Download - 27482_Urinary Tract Infection
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Urinary tract infection
Dr. Mai Banakhar
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UTI
inflammatory response of urothelium to
bacterial invasion.
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Bacteriuria: bacteria in urine
Asymptomatic or symptomatic Bacteriuria + pyuria= infection
Bacteriuria NO pyuria = colonization
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Pyuria :
WBCs in urine.
Infection T.B
Bladder stone.
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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
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Isolated UTI:
6 months between infections.
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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.
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Unresolved infection:
in adequate therapy , bacterial resistance
to ttt.
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Risk factors to bacteriuria
Female
Age
Low estrogen (
menopause)
Pregnancy.
D.M
Previous UTI. FC
Stone
GU malignancy.
Obstruction.
Voiding dysfunction.
Institutionalized
elderly
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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
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Route of infection
Ascending
Short urethra
Reflux
Impair urtericperistalisis.
Pregnancy
Obstruction
G-ve , Edotoxins
Organism P pili
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Route of infection
Haematogenous:
Uncommon.
Staph aureus.
Candida fungemia.
T.B
Lymphatics:
Rarely in
inflammatory bowel
disease,reteroperitoneal
abscess
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Increase UTI risk
Increase bacterialvirulence
Protect against UTI
Host defences
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Factors increasing bacterial
virulence
Adhesion factors
Toxins
Enzyme production. Avoidance of host defense mechanisms
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Factors increasing bacterial
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)
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Factors increasing bacterial
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
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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
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Lower UTI
Cystitis: infection& inflammation of the
bladder
Frequency, samll volumes, dysuria,
urgency, offensive urine SP pain,
haematuria, fever & incontinence.
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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
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Investigation
Microscopy :
Bacteria :
False
ve low bacterial count False +ve contamination (lactobacilli &
corynebacteria ) epithelial cells
RBCs & pyuria
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Investigation
Indications for furtherinvestigations in LUTI.
Symptoms of Upper
UTI. Recurrent UTI.
Pregnancy
Unusal infecting
organism ( proteussuggest infectionstone)
KUB
Ultrasound IVU
cystoscopy
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DD
Non-infective cystitis:
radiation cystitis
Drud cystitis ( cyclophosphamide ) Haemorrhagic cystitis
Urethritis
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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.
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Recurrent UTI
>2 in 6 months or 3 within 12 months
Reinfection Bacterial persistence
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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
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Management Reinfection UTI
Females
KUB, Ultrasound, cystoscopy
Simple ReinfectionTTT
Avoid spermicides
Estrogen replacement therapyLow dose antibiotic prophylaxis
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Female recurrent reinfection
Prophylactic antibiotic:
Reduce infection 90% at bed time 6-12months
Symptomatic reinfection
Trimethoprim
Nitrofurantoin
Cephalexin
Fluoroquinolones
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Female recurrent reinfection
Natural youghart
Post-intercourse antibiotic prophylactic
Self-started therapy
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Management of bacteria
persistance
Investigations:
Kub, renal ultrasound.
C.T, IVU Cystoscopy
Treatment : For the functional or anatomical anomaly
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Antibiotics
Empirical therapy.
Definitive therapy.
Bacterial resistance to drug therapy.
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Acute pyelonephritis
Clinical Dx:
Flank pain
Fever.
Elevated WBCs
DD:
acute cholecystitis.
Pancreatitis.
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Acute pyelonephritis
Risk factors:
VUR
UTO
Spinal cord injury
D.M
Malformation
pregnancy
FC
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Acute pyelonephritis
Pathogenisis :
Initially patchy
Inflammatory bands from renal papilla tocortex.
80% E.coli, others klebsiella, proteus&
pseudomonas.
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Acute pyelonephritis
Urine analysis & culture.
CBC , U&E
KUB & ultrasoundif no response with I.Vantibiotic for 3 days go for CTU
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Perinephric abscess
Pathogenesis.
Suspected??
C.T, ultrasound PC drainage .
Open surgical
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Pyonephrosis
Infected hydronephrosis.
Pus accumulation
Causes Ultrasound. C.T
Management: PCN, I.V antibiotic, I.V
fluids.
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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
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Emphysematous pyelonephritis
Presentation: sever acute pyelonephritis
High fever & systemic upset
E.coli, commonly, Klebsiella & proteus less frequent
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Management
KUB
Ultrasound, C.T
Patients are unwell Mortality is high
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Management
Conservative ?
I.V antibiotic , IVF
PC drainage Control D.M
Sepsis is poorly controlled
Nephrectomy
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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
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Xanthogranulomatous
pyelonephritis
Acute flank pain
Fever & tender flank mass
C.T , Ultrasound
Stone , mass ?? RCC
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Xanthogranulomatous
pyelonephritis
IV antibiotic ,
Nephrectomy
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