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Urinary Tract Infections


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Urinary Tract Infections

  2. 2. Over view of Urinary Tract Infections <ul><li>Most common infectious disease </li></ul><ul><li>Most Numerous specimens are received in the Laboratory </li></ul><ul><li>30 to 40 % of specimens received in Microbiology laboratories are Urine specimens, to Identify the Infection. </li></ul><ul><li>Diagnostic information is important for the clinician. </li></ul><ul><li>Appropriate clinical information gives many clues for better diagnostic evaluations . </li></ul><ul><li>Specimen collection is the primary objective in getting an ideal sample. </li></ul>
  3. 3. Why women are at More Risk for Urinary Tract Infections <ul><li>Women tend to have urinary tract infections more often than men do because the urethra is shorter in women than in men, so bacteria have a shorter distance to travel. </li></ul>
  4. 4. Who are at Risk with UTI <ul><li>Urinary tract infection is much more common in adults than in children, but about 1-2% of children do get urinary tract infections. Urinary tract infections in children are more likely to be serious than those in adults and should not be ignored. </li></ul>
  5. 5. Most Important facts to establish Infection <ul><li>Simple microscopic examination of wet films of unconcentrated urine for detection of Polymorphonuclear leucocytes - pus cells gives leading clues </li></ul><ul><li>Semiquantitative culture of urine to detemine wether urine contain potentially pathogenic bacteria in Numbers sufficent to identify it as causative agent causing infection. </li></ul>
  6. 6. Common Presenting Symptoms <ul><li>Urgency </li></ul><ul><li>Frequency of Micturation </li></ul><ul><li>Discomfort and pain in abodemen or on passing urine </li></ul>
  7. 7. Organs Involved in UTI <ul><li>The following organs are infected </li></ul><ul><li>Kidney </li></ul><ul><li>Bladder </li></ul><ul><li>Ureters </li></ul><ul><li>Donot include Urethra, Infections of Urethra is called as Urethritis, dealt under different clinical syndromes </li></ul>
  8. 8. Common site and Microbes <ul><li>Patients in majority of cases present with infection of Urinary Bladder and called as Cystitis </li></ul><ul><li>Most common pathogen is Escherichia coli. </li></ul>
  9. 9. Common Pathogens causing UTI <ul><li>Staphylococcus saprophyticus </li></ul><ul><li>Klebsiella pneumonia – var aerogenes or oxytoca </li></ul><ul><li>Proteus mirabilus, other coliforms </li></ul><ul><li>Pseudomonas aeruginosa </li></ul><ul><li>Streptococcus faecalis </li></ul><ul><li>Candida being a fungus can cause infections in Diabetic or Immunocompromised patients. </li></ul>
  10. 10. Rare Microbes causing UTI <ul><li>Streptococcus agalactiae </li></ul><ul><li>Streptococcus milleri </li></ul><ul><li>Other Streptococci </li></ul><ul><li>Anaerobic Streptococci </li></ul><ul><li>Gardernella vaginalis </li></ul>
  11. 11. Serious Infections associated with UTI <ul><li>Acute pyelitis </li></ul><ul><li>Pyelonephritis </li></ul><ul><li>May lead to Bacterimias detected by Blood culture </li></ul><ul><li>A prominent infection with Staphylococcus aureus can cause above manifestions. </li></ul>
  12. 12. UTI without Routine Bacterial isolates <ul><li>Some times it puzzles the clinicians, patients present with symptoms of urinary tract infection but bacteria donot grow on Routine culture Media </li></ul><ul><li>May be associated with </li></ul><ul><li>Organisms that donot grow on selected media </li></ul><ul><li>Can be a Genito urinary tract Tuberculosis </li></ul><ul><li>Gonococcal infections </li></ul><ul><li>Nationally exacting or anaerobic bacteria </li></ul>
  13. 13. Non Bacterial Urethritis,Cystitis and Urethral syndromes <ul><li>One should be familiar with </li></ul><ul><li>Urethral or Bladder infections with </li></ul><ul><li>Chlamydia </li></ul><ul><li>Ureaplasma </li></ul><ul><li>Trichomonas </li></ul><ul><li>Viral infections </li></ul>
  14. 14. Simple tests to rule out Urinary tract infections <ul><li>In les equipped laboratories routine testing for detection of </li></ul><ul><li>Nitrite </li></ul><ul><li>Blood </li></ul><ul><li>Protein </li></ul><ul><li>By rapid automated dipsticks can give basic information </li></ul><ul><li>But eliminates about ½ of culture negative specimens. </li></ul>
  15. 15. Collecting Urine for examination <ul><li>Collect the Mid stream specimens of Urine </li></ul><ul><li>Donot collect spontaneously collected urine without instructions, which can lead to contamination with commensals bacteria Colonised on urethral orifice and perineum </li></ul>
  16. 16. Specimen Collection <ul><li>The urine collected in a wide mouthed container from patients </li></ul><ul><li>A mid stream specimen is the most ideal for processing </li></ul><ul><li>Female patients passes urine with a labia separated and mid stream sample is collected </li></ul>
  17. 17. Specimen collected in young and Children <ul><li>Non invasive methods are safe and ideal </li></ul><ul><li>Follow the Broomhall et al method </li></ul><ul><li>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 aperiod of 1 minute, if not succesul tapping is repated once agin. </li></ul><ul><li>The child spontaneously pass the Urine and to be collected in a sterile container </li></ul>
  18. 18. Transport of Urine for Culturing Urine <ul><li>All collected specimens of urine to be transported to laboratory with out delay </li></ul><ul><li>Delay of 1 – 2 hour deter the quality of diagnostic evaluations. </li></ul><ul><li>If the delay is anticipated the specimens are at preserved at 4 0 c </li></ul><ul><li>In field conditions Boric acid can be added at a concentration of 1.8 % </li></ul>
  19. 19. Proof of Urinary Tract Infection <ul><li>Needs presence of potential pathogens in the freshly voided urine or scientifically preserved specimens in numbers greater than those likely to result from contamination from urethral meatus and the surrounding, </li></ul><ul><li>Kass suggested the Number to be about 10 5 or more ( 1,00,000 / ml of urine ) </li></ul>
  20. 20. Diagnosis of Urinary Tract Infection <ul><li>Step 1 </li></ul><ul><li>Microscopy of Urine for detection of Pyuria. </li></ul><ul><li>Leucocytes should be found in numbers of at least as great as 10 4 / ml before the pyuria is established </li></ul>
  21. 21. Wet Film examination of Urine <ul><li>All wet films to be examined with high power ( x 40 ) objective. </li></ul><ul><li>Prepare the drop of urine after mixing the urine without centrifugation </li></ul><ul><li>Transfer 0.05 ml on the middle of the microscope slide and cover slip is applied. </li></ul><ul><li>The prepared specimen show a small excess of fluid along the edges of the cover slip. </li></ul><ul><li>A approximate finding of 1 leukocyte / 7 high power fields corresponds to presence of pyuria. </li></ul>
  22. 22. Culturing of urine for Isolation of Bacterial pathogens <ul><li>Semiquantitative culture </li></ul><ul><li>Select the Media </li></ul><ul><li>For common isolates </li></ul><ul><li>Mac Conkey’s agar </li></ul><ul><li>helps in differentation of Lactose fermenting organisms from non lactose fermenting pathogens </li></ul>
  23. 23. Selection of Loop for Semiquantitative Method
  24. 24. Culture Media for isolations- CLED Medium <ul><li>It is also an excellent universal culture medium owing to its wide spectrum of nutrients, lack of inhibitors and the fact that it allows a certain degree or differentiation between the colonies. It contains lactose as a reactive compound which, when degraded to acid, causes bromothymol blue to change its colour to yellow. Alkalinization produces a deep blue colouration. The lack of electrolytes suppresses the swarming of Proteus </li></ul>
  25. 25. Culture Media for Isolation <ul><li>Blood agar </li></ul><ul><li>helps in isolation of fastidious, extracting strains </li></ul><ul><li>May extended incubation for isolation of pathogens for more than 48 hours with added atmosphere of 5 – 10 % co 2 </li></ul>
  26. 26. Specimen Inoculations <ul><li>All cultures processed by Semiquantitative method a loop of standard dimension of approximately known volume is inoculated into selected culture plate </li></ul><ul><li>In general a loop of SWG – 28 with a diameter of 3.26 mm internal diameter which can hold a drop of water or urine 0.004 ml. </li></ul><ul><li>After inoculation the culture plates are incubated at 37 0 c extending to > 18 hours are read </li></ul><ul><li>The colony counts are made, as each colony corropsdes to number of viable bacteria per ml of urine </li></ul>
  27. 27. Reading the Culture Plates <ul><li>A true infection in the absence of prior antibiotic therpay the number of bacteria is likely to be at least 10 5 or more. </li></ul><ul><li>Contaminated specimens present with colony counts <10 4, however even less than 10 3 </li></ul><ul><li>On several occasions the colonies are diverse species </li></ul><ul><li>Several studies prove counts >10 4 to be considered as presence of Urinary tract infection with the supporting clinical history </li></ul><ul><li>On some occasions more than one pathogen is isolated but should be processed for all practical purposes </li></ul><ul><li>eg E.coli along with Streptococcus fecalis </li></ul><ul><li>On few occasions even counts 10 3 are proved significant </li></ul>
  28. 28. Identification of Gram + organisms <ul><li>All colonies identified morphologically as Staphylococcus to be characterized as </li></ul><ul><li>Staphylococcus aureus </li></ul><ul><li>Staphylococcus saprophyticus </li></ul><ul><li>Staphylococcus epidermidis </li></ul><ul><li>Enterococci - fecal group of organisms </li></ul>
  29. 29. Identification of Isolates Gram + isolates <ul><li>The minimal tests to differentiate Gram + cocci include </li></ul><ul><li>1 Catalase </li></ul><ul><li>2 Coagulase test </li></ul><ul><li>3 Bile esculin testing </li></ul><ul><li>4 Bacitricin in Streptococcus isolates </li></ul>
  30. 30. Biochemical tests in Gram - bacilli <ul><li>Catalase test </li></ul><ul><li>Oxidase test </li></ul><ul><li>Nitrite reduction test </li></ul><ul><li>Indole test </li></ul><ul><li>Methyl red test </li></ul><ul><li>V P test </li></ul><ul><li>Citrate test </li></ul><ul><li>Decarboxylation tests </li></ul><ul><li>Lysine, ornithine, Arginine tests </li></ul>
  31. 31. Mac Conkey’s agar showing Proteus and E.coli
  32. 32. Blood agar showing Coagulase negative Staphylococcus
  33. 33. Most important <ul><li>Yet many theories on Significant bactenuria are contraversioal. </li></ul><ul><li>The reporting of results should be maninly based on clinical history. </li></ul><ul><li>Even a true infection may contain only 10 3 </li></ul><ul><li>In such circumstances tests to be reported as probably or possibly significant </li></ul><ul><li>A good coordination between a Microbiologist and Physcian is the best solution associated with best solutions to patients with Urinary tract infections. </li></ul>
  34. 34. Reporting of Contaminated specimens <ul><li>Microscopy helps to detect pus cells and epithelial cells, an insignificant grwoth with few pus cells can ignored as contaminants </li></ul><ul><li>In females even the presence of leucocytes with Squamous epthelial cells without a defined significatn growth should be ignored. </li></ul>
  35. 35. Antibiotic Sensitivity <ul><li>Always use a pure grwoth of the isolates. </li></ul><ul><li>Perform testing for antibiotic sensitivity with inoculam which is comparable to defined Macfarland standards. </li></ul>
  36. 36. Most serious Infections presenting as Urinary tract Infections <ul><li>Acute pyelitis </li></ul><ul><li>Pyelonephritis </li></ul><ul><li>May present with loin pain, fever, </li></ul><ul><li>Apart from Urine culture patients present with Bacteriaemia - can be detected by Blood culture. </li></ul><ul><li>Causative agent can be </li></ul><ul><li>Staphylococcu aureus </li></ul>
  37. 37. Clinical Problems manifesting as Urinary tract Infections <ul><li>An infection of the Genitourinary tract where the Microbes donot grow on selected media as in Mycobacterium tuberculosis </li></ul><ul><li>Gonococcus </li></ul><ul><li>Nutritionally exacting or anaerobic bacteria </li></ul>
  38. 38. Non Specific Urethritis <ul><li>Several conditions mimic Urinary tract infection which are associated with organism other than routinely isolated in simple and few selective media, they can be </li></ul><ul><li>Can be urethral or Bladder infections with </li></ul><ul><li>Chlamydia </li></ul><ul><li>Ureplasma </li></ul><ul><li>Trichomonas, </li></ul><ul><li>Few viruses </li></ul>
  39. 39. Dealing with UTI <ul><li>The chemotherapy of proven infection may guided by in vitrosensitivity tests on the pathogen isolated by culture and outcome of therpay assessed by examination of urine at the conclusion of treatment. </li></ul><ul><li>Follow up examination of patients with UTI is important, if neglected can lead to chronic and permanent complications. </li></ul>
  40. 40. Antibiotic Sensitivity Testing <ul><li>All the isolated bacteria identified as pathogenic to be tested for Antibiotic Sensitivity/Resistance pattern by disk diffusion methods </li></ul>
  41. 41. Antibiotic Sensitivity <ul><li>Always use a pure grwoth of the isolate. </li></ul><ul><li>Perform testing for antibiotic sensitivity with inoculam which is comparable to defined Macfarland standards </li></ul>
  42. 42. Rationalsim of Antibiotic Selection <ul><li>If the patient is attending a General practice, outpatient clinic, drugs suitable by oral administration should be selected </li></ul><ul><li>The discks are with defined content to test the pathogens in the urine </li></ul><ul><li>Amoxycillin or Ampicillin 25 </li></ul><ul><li>Cephelexin 30 µg </li></ul><ul><li>Nalidixic acid 30µg </li></ul><ul><li>Ciprofloxacin 5µg </li></ul><ul><li>Nitrofurantoin 50µg </li></ul><ul><li>Trimethoprim 2.5 </li></ul>
  43. 43. ß Lactamase producing Gram negative strains <ul><li>There is a grwoing incidence of ßlactamase producing strains in particular associated with Hospital acquired infections </li></ul><ul><li>The newly defined methods to be used as per the NCCL guidelines. </li></ul><ul><li>There is a growing need for testing for </li></ul><ul><li>Amikacin, </li></ul><ul><li>Netilmicin, </li></ul><ul><li>Tobramycin </li></ul><ul><li>Netilmicin </li></ul><ul><li>Ticarcillin </li></ul><ul><li>There is a grwoing list organisms associated with Hospital Infections need better identification testing with new generation of drugs. </li></ul>
  44. 44. Created as Teaching Module for Medical Students in Devloping world Dr.T.V.Rao MD Email [email_address]