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Urinary Tract Infection (UTI)


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Urinary Tract Infections

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Urinary Tract Infection (UTI)

  1. 1. URINARY TRACT INFECTIONS Presented by Bibek Bhandari IInd batch
  2. 2. Epidemiology of UTI Worldwide, 150 million cases / yearWorldwide, 150 million cases / year 90 % cystitis, 10 % pyelonephritis 75 % sporadic 25 % recurrent 2 % complicated
  3. 3. Prevalence of urinary tract infections (UTI)  almost half of all womenwomen will have at least one UTI in their lives.  the risk of UTI in women increases after menopause  after a UTI: 20 - 40 % will have a recurrence  recurring infections are usually reinfections.
  4. 4.  UTI is rare in young and middle-aged menmen & often with catheterisation or urological procedures.  Urinary catheter increases the risk almost ten-fold in hospitalised patients and those in other care homes.  Pyelonephritis is common in patients who have been catheterised for over a month.
  5. 5. Gender and sexual contact Infant and children : Male >> femaleInfant and children : Male >> female Adolescent-menopause : Female >> maleAdolescent-menopause : Female >> male Older age : Female = = maleOlder age : Female = = male Women: Short ureterWomen: Short ureter Sexual contact : colonization of pathogensSexual contact : colonization of pathogens in bladderin bladder Spermicidal : Change of normal floraSpermicidal : Change of normal flora Men (<50)Men (<50) : Prostate infection, anatomical defects ,: Prostate infection, anatomical defects , Lack of circumcision, homosexualsLack of circumcision, homosexuals
  6. 6. Classification by Type of UTI Upper / Lower UTI Pyelonephritis Asymptomatic bacteriuria Cystitis Symptoms Symptomatic Asymptomatic Recurrence Sporadic < 1 UTI / 6 m Recurrent ≥ 1 UTI / 6m Complicating factors Uncomplicated Complicated Classification of UTIs
  7. 7. Urinary Tract Infection- Types Urethritis Cystitis Lower Prostatitis Pyelonephritis Intrarenal & Upper Perinephric abscess
  8. 8. vs Pathophysiology
  9. 9. Host protective factors in UTI  Flushing mechanism of micturition  Acid pH of urine (4.6- 6) anti-bacterial  Acid vaginal pH (3.5-4.5)) suppresses colonization  Urinary Tamm-Horsefall protein (secreted by ascending loop of Henle) & blocks E. coli  Chemotactic factors - interleukin-8
  10. 10. Facilitate bacteriuriaFacilitate bacteriuria Residual bladder urine after voiding Turbulent urethral flow(stricture) Foreign bodies Atrophic vaginal mucosa Vesico-ureteral reflux Worse prognosis of UTIsWorse prognosis of UTIs Childhood pyelonephritis Diabetic nephropathy Malignant hypertension Chronic pyelonephritis Host Factors Complicating Bacteriuria
  11. 11. Bacterial virulence factors in UTI  Escherichia coli strains expressing O-antigens cause high proportion of infections  Capsular antigens of E. coli associated with clinical severity (antiphagocytic)  P-fimbriae enhance attachment of E. coli) to uroepithelial cells  Motile bacteria ascend the ureter against urine flow
  12. 12. Bacterial virulence factors in UTI  Bacterial urease (Proteus) splits urea →NH4 ion alkalinizes urine with loss of acid pH → stone formation → obstruction & survivial of bacteria within stones resisting eradication  Gram-negative endotoxin decreases ureteral peristalsis  Hemolysin damages renal tubular epithelium & promotes invasive infection  Aerobactin of E. coli promote iron accumulation for bacterial replication
  13. 13. Pathogenesis of UTI  Ascending route most common  Colonization of urethra and peri-urethral tissue is the initial event  More in women than men due to short female urethra ,so urethral organisms enter bladder during micturition & in close proximity to perianal areas  Once in the bladder , multiply, then pass up the ureters (esp. if vesico-ureteral reflux) to the renal pelvis & parenchyma  Hospital infection associated with lower urinary tract instrumentation (catheterization, cystoscopy)
  14. 14. Pathogenesis of UTI- blood borne  Hematogenous seeding less frequent than ascending infection  Kidney a common site of abscess formation in Staphylococcus aureus bacteremia, less often in candidemia, rarely with gram-negative bacteremia  Hematogenous seeding of kidney also occurs with Salmonella (typhoid) and Mycobacterium tuberculosis  Source of uropathogens: enteric bacteria
  15. 15. Pathogenesis of UTI: Risk Factors  ↓ resistance of mucous membranes (e.g. in menopause)  sexual intercourse  disturbances in ureteral functioning  in children the re-entering of urine back into the ureters (vesicoureteral reflux),  Uterine prolapse  Diabetes
  16. 16. Pathogenesis of UTIs Predisposing Conditions- contdPredisposing Conditions- contd  Benign prostatic hypertrophy  Any illness, eg diabetes, affecting the emptying -Neurogenic Bladder  Spinal injury →disturbances in bladder emptying or urinary catheter)  Stones  Catheterisation & other urological procedures  Renal Transplantation
  17. 17. Types of UTI Typical Symptoms & Signs Cystitis Frequent voiding, suprapubic pain Burning micturition Hematuria, cloudy urine Pyelonephritis Fever chills, flank pains, N/Vomiting Cystitis Sx ± Urosepsis Fever- chills Shock Clinical Symptoms of UTI
  18. 18. Urethritis  Acute dysuria, frequency  Suspect sexually transmitted pathogens, no hematuria, no suprapubic pain, new sexual partner, cervicitis
  19. 19. Cystitis  Symptoms: frequency, dysuria, urgency, suprapubic pain  Cloudy, mal-odorous urine (nonspecific)  Pyuria  WBC (2-5 with symptoms) and bacteria on urine microscopy
  20. 20. Cystitis
  21. 21. Acute Pyelonephritis
  22. 22. Pyelonephritis  Fever, chills  Nausea/Vomiting, diarrhea, tachycardia,  Costo-vertebral angleTenderness or deep abdominal tenderness  Leukocytosis  Urine microscopy: Pyuria + WBC casts, bacteria & hematuria  Possibly signs of Gram negative sepsis
  23. 23. Pyelonephritis  Complications: Sepsis Papillary necrosis Abscess, Ureteral obstruction ↓ renal function if scarring, In pregnancy – ↑incidence of preterm labor
  24. 24. Diagnosis of UTI  History  Physical exam  Lab parameters:  Urinalysis with microscopy for WBC, bacteria  Urine culture with sensitivities  Diagnose acute uncomplicated cystitis in women based on Hx, PE, and UA alone, no need for culture to treat
  25. 25. Diagnosis  Urinalysis  Leukocyte-esterase positive. = pyuria  Nitrite positive from urease producing bacteria eg proteus (but not always)  Microscopy – WBC ( > 5 in pt with symptoms) -- Bacteria
  26. 26. Collecting a sample  in adults, mid stream urine (MSU)(MSU) sample usually reliably represents the urine in the bladder.  samples from urinary bags or bedpans should not be used as they invariably will be contaminated  the most reliable sample is obtained via a suprapubic puncture  urine in bladder >4 hoursurine in bladder >4 hours (any shorter time will increase the risk of false negative findings)
  27. 27. Diagnosis- interpretation  Urine culture  105 colonies per mL considered standard for diagnosis - but misses up to 50%  Now, 103 to 104 accepted as significant if patient symptomatic  if several bacterial strains are grown on culture; contamination of the sample is the likely cause  Sensitivities for better tailoring of therapy
  28. 28. Significant bacteriuria Clinical status or methods of sampling Significant concentration (microbes / ml) MSU; symptomatic patient or urine in bladder <4 h >103 MSU; urine in bladder >4 h >104-5 Male patient, catheter specimen sample >103 Female patient, catheter specimen sample >104 Asymptomatic bacteriuria >105 Suprapubic puncture sample any growth
  29. 29. Positive Urine culture repeatedly (10Positive Urine culture repeatedly (1055 cfu/ml)cfu/ml) in the absence of signs of UTI  pyuria does not affect interpretation  Investige & treat asymptomatic bacteriuria → only in pregnant women Its prevalence varies from 1-5% to 100% in selected population groups. . Asymptomatic bacteriuria microbiological diagnosis
  30. 30.  Escherichia coliEscherichia coli  most common  80% of community - acquired  50% of hospital-acquired  Others:  enterococcienterococci  Staphylococcus saprophyticusStaphylococcus saprophyticus and  klebsiellaklebsiella  pseudomonaspseudomonas and proteusproteus are more rare Causative agents of UTIs
  31. 31. % of types of Organisms in UTI
  32. 32. Diagnostic Flowchart for evaluatingDiagnostic Flowchart for evaluating Patients with UTIPatients with UTI
  33. 33. Antibiotic Regimen for UTI
  34. 34. Prevention of UTIPrevention of UTI Recurrent UTI >3 episodes of UTI per year or >2 in 6 months Avoidance of spermicidal or diaphragm Frequent and complete voiding Immediate voiding after sexual contact Good hydration Low dose antibiotics prophylaxis
  35. 35.  Prophylaxis should be considered when more thanmore than 3 infections per year or3 infections per year or 2 in 6 months  Prophylaxis to continue for 6 months  If infections recur after prophylactic treatment, the prophylaxis is re- commenced for 6 – 12 months (D)(D) Prophylaxis of recurrent UTI with antimicrobial agents
  36. 36. THANKYOU