pyelunephritis

1. Nur Amalina Aminuddin Baki
60

2.  Definition
 Etiology
 Pathogenesis
 Clinical feature
 Lab diagnosis
 Treatment

3.  inflammation of the
parenchyma and
lining of renal pelvis
of kidney

4.  Epidemiological viewpoint
 Community acquired ( common)
 hospital acquired (catherization)(40%)

6. ASCENDING ROUTE
 Gram negative organism
 E.coli (common)
 Proteus mirabilis,
Citrobacter, klebsiella,
enterobacter, proteus
pseudomonas aeruginosa
 Gram positive organism
 Staph.saprophyticus,
Staph. Epidermidis
enterococcus,
Corynebacteria and
lactobacilli
BY HEMATOGENOUS
SPREAD
 Salmonella typhi,
staphylococcus aureus and
mycobacterium
tuberculosis

7. VIRUS
 Rare
 Virus Human
polymaviruses , JC and BK
 Cytomegalovirus and
rubella
 Korean hemorrhagic fever
virus
 Mumps and HIV
 Recovered in urine in
absence of UTI
PARASITE
 Fungi : candida spp and
histoplasma capsulatum
 Protozoa : trichomonas
vaginalis
 Helminth: schistosoma
haematobium

9.  Female :Shorter urethra
 Male : uncircumcised infant  bacterial
colonization inside prepuce and urethra
 Catherization
 DIRECT: Bacteria carried directly into bladder
during insertion
 INDIRECT:Facilitation of bacterial access via
▪ lumen of catheter
▪ Tracking up between outside catheter and urethral wall

11. • Normal urine flow
disruption ( obstruction )
Incomplete bladder
emptying  > 2-3ml
residual urine infection
 ascent of infection 
pyelonephritis
 Pregnancy
 Prostatic hypertrophy
 Renal calculi
 Tumor
 Stricture
 Loss of neurological
control of bladder and
sphincter( spina bifida ,
paraplegia, multiple
sclerosis)
 Vesicourethral reflux
( urine reflux from bladder
to ureter, renal pelvis and
parenchyma)
 Diabetes Mellitus 
diabetic neuropathy
interfere with bladder
function

12.  Uropathogenic E. Coli (UPEC)
 Pyelonephritis associated pili (PAP) adhesion to
urethral and bladder epithellium in
 K antigen that help E coli to be phagocytosis-
resistant
 Hemolysin ( membrane damaging toxin)
 Proteus spp
 Urease

14.  Asymptomatic infection
 Pregnant woman and young
children
 The elderly and those with
diabetes
 People undergoing
instrumentation of urinary
tract
 Detect only by urine
screening
 Lower UTI symptoms :
 Dysuria
 Urgency
 Frequent micturition
 Fever
 Hematuria
 Pyuria ( M. TB)
 Renal hypertension renal
damage
 Renal tract obstruction
 Septicemia

15.  Sample collection
 Sample transport
 Laboratory investigation

16.  Collected before start of antimicrobial therapy
 State on request form if patient received therapy
within previous 48 hours
 Adult: Midstream urine sample
 Children : Bag Urine, Suprapubic aspiration
 Sample from catheter

17.  MidStream Urine
 Clean labia/ glans with non-antiseptic soap and
water
 Void first part of urine stream
 Collect midstream sample into sterile wide
mouthed container
 difficult in babies and young children

18.  Bacteriuria considered SIGNIFICANT when
 Properly collected
 > 105 organism /ml
 Only a single bacterial species
 Not apply to urine specimen not contaminated by
periurethral flora
 Contaminated urine of MSU
 < 104 organism /ml
 Contain > 1 bacterial species

19.  BAG URINE :
 Stick plastic bag to perineum/ penis
 Frequent heavy contamination
 Suprapubic aspiration
 Collected directly from bladder by needle
insertion
 No contamination
 Significant bacteruria not applied

21.  M. Tuberculosis
 3 early morning urine sample
 Do not require precaution as MSU
 Culture technique inhibit other organism’s growth
 S. haematobium
 Last few ml of late morning sample after exercise

22.  Only in patient undergoing catherization
 Withdraw using a syringe and needle from
catheter tube
 Do not take urine from catheter drainage bag
( bacterial multiplication)
 Significant bacteruria not applied

24.  Immediate with minimum delay
 Multiplication of organism in specimen alters
result

25.  Macroscopic :
 appearance
 colour
 turbidity
 Microscopic : enable Rapid preliminary report
 Presence of
▪ RBC
▪ WBC
▪ pus

26. PRESENCE OF RBC
 Hematuria:
 Infection of urinary tract
and elsewhere ( bacterial
endocarditis)
 Renal trauma
 Calculi
 Urinary tract carcinoma
 Clotting disorder
 Thrombocytopenia
 RBC contamination of
menstruating women
PRESENCE OF WBC
 Normal : <10/ml
 Abnormal : > 10/ml
 Not always associated
with bacteruria
 Confused with renal
tubular cell in urine of
aspirin-misuser

27.  An important finding and may reflect :
 Concurrent antibiotic therapy
 Other diseases( neoplasm, urinary calculi)
 Infection with organism not detected by routine
urine culture method

28.  Based on factor:
 Collection- carried out properly
 Storage
▪ cultured within one hour of collection
▪ Stored at 4 Celsius not > 18 hour before culture
 Antibiotic treatment – smaller number of
organism may be significant
 Fluid intake - influence quantitative result
 Specimen – for MSU specimen

29.  Colony Morphology on Mc Conkey agar:
 LF : E.coli, Klebsiella, Enterobacter
 NLF: Proteus mirabilis, Pseudomonas, Staph.
Aureus, S. Typhi
 Colony morphology on Blood agar:
 Gamma: E.coli, proteus mirabilis
 Beta: Staph. Aureus, Pseudomonas

30.  Gram Stain
 Positive:
▪ Staphylococcus saprophyticus ,Staph. Epidermidis and
enterococcus, Corynebacteria and lactobacilli
 Negative:
▪ E.coli,Proteus mirabilis, Citrobacter ,Klebsiella,
enterobacter, proteus and pseudomonas aeruginosa

31. Catalase Coagulase Acid , Gas
production
Staph.
Epidermidis + - AG
Staphylococcus
aureus + + A
Corynebacteria
+ - A
Enterococcus
- X A
Lactobacilli
- X AG

32. IMViC Acid , Gas production
Klebsiella,
--++ AG
Enterobacter,
--++ AG
Pseudomonas
aeruginosa ---+ A
Salmonella typhi,
-+-- A
E.Coli
++-- AG
Proteus mirabilis
-+-+ AG
Citrobacter ,
V+-+ AG

33.  Specific antibacterial therapy
 Drink large volume of fluid
 Continued systemic treatment till sign and
symptom subsides
 Usually 10 days
 > 10 days to sterilize kidney

34.  Regularly emptying bladder in healthy
women
 Prevention of hospital-acquired infection in
catheterized patient by :
 Avoid catherization whenever possible
 Minimize duration of catheterization
 Insert catheter with good aseptic technique
 Use closed sterile drainage system
 Maintain a gravity drain
 Use topical antiseptic around meatus in women
 Wash hand before and after inserting catheter,
collecting specimen and emptying drainage bags

35.  Inflammation of pelvis and kidney
 Complication from UTI
 Mainly by E. coli
 Collection: MSU, bag urine, suprapubic
aspiration, catheter
 Treatment based on infection

36.  Textbook of Microbiology, 4th
Edition, Dir. Prof. C
P Baveja, 2013, Arya Publications
 Mims’ Medical Microbiology, 4th
edition, Mims,
2008 , MOSBY Elsevier