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1、Urinary Tract Infections,UTI,UTI-common affliction for which patients seek medical attentionUTI can occur from infancy through old agemore common in females than males 20%of all females will experience a UTI during their lifetime,UTIDefinitions,The term“UTI”represents a wide range of clinical syndro
2、mes Bacteriuria:the presence of bacteria in urine-does not necessarily imply infectionAsymptomatic bacteriuria:presence of bacteria in the urinary tract in the absence of symptoms-clinical significance controversial outside certain patient populations-pregnant women-patients undergoing invasive proc
3、edures of the urinary tract,UTIDefinitions,Cystitis:UTI presumed to be confined to the bladder-painful/burning urination-urgency or frequency-absence of symptoms or physical signs suggesting inflammation at other sites within the urinary tractNote:clinical criteria are notoriously inaccurate in iden
4、tifying the actual anatomic site of infection,UTIDefinitions,Pyelonephritis:clinical diagnosis which implies a more invasive infection-inflammation of the kidney and renal pelvis is assumed to be present when patients have pain or tenderness involving the flank,together with other clinical or labora
5、tory evidence of UTI-fever,nausea,chills,malaise,headache,etc,UTIDefinitions,Prostatitis:inflammation/infection of the prostate gland-may present as acute or chronicIntrarenal abscess/perinephric abscess:collection of pus in the kidney or in the soft tissue surrounding the kidney,UTIDefinitions,Comp
6、licated infections-underlying abnormality that predisposes patient to UTI or makes UTI more difficult to treat effectivelyRecurrent Infections Relapse-recurrence of infection by same organism after discontinuation of treatment Reinfection-recurrence of infection by a different organism after discont
7、inuation of treatment,UTIPathogenesis,UTI usually due to patients own intestinal flora-ascending route of infection-organisms enter the urinary tract in a retrograde fashion via the urethraComplicating factors such as catheters,nephrostomy tubes,surgery,urinary stones,etc-allow organisms to enter an
8、d persist in urinary tract-alter the typical spectrum of organisms-may have multiple etiologies,UTIPathogenesis,Elderly patients-incontinant-functionally impaired-postmenopausal changes-neurological alterationsPregnant women-altered anatomyHematogenous route-endocarditis,bacteremias,tuberculosis-dis
9、seminated infections,UTIEtiology,Majority of UTI are due to a single pathogenThe Enterobacteriaceae responsible for 90%of all UTI-gram negative bacilli-facultatively anaerobic-common intestinal floraEscherichia coli most commonly isolated pathogen 80%of all UTI,Community-Acquired UTI,E.coli,K.pneumo
10、niae,Proteus,S.saprophyticus,S.epi&gm-enterics,Enterococcus,Uro-pathogens,E.coli,Klebsiella spp.-intrinsic gut organisms-highly motile-produce fimbriae(pili)attachmentProteus,Morganella,Providencia-Urease producing organisms-increases urinary pH-leads to crystal formation biofilmscolonization of cat
11、heterprotects bacteria from host defenses&antibiotics,Nosocomial UTIcatheter associated,Short Term,Long Term,E.coli,E.coli,Pseudomonas,Pseudomonas,Proteus,Proteus,Enterobacter,Candida,Providencia,Morganella,S.aureus,Enterococcus,Urinalysis,usually have increased numbers of WBCleukocyte esterase test
12、 is often positivenitrate test is often positive,Urinalysis,Urine culture:significant bacteriuria usually defined as 105 bacteria/ml.(108/litre)lower numbers may be significant in children and in catheter collected specimens,Specimen collection,Should all patients with a suspected UTI be cultured?Co
13、mmunity acquired vs nosocomial?Should all isolates be identified?Susceptibility testing?,Specimen collection,Clean catch mid stream specimens-most frequently used method-urethra cleaned prior to collection-first void urine allowed to pass to clear urethra-mid-stream collected in sterile containerCol
14、lection bags(children)-used in young children lacking bladder control-often contaminated-most meaningful result is a negative culture,Specimen collection,Suprapubic aspiration/straight catheters-invasive-specimen obtained directly from bladderIndwelling catheters-urine obtained by inserting needle i
15、nto catheter or through diaphram-preferable to obtain specimen from new catheter,rather than old catheter,Specimen transport,Sent to and processed by lab as quickly as possible-Require:method of collection time of collection patients antibioticsSpecimens not received by lab in 1-2 hours MUST be refr
16、idgeratedUrines not received within 24 hours or not refridgerated will be rejected by laboratory,Antimicrobial Therapy,Empiric Therapy-based on most probable pathogens-local rates of resistance-acute infection vs chronic-reinfection or relapse-indwelling catheter etc,Management of UTI,Anatomical/Fun
17、ctional Predisposition to UTIImpaired bladder emptyingDysfunctionNeuropathyVURBOODiverticulum,Management of UTI,Anatomical/Functional Predisposition to UTIObstructionAny levelVURCalculivery difficult to eradicate if UTI and stones,Management of UTI,Anatomical/Functional Predisposition to UTIIntraren
18、alRenal scarsInterstitial nephritisPapillary necrosisMedullary sponge kidneyAPKDCongenital calyceal obstruction,Management of UTI,Anatomical/Functional Predisposition to UTIAssociated conditionsDiabetes mellitusPregnancyImmunosuppressionElderly,Management of Female UTI,Bacterial FactorsAdherenceAdhe
19、sinsFimbriaeNon-fimbrial AdhesinsBiofilmsImportant in catheter UTISoluble Virulence Factor ProductionDisrupt bladder protective mucus layer,Management of Female UTI,Bacterial FactorsIron Acquisition MechanismsSiderophores and HaemolysinsAllow growthSerogroup and Serum RO ag LPS outer G-ve Prevent co
20、mplement destructionCapsulesK ag covers bacteria capsuleProtects v phagocytosis and complement attack,Management of Female UTI,Bacterial FactorsIg ProteasesCleave gut IgAUreteric ParalysisP.Fimbriae and endotoxinMotilityAscent of LUTUrease ProductionHydrolyse urea and increases ammonia which increas
21、es bacterial adherence,Management of Female UTI,Host FactorsColonisation of vagina,introitus,urethraBiological predispositionHormone deficiency vaginal atrophySpermicidal jelly increases vaginal pHAntibiotics reduce vaginal lactobacilli and increase pHAscent to bladderSexual milkbackCatheterisation,
22、Management of Female UTI,Host FactorsEstablishment of bacteria in bladderUrine composition(extremes inhibit bacterial growth)Reduced IgA and IgGReduced GAG layer in the bladderLow urine flowIncomplete emptying,Management of Female UTI,MSSU when symptomaticUSS renal tract with post void residualKUBTa
23、rgeted flexible cystoscopy(8%yield)macroscopic haematuriamicroscopic haematuria between UTIspersistent UTI,Management of Female UTI,3 days oral antibiotics or x1 high dose if compliance poor14 days antibiotics if pyelonephritisAddress any underlying cause(rare)General adviceincrease fluid intakecran
24、berry juicevoid before and after si,Management of Female UTI,Hygienewash without soappat or air drycotton pants6 months low dose prophylactic antibioticsalter gut floramay affect COCPSelf-start antibiotic therapy,Management of Male UTI,MSSU when symptomaticUSS renal tract with flow rate and post voi
25、d residualKUBFlexible cystoscopymacroscopic haematuriamicroscopic haematuriapersistent UTI,Management of Male UTI,UTI-7 days oral antibioticsAddress underlying cause,Management of Childhood UTI,Historyfevers and rigorsirritative LUTSincontinencechange in voiding patternbowel dysfunctionExaminationin
26、cluding neurology,Management of Childhood UTI,TREAT IMMEDIATELY AFTER MSSU COLLECTED WITH THERAPEUTIC ANTIBIOTICS AND CONTINUE PROPHYLACTIC ANTIBIOTICS UNTIL INVESTIGATIONS COMPLETEDONLY DISCONTINUE IF ALL INVESTIGATIONS NEGATIVE,Management of Childhood UTI,MSSU/Suprapubic aspiration/Bladder cathete
27、risation when symptomaticUSS renal tract with post void residualDMSA/MAG3(if hydronephrosis)VCUG(if DMSA or MAG3+ve)at least 6 weeks post UTIKUB(if?SB/sacral agenesis)MRI(if spinal anomalies),Management of Childhood UTI,UTI 3-5 days antibioticsPyelonephritisnon-toxic/3 months:im ab x1+10-14 days antibioticstoxic/3 months:iv antibiotics+10-14 days antibiotics when stableAsymptomatic bacteriuria:no treatment unless have VUR,Thank you!,
