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Basics of Urinary Tract Infection
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UTI.pptx
1.
URINARY TRACT INFECTION
2.
Essentials of Medical
Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers URINARY TRACT INFECTION 2 ▰ Disease caused by microbial invasion of the urinary tract that extends from the renal cortex of the kidney to the urethral meatus. ▰ Leading cause of morbidity and healthcare expenditures in persons of all ages
3.
Essentials of Medical
Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers Classification 3 ▰ UTIs - classified into two types—lower UTI and upper UTI - depending upon the anatomical sites involved ▰ Depending upon the source of infection: healthcare-associated (e.g. CAUTI) and community-acquired.
4.
Essentials of Medical
Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers Comparison between lower and upper UTIs 4 Lower UTI Upper UTI Sites involved Urethra, and bladder Kidney and ureter Symptoms Local manifestations: dysuria, urgency, frequency Local and systemic manifestations (fever, vomiting, abdominal pain) Route of spread Ascending route Both ascending (common) and descending route
5.
Essentials of Medical
Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers Epidemiology 5 ▰ Second most common infection after respiratory tract infections in the community ▰ most common HAIs (hospital acquired infections) - 35% of total HAIs ▰ Prevalence: About 10% of humans develop UTI in some part of their life
6.
Essentials of Medical
Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers Predisposing Factors 6 ▰ Gender: Higher prevalence in females Short urethra Close proximity of urethral meatus to anus ▰ Age: Incidence increases with age ▰ During first year of life prevalence same in both females and males - incidence in males until old age
7.
Essentials of Medical
Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers Predisposing Factors (Cont..) 7 ▰ Females: incidence keeps increasing after first year of life 5–17 years - incidence of bacteriuria - 1–3% Adult life - incidence is around 10–20% Reinfection is common in females (20–40 years of age) ▰ Pregnancy: Anatomical and hormonal changes - asymptomatic bacteriuria common
8.
Essentials of Medical
Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers Predisposing Factors (Cont..) 8 ▰ Structural and functional abnormality of urinary tract - obstruction to the urine flow - urinary stasis - infection Structural obstruction: urethral stricture, renal and ureteric stones, prostate enlargement, tumors, renal transplants, etc. Functional obstruction: neurogenic bladder due to spinal cord injury or multiple sclerosis
9.
Essentials of Medical
Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers Predisposing Factors (Cont..) 9 ▰ Bacterial virulence: pili - adhesion to uroepithelium ▰ Vesico-ureteric reflux: allows urine from bladder up into ureters and sometimes into the renal pelvis ▰ Genetic factors: Genetically determined receptors help in bacterial attachment
10.
Essentials of Medical
Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers Etiology 10 ▰ Escherichia coli (uropathogenic E. coli) Commonest cause (70%) of all forms of UTIs - community acquired & nosocomial UTI and upper & lower UTI ▰ Other endogenous flora - gram-negative bacilli (E.coli, Klebsiella, Proteus, etc.) & Enterococci ▰ Hospital acquired UTIs - Enterobacteriaceae and Staphylococci, Pseudomonas
11.
Essentials of Medical
Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers Common microorganisms causing UTIs 11 Bacterial agents Other agents Gram-negative bacilli: Enterobacteriaceae Escherichia coli: Most common (70%) Klebsiella pneumoniae Enterobacter species Proteus species Serratia species Non-fermenters Pseudomonas aeruginosa Acinetobacter species Fungus: Candida albicans Parasites: ••Schistosoma haematobium ••Trichomonas vaginalis ••Dioctophyme renale Gram-positive bacilli: Mycobacterium tuberculosis Viruses: BK virus Adenovirus types– 11
12.
Essentials of Medical
Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers Common microorganisms causing UTIs (Cont..) 12 Bacterial agents Gram-positive cocci: Enterococcus species Staphylococcus saprophyticus Staphylococcus aureus Staphylococcus epidermidis Streptococcus agalactiae
13.
Essentials of Medical
Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers Pathogenesis 13
14.
Essentials of Medical
Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers Ascending Route 14 ▰ Most common route ▰ Enteric endogenous bacteria (E. coli, other gram-negative bacilli, enterococci) ▰ Facilitated by sexual intercourse, or instrumentation ▰ Colonization: Adhesion to urethral epithelium with help of P fimbriae, mannose resistant fimbria in E. Coli, etc
15.
Essentials of Medical
Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers Ascending Route (Cont..) 15 ▰ Ascension: pathogen ascends through urethra upwards towards bladder to cause cystitis Bacterial toxins may facilitate ascension by inhibiting peristalsis ▰ Further ascension through ureter - vesico-ureteric reflux - pyelonephritis ▰ Acute tubular injury: inflammatory cascade - tubular obstruction and damage occurs - interstitial nephritis
16.
Essentials of Medical
Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers Descending Route 16 ▰ Bacteremia - Hematogenous seedling of pathogen (5% of UTIs) ▰ Organisms commonly associated with descending infection — Staphylococcus aureus, Salmonella,Mycobacterium tuberculosis, Leptospira and Candida.
17.
Essentials of Medical
Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers Host Defense Mechanisms 17 1. Factors related to urine 2. Activation of host’s mucosal immunity by the uropathogens
18.
Essentials of Medical
Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers Host defense mechanisms against UTIs 18 Urinary factors Mucosal immunity Acidic urine: inhibits pathogens Uroepithelial secretion of cytokines (induced by bacterial LPS) High urine osmolality: inhibits pathogens Mucosal IgA–prevent attachment of pathogen to uroepithelium Urinary inhibition of bacterial adherence Tamm-Horsfall protein (uromodulin)—a glycoprotein secreted by epithelial cells of kidney, serves as anti-adherence factor by binding to type-I fimbriae of E. coli Mechanical flushing by In men: (1) Zinc in prostatic secretion is
19.
Essentials of Medical
Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers Clinical Manifestations 19 ▰ Lower UTI: Asymptomatic bacteriuria, cystitis, urethritis, acute urethral syndrome ▰ Upper UTI: Pyelonephritis, ureteritis, perinephric abscess, renal abscess, renal tuberculosis ▰ Immunological sequela: Post-streptococcal glomerulonephritis (PSGN).
20.
Essentials of Medical
Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers 1. Asymptomatic Bacteriuria 20 ▰ Isolation of specified quantitative count of bacteria in an appropriately collected urine specimen, obtained from a person without symptoms of UTI ▰ Common in females and incidence increases with age
21.
Essentials of Medical
Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers 1. Asymptomatic Bacteriuria (Cont..) 21 ▰ Clinically significant in - pregnant women, people undergoing prostatic surgery or any urologic procedure where bleeding is anticipated ▰ Routine screening & treatment for asymptomatic UTI is highly recommended
22.
Essentials of Medical
Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers 1. Asymptomatic Bacteriuria (Cont..) 22 ▰ Clinically not significant - in non-pregnant, pre-menopausal women, old age, catheterized patient, or patients with spinal injury ▰ Neither screening nor treatment of asymptomatic UTI is needed
23.
Essentials of Medical
Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers 2. Cystitis (Infection of Bladder) 23 ▰ Dysuria, frequency, urgency, and suprapubic tenderness ▰ Urine becomes cloudy, with bad odor, and in some cases hematuria ▰ No associated systemic manifestation
24.
Essentials of Medical
Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers 3. Acute Urethral Syndrome 24 ▰ Seen in young sexually active females ▰ Classical symptoms of lower UTI as described for cystitis ▰ Bacterial count is often low (102 to 105 CFU/mL) ▰ Pyuria is present ▰ Agents: Mostly due to usual agents of UTI, few cases - caused by gonococcus, Chlamydia, herpes simplex virus, etc
25.
Essentials of Medical
Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers Upper UTI (Pyelonephritis) 25 ▰ Inflammation of kidney parenchyma, calyces and the renal pelvis ▰ Associated with systemic manifestations - fever, flank pain, vomiting ▰ Lower tract symptoms such as frequency, urgency and dysuria
26.
Essentials of Medical
Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers Laboratory Diagnosis - Specimen Collection 26 ▰ Specimen: 1. Clean catch midstream urine 2. Suprapubic aspiration from bladder 3. Catheterized patients—urine aspirated from the catheter tube after clamping distally and disinfecting, but never collected from urine bag ▰ Transport : Processed immediately - expected delay - refrigerated or stored by adding boric acid
27.
Essentials of Medical
Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers Laboratory Diagnosis - Direct Examination 27 ▰ Wet mount examination - pus cells ▰ Leukocyte esterase test ▰ Nitrate reduction test (Griess test) ▰ Gram-staining
28.
Essentials of Medical
Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers Laboratory Diagnosis - Culture 28 ▰ Culture media: CLED agar (cysteine lactose electrolyte deficient agar) or combination of MacConkey agar and blood agar. ▰ Kass concept of significant bacteriuria: Based on the fact that, though the normal urine is sterile - may get contaminated during voiding, with normal urethral flora.
29.
Essentials of Medical
Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers Culture identification features of common organisms causing UTI 29 Culture Culture smear and motility testing Biochemical reactions Escherichia coli MAC or CLED: flat lactose fermenting colonies BA: gray moist colonies Gram- negative bacilli Motile Catalase positive, oxidase negative ICUT tests: I+ C– U– TSI (acidic slant/acidic butt, gas+, H2S–) Klebsiella pneumoniae MAC or CLED: mucoid lactose fermenting colonies BA: gray mucoid colonies Gram- negative bacilli Non- motile Catalase positive, oxidase negative ICUT tests: I– C+ U+ TSI (acidic slant/acidic butt, gas+, H2S–) Proteus species MAC or CLED: lactose non- fermenting Gram-negative pleomorphic bacilli Motile Catalase positive, oxidase negative ICUT tests: I–/+ C+/– U+
30.
Essentials of Medical
Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers Culture identification features of common organisms causing UTI (Cont..) 30 Culture Culture smear and motility testing Biochemical reactions Enterococcus MAC: magenta pink colonies BA: translucent non- hemolytic colonies Gram-positive cocci in pair, spectacle shaped Non-motile Catalase negative Bile aesculin test positive Staphylococcu s aureus BA: golden yellow hemolytic colonies Gram-positive cocci in clusters Non-motile Catalase positive, coagulase positive Staphyloco ccus BA: white non- hemolytic colonies Gram-positive cocci in clusters Catalase positive, coagulase negative,
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Essentials of Medical
Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers Laboratory Diagnosis - Antibody Coated Bacteria Test 31 ▰ Done to differentiate upper and lower UTI. ▰ In upper UTI - route of spread is hematogenous - bacteria coated with specific antibodies are found in urine. ▰ In lower UTI, bacteria found in urine are never coated with specific antibodies.
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Essentials of Medical
Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers Treatment of Urinary tract infections 32 ▰ Based on antimicrobial susceptibility testing report ▰ Preferred Drugs: Quinolones (e.g. norfloxacin), nitrofurantoin, cephalosporins, and aminoglycosides ▰ Hopsital acquired UTIs with MDR strains: Carbapenem (e.g. meropenem), beta lactam-beta lactam inhibitor combinations (e.g. piperacillintazobactam) or fosfomycin
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Essentials of Medical
Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers Enterobacteriaceae Causing UTI 33 ▰ Several members of the family Enterobacteriaceae can cause UTI; among which uropathogenic E. coli is most important.
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Essentials of Medical
Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers 1. Uropathogenic E. coli 34 ▰ Uropathogenic E. coli (UPEC) is the single most common pathogen of UTI. ▰ Accounting for 70–75% of all cases. ▰ UPEC serotypes O1, O2, O4, O6, O7 and O75 - responsible for most UTIs
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Essentials of Medical
Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers 1. Uropathogenic E. coli (Cont..) 35 ▰ The virulence factors of UPEC include: Cytotoxins (CNF 1–cytotoxic necrotizing factor 1 and SAT: Secreted autotransporter toxin) Hemolysins Fimbriae (e.g. P fimbriae)–specific for strains causing lower UTI Capsular K antigen–specific for strains causing upper UTI.
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