27482_urinary tract infection

8/10/2019 27482_Urinary Tract Infection

1/46

Urinary tract infection

Dr. Mai Banakhar


2/46

UTI

inflammatory response of urothelium to

bacterial invasion.


3/46

Bacteriuria: bacteria in urine

Asymptomatic or symptomatic Bacteriuria + pyuria= infection

Bacteriuria NO pyuria = colonization


4/46

Pyuria :

WBCs in urine.

Infection T.B

Bladder stone.


5/46

Complicated VS uncomplicated

Un complicated UTI:

UTI structurally &

functionally normal

urinary tract. Female.

Respond to short

course of antibiotic

Complicated UTI:

Anatomical or

funtional abnormality.

Male.

Longer time to

respond to ttt


6/46

Isolated UTI:

6 months between infections.


7/46

Recurrent UTI:>2 infections in 6 months

3 UTI in 12 months.

Reinfection by different bacteria.

Persistence : same organism from focus withinthe urinary tract.

Struvate stone.

Bacterial prostatitis.

Fistula Urethral diverticulum.

atrophic infected kidney.


8/46

Unresolved infection:

in adequate therapy , bacterial resistance

to ttt.


9/46

Risk factors to bacteriuria

Female

Age

Low estrogen (

menopause)

Pregnancy.

D.M

Previous UTI. FC

Stone

GU malignancy.

Obstruction.

Voiding dysfunction.

Institutionalized

elderly


10/46

Microbiology

Faecal-drived bacteria

Uncomplicated UTI

E.Coli, G-ve baccillus,

(85%- 50%)

Staph saprophyticus

Enterococ faecalis

ProteusKlebsiella.

Complicated UTI

E.coli 505

Enterococ faecalis.

Staph aureus

Staph epidermidis

Pseudomonas

aeruginosa


11/46

Route of infection

Ascending

Short urethra

Reflux

Impair urtericperistalisis.

Pregnancy

Obstruction

G-ve , Edotoxins

Organism P pili


12/46

Route of infection

Haematogenous:

Uncommon.

Staph aureus.

Candida fungemia.

T.B

Lymphatics:

Rarely in

inflammatory bowel

disease,reteroperitoneal

abscess


13/46

Increase UTI risk

Increase bacterialvirulence

Protect against UTI

Host defences


14/46

Factors increasing bacterial

virulence

Adhesion factors

Toxins

Enzyme production. Avoidance of host defense mechanisms


15/46


virulence

Adhesion factors

G-ve bacteria, Pili

Attachment to host

urothelial cells. Single type or different

types e.x E.coli

Defined functionally be

mediatinghemagglutination (HA) of

specific erythrocytes

Mannose sensitive

(type 1)

Produced by all strains

E.coli

Certain pathogenic types

of E.coli mannose

resistant pili( pyelonephritis)


16/46


virulence

Avoidance of hostdefense mechanisms

E.coli

Extracellular capsule

Immunogenisity phagocytosis

M.Tuberculosis reisit

phagocytosis bypreventingphagolysosome fusion

Toxins:

E.coli cytokines,pathogenic effect on

host tissues

Enzyme production:

Proteus ureases

Ammonia struvitestone formation


17/46

Host defences

Protective

Mechanical (flushing of urine) antegrade flow of

urine

Tamm-Horsfall protein (mucopolysaccharidecoating bladder prevent bacterial attachment)

chemical : Low Urine PH & high osmolality

Urinary Immunoglobulin I gA inhibit adherence


18/46

Lower UTI

Cystitis: infection& inflammation of the

bladder

Frequency, samll volumes, dysuria,

urgency, offensive urine SP pain,

haematuria, fever & incontinence.


19/46

Investigation

Dipstick of MSU

WBC ( pyuria )

75 -95% sensitivity

infection

False ve

False +ve

Other causes ofpyuria

Nitrite testing:

Bacteriuria.

Specificity >90%

Sensitivity 35- 85%

+ test ------- infection

- --------infection


20/46

Investigation

Microscopy :

Bacteria :

False

ve low bacterial count False +ve contamination (lactobacilli &

corynebacteria ) epithelial cells

RBCs & pyuria


21/46

Investigation

Indications for furtherinvestigations in LUTI.

Symptoms of Upper

UTI. Recurrent UTI.

Pregnancy

Unusal infecting

organism ( proteussuggest infectionstone)

KUB

Ultrasound IVU

cystoscopy


22/46

DD

Non-infective cystitis:

radiation cystitis

Drud cystitis ( cyclophosphamide ) Haemorrhagic cystitis

Urethritis


23/46

Treatment

Aim :

Eliminate bacterialgrowth from urine.

Empirical ttt beforeculture & sensitivityfor the most likelyorganism.

Adgusted accordingto the culture &sensitivity.

Resistance :

Intrinsic (proteus)

Genetically

transferred betweenbacteria by Rplasmids.


24/46

Recurrent UTI

>2 in 6 months or 3 within 12 months

Reinfection Bacterial persistence


25/46

Recurrent UTI

Reinfection ( differentbacteria)

After prolonged

interval withadifferent organism

Reinfection in females

No anatomical nor

functional pathology In males BOO,

urethral stricture

Bacterial persistance( same organismfrom a focus withintract) within shortinterval

Functional oranatomical problem.

The underlyingproblem should betreated


26/46

Management Reinfection UTI

Females

KUB, Ultrasound, cystoscopy

Simple ReinfectionTTT

Avoid spermicides

Estrogen replacement therapyLow dose antibiotic prophylaxis


27/46

Female recurrent reinfection

Prophylactic antibiotic:

Reduce infection 90% at bed time 6-12months

Symptomatic reinfection

Trimethoprim

Nitrofurantoin

Cephalexin

Fluoroquinolones


28/46

Female recurrent reinfection

Natural youghart

Post-intercourse antibiotic prophylactic

Self-started therapy


29/46

Management of bacteria

persistance

Investigations:

Kub, renal ultrasound.

C.T, IVU Cystoscopy

Treatment : For the functional or anatomical anomaly


30/46

Antibiotics

Empirical therapy.

Definitive therapy.

Bacterial resistance to drug therapy.


31/46

Acute pyelonephritis

Clinical Dx:

Flank pain

Fever.

Elevated WBCs

DD:

acute cholecystitis.

Pancreatitis.


32/46


Risk factors:

VUR

UTO

Spinal cord injury

D.M

Malformation

pregnancy

FC


33/46


Pathogenisis :

Initially patchy

Inflammatory bands from renal papilla tocortex.

80% E.coli, others klebsiella, proteus&

pseudomonas.


34/46


Urine analysis & culture.

CBC , U&E

KUB & ultrasoundif no response with I.Vantibiotic for 3 days go for CTU


35/46

Perinephric abscess

Pathogenesis.

Suspected??

C.T, ultrasound PC drainage .

Open surgical


36/46

Pyonephrosis

Infected hydronephrosis.

Pus accumulation

Causes Ultrasound. C.T

Management: PCN, I.V antibiotic, I.V

fluids.


37/46

Emphysematous pyelonephritis

Severe form of acute pyelonephritis

Gas forming organism

Fever, abdominal pain with radiographicevidence of gas within the kidney.

D.M

Urinary obstruction. High glucose level-------fermentation,CO2

production


38/46

Emphysematous pyelonephritis

Presentation: sever acute pyelonephritis

High fever & systemic upset

E.coli, commonly, Klebsiella & proteus less frequent


39/46

Management

KUB

Ultrasound, C.T

Patients are unwell Mortality is high


40/46

Management

Conservative ?

I.V antibiotic , IVF

PC drainage Control D.M

Sepsis is poorly controlled

Nephrectomy


41/46

Xanthogranulomatous

pyelonephritis

Severe renal infection

Renal calculi & obstruction.

Result in non-functioning kidney E.coli & proteus common.

Macrophage full of fat deposit around the

abscess Kidney, perinephric fat


42/46

Xanthogranulomatous

pyelonephritis

Acute flank pain

Fever & tender flank mass

C.T , Ultrasound

Stone , mass ?? RCC


43/46

Xanthogranulomatous

pyelonephritis

IV antibiotic ,

Nephrectomy


44/46


45/46


46/46

27482_urinary tract infection

Documents