units  Clean catch – 105 colony forming units Friday, October 18, 2013
  • 48. Know the Adequacy of Your Tests  “standard urinalysis” – Urine dipstick – Microscopy  “enhanced urinalysis” – – –  Nitrites Leukocyte esterase Microscopy Gram stain 84% sensitivity Neither is sensitive enough to rule out UTI 15% of UTIs missed if culture not done Friday, October 18, 2013
  • 49. UTI - Who should be studied?  Acute pyelonephritis All febrile UTIs  Males of any age with first UTI Girls younger than 3 years with first UTI Girls older than 3 years with second UTI Girls older than 3 years with first UTI with: – Family history of UTIs – Abnormal voiding pattern – Poor growth – Hypertension – Abnormalities of urinary tract – Failure to respond promptly to therapy    Friday, October 18, 2013
  • 50. Urinary Tract Infections Clinical Manifestations Feature Cystitis Pyelonephritis Urosepsis Dysuria, frequency Suprapubic pain + + or - + or - + + or - + or Ğ Fever, tachycardia, hypotension etc. CVA tenderness - + + - + + or - Duration of symptoms (days) 1Ğ7 1Ğ2 <1 - 1
  • 51. Imaging Techniques  Indications – Evaluation of obstruction – Persistence of fever after 5-6 days of treatment – Diabetes Mellitus – TB, fungus, urea Friday, October 18, 2013 splitting
  • 52. Pyelonephritis by MRI
  • 53. Intrarenal abscess by CT
  • 54. Perinephric abscess by CT
  • 55. A 3y/o boy has fever, shaking chills, and flank pain consistent with a diagnosis of pyelonephritits. Of the following, the BEST procedure to perform immediately to define the anatomy of the genitourinary tract is: – – – – – A. cystoscopy B. intravenous pyelography C. radioisotopic renography D. renal ultrasonography E. voiding cysourethrogram
  • 56. Urinary Tract Infections Acute Uncomplicated Pyelonephritis in Women  Mild-to-moderate illness – Outpatient therapy – Fluoroquinolone 7 - 14 days  Severe illness – Hospitalization required – Parenteral cephalosporin, fluoroquinolone or aminoglycoside, after afebrile - oral therapy (10 - 14 day total)  Pregnancy - avoid fluoroquinolones
  • 57. What determines a positive urine culture?  Suprapubic?  Transurethral?  Clean-Catch? Suprapubic 13-15% of end stage renal disease Any number of pathogens Due to Transurethral 103 colony forming units Undiagnosed/Untreated UTI in childhood Clean catch  Why do we care so much about prompt diagnosis and 105 colony forming units treatment?  27-64% Friday, October 18, 2013 of those with pyelonephritis develop renal scarring
  • 58. Emphysematous Pyelonephritis        pneumaturia An acute necrotizing infection cause by gas formation Incidence: middle-aged or elderly Diabetes (90%), or obstructive renal unit Female-to-man = 6:1 Left kidney: 60% Mortality: 20~80%
  • 59. Emphysematous Pyelonephritis / Pathogenesis Acute bacterial and fungal infection: -- E. Coli: 70~90% -- Klebsiella, Proteus, Clostridium and Candida  Gas in upper urinary tract: -- iatrogenically via upper tract manipulation -- fistula to bowel -- ascending infection 
  • 60. Emphysematous Pyelonephritis / pathogenesis Gas extension: renal and hepatic vein  Diabetics predisposed to gas formation: -- high glucose level throughout tissue -- diabetic microangiopathic disease -- immunodeficient-like state 
  • 61. Emphysematous Pyelonephritis / clinical findings Unilateral: 90%  Clinical findings: -- fever and pyuria: 80% -- flank or abdominal pain: 70% 
  • 62. Emphysematous Pyelonephritis / clinical findings  Huang et al: -- 48 cases -- 46 cases: diabetics -- mortality: initial presentation 1). thrombocytopenia 2). acute renal insufficiency 3). Proteinuria 4). Mental status change 5). Shock -- no affect: age, sex, site of infection and glucose level
  • 63. Emphysematous Pyelonephritis / Radiological findings CT: modality of choice -- excellent sensitivity and precise localization of gas  Abdomen radiograph: poor sensitivity (33%) 
  • 64. Emphysematous Pyelonephritis / Management Traditionally: requiring emergent nephrectomy  Minimally invasive drainage: acceptable -- equivalent success to surgery  Release obstruction  Quinolone therapy  Huang: thrombocytopenia, acute renal insufficiency, mental status change and shock -- <2: percutaneous drainage + IV antibiotics -- ≥2: emergency nephrectomy 
  • 65. Xanthogranulomatous pyelonephritis XGP: chronic suppurative atypical renal parenchymal infection  : RCC, abscess and inflammatory disease  Associated: renal calculi and chronic urinary tract infection  Majority involve: non-functional kidney 
  • 66. XGP / Incidence 0.6% of all surgically proven renal infection  Women : men = 4:1  More commonly in diabetics  5th ~ 7th decades  Almost always unilateral 
  • 67. XGP / Pathogenesis Not been elucidated  Play a role: -- urinary tract anomalies, obstruction, chronic infection, renal ischemia, immunodeficiency and abnormal lipid metabolism  Diagnosis: made by histological examination of surgically removed kidney  Characteristic: foamy macrophage  Culture: proteus mirabilus (50%), E. Coli (20%) 
  • 68. XGP / Clinical findings Quite nonspecific: -- anemia, malaise, leukocytosis, pyuria, flank pain or flank mass …  Children: weight loss or failure to thrive  Associated: -- renal calculi: 75% -- CPN: 78% 
  • 69. XGP / Radiological findings Renal ultrasound: hypoechoic mass  Advent CT: accurate with sensitivity (90%) -- poor enhancing mass, thickened Gerota’s fascia 
  • 70. XGP / Management    Absolutely no medical therapy Open surgical nephrectomy: standard care XGP kidney: extension to hilium and contiguous organ
  • 71. Treatment  Cystitis—3 Days – 7 Days if duration of symptoms, Diabetes, age greater than 65, or pregnancy  Pyelonephritis – Women » 7 days uncomplicated without sepsis » Inpatient 10-14 days Friday, October 18, 2013  Comlicated Pyelonephritis – 14-21 day course  Prophylaxis – Endocarditis—Amp/Gent or Vanc/Gent – Indwelling catheter—2 Doses(prior susceptibility) – Catheter removal—preop and 72 hours after – TURP—Pre and Post Op
  • 72. Urinary Tract Infections Candidates for Prophylaxis Women with ≥ 3 symptomatic uncomplicated infections per 12 months  Pregnant women with asymptomatic bacteriuria or previous symptomatic UTI is pregnancy  Men with recurrent UTIs 
  • 73. Prostatitis Friday, October 18, 2013
  • 74. Prostatitis: classification   Acute vs. chronic vs. prostatodynia Source of infection – Ascending urethral infection, urinary reflux, extension of rectal infection, or hematogenous spread  Bacterial – E. coli, Proteus, Klebsiella, Pseudomonas, enterococci, Chlamydia, Ureaplasma  Other agents – Viral, fungal, and Trichomonas
  • 75. Prostatitis: classification Bacteriuria Localized Inflammatory Abnormal Systemic prostate response illness prostate infection exam Acute bacterial prostatitis + + + + + Chronic bacterial prostatitis + + + - - - - +/- +/- - Prostatodynia
  • 76. Prostatic massage   AVOID IN ACUTE PROSTATITIS 4 tube approach – – – – VB1: urethral urinary sample VB2: bladder urinary sample EPS: expressed prostate secretions VB3: post-massage urinary sample » >10 WBC/hpf abnormal » >5,000 colonies/mm abnormal  2 tube approach
  • 77. Acute bacterial prostatitis  History – Lower urinary tract obstruction, perineal pain, dysuria, and fever – Systemic symptoms  Physical – – Tender, warm, boggy, swollen prostate Massage is NOT indicated in acute prostatitis
  • 78. Acute bacterial prostatitis  Management – Outpatient therapy » Bactrim, ampicillin, or quinolone for 4 – 6 weeks » Bedrest, analgesics, antipyretics, stool softeners – Inpatient therapy » Parental antibiotics: ampicillin and gentamycin » Avoid urethral catheterization for retention » Urology consult
  • 79. Chronic bacterial prostatitis  History – Bladder outflow obstruction – Dysuria; perineal, low back, or testicular pain – Hematuria, hematospermia, painful ejaculation  Physical examination – Variable prostate exam  Relapsing UTI in men is the hallmark of chronic bacterial prostatitis – GNR most common; also Enterococcus and S. saprophyticus
  • 80. Chronic bacterial prostatitis  Management – Difficult to eradicate given poor penetration of antibiotic into the non-inflamed prostate – Bactrim and fluoroquinolones » Doxycycline and macrolides second-line – – – – Prolonged treatment required Recheck prostatic fluid after treatment Alpha-blockers to reduce symptoms Suppressive therapy
  • 81. Prostatitis: complications Renal parenchymal infection  Bacteremia  Prostate abscess  – Immunocompromised – FB; obstruction  Prostatic stones – Nidus for persistent infection
  • 82. Prostatodynia  History – Persistent pelvic, suprapubic, infrapubic, scrotal, inguinal, or perineal pain – Lower tract obstruction and dysuria – Absence of systemic symptoms    Physical exam usually unremarkable No bacteria identified and no evidence of inflammation present Limited course of antibiotics, alpha blockade