k9_pd_kuliah uti - k8
TRANSCRIPT
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Urinary Tract Infections
Lecture 1: Genito-urinary system.
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Getting Clear on the
Terminology
UTI
Asymptomatic
Bacteriuria
Symptomatic
UTI
Cystitis
Urosepsis
Asymptomatic
UTI
Pylonephritis
Pyuria
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3
Infection
Infection is defined as the entry and
multiplication of microorganism(s) in the
tissues of the host that produces injuriouseffects.
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Cystitis
Infection of the urinary tract limited to the
bladder, usually involving only the mucosal
surface – Most common type of UTI in the long-term care
setting
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5
Pyelonephritis
Infection of the kidney usually resulting from
travel of the infection from the bladder to the
ureter and then to the kidney.(ascending)
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6
Urosepsis
Sepsis occurs when bacteria have entered the
bloodstream and lead to a widespread
(systemic) inflammatory response.Urosepsis means the infection has stemmed
from an infection of the urinary tract
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Asymptomatic Bacteriuria
The presence of bacteria in the urine of a
person without symptoms of infection.
–
Should not be called a UTI – Should not be treated with antibiotics
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Pyuria
The presence of white blood cells in the urine.
– The body’s reaction to invasion by bacteria.
–
One of the key differentiating points betweenUTI and assymptomatic bacteriuria
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Getting Clear on the
Terminology
Pollakisuria
Pollakisuria/dysuria
syndrome
Anuria
Dysuria
Polyuria
Oliguria
Cylindruria
Hematuria
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◙ The risk of uti in women 10x men.
Why?
the shorter distance between anus andmeatus urethrae externum.
◙ almost half of all women will have at least
one UTI in their lives.◙ the risk of UTI in women increases after
menopause
U.T.I.
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◙ after a UTI 20 - 40 % will have a recurrence
◙ the recurring infections are usually
re-infections.◙ asymptomatic bacteriuria in women occurs in
2.7% of 15 - 24 year olds
9.3% of over 65 year olds and
20 - 50% of over 80 year olds
U.T.I.
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UTI is rare in young and middle-aged men
UTI in men is often associated with catheterisation or
urological procedures.
bacteriuria in elderly men occurs in
– about 10% of those living at home,
– about 20% of those living in nursing homes and
– 30% of those who are in-patients in hospitals
urinary catheter increases the risk almost ten-fold inhospitalised patients and those in other care homes.
pyelonephritis is common in patients who have been
catheterised for over a month.
PREVALENCE
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Urinary tract infection occurs when bacteria whichcolonise the anal area ascend through urethra to the
bladder
Risk factors include
– reduced resistance offered by the mucous membranes (e.g.after menopause)
– sexual intercourse
– disturbances in ureteral functioning
– in children the re-entering of urine back into the ureters
(vesicoureteral reflux), which predisposes them particularly
to upper UTI’s
Pathogenesis
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Pathogenesis
Other risk factors:
benign prostatic hypertrophy
any illness, such as diabetes, which affects theemptying of the bladder
spinal injury (associated with disturbances inbladder emptying or urinary catheter)
catheterisation in hospital or residential care
other urological procedures
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Causative agents of UTIs
Escherich ia co l i
– most common
– about 80% of primary care infections
– about 50% of hospital-acquired infections
Others:
– enterococc i
– Staphy lococ cus saprophy t icus and
– klebs iel las – various types of pseudomonas and proteus are
more rare
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’Complicated’ or ’uncomplicated’?
‘Uncomplicated’ urinary tract infections are
– occasional lower urinary tract infections in women
with no predisposing factors to infections
‘Complicated’ infections are all other UTIs including lower
UTIs in
– pregnant women
– men
– children
– and catheter-induced infections
– The investigations and treatment of these entail special
features
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Symptoms of UTIs 1
Cystitis:
typical symptoms include frequency and burning sensation
when passing urine.
Pyelonephritis:
only some patients have difficulties in micturition
temperature (> 38oC) and flank or back pain
nausea in the elderly or sudden collapse in health status(”off -legs”)
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Symptoms of UTIs 2
incontinence or offensive urine in the elderly should not be
considered as UTI as such; even though they may be
indicative signs of an infection
almost any signs of infection in infants may be indicative of aUTI (C)
in a small child a temperature alone, without any other signs
of an infection, should raise a suspicion of a UTI
UTI in children and the elderly may manifest itself asincontinence or retention.
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Diagnosis of UTIs
Based on the symptoms both
a clinical diagnosis of a UTI anda differentiation between lower (cystitis) or
upper (pyelonephritis) UTI should be made
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Collecting a sample
in adults and older children a mid stream urine (MSU)sample usually reliably represents the urine in thebladder.
samples collected from urinary bags or bedpansshould not be used to diagnose UTI as they invariablywill be contaminated
the most reliable sample is obtained via a suprapubic
punctureurine in bladder >4 hours (any shorter time willincrease the risk of false negative findings)
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Clinically significant pathogen concentrations
Clinical status or methods of sampling
Significantconcentration(microbes / ml)
MSU; symptomatic patient or urine inbladder <4 h
>103
MSU; urine in bladder >4 h >104-5
Male patient, catheter specimen sample >103
Female patient, catheter specimen sample >104
Asymptomatic bacteriuria >105
Suprapubic puncture sample any growth
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Diagnosis of UTIs 1
No need to do any urinalysis, if a female
patient, who does not belong to any of the
risk groups,
Urine microscopy is not usually necessary to
diagnose cystitis
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Symptomaticpatient
Uncomplicated cystitisin a woman,
no risk factorsnot a relapse
Typical symptoms,
< 2 infections / year,
patient familiar withher illness
Bacterial culture,
"on the spot" testingto confirm diagnosis
Starttreatment
based onresults
Antibiotictherapy
Yes
No
No
Yes
Diagnosis algorithm
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Asymptomatic bacteriuria
Results of urine culture have repeatedly shownbacterial growth above 105 bacteria (cfu)/ml
possible pyuria does not affect interpretationif several bacterial strains are grown on culture;contamination of the sample is the likely cause
investigations and treatment of asymptomaticbacteriuria should be instigated only in pregnantwomen
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Antimicrobial therapy in UTIs 1
Acute uncomplicated cystitis:
– patient with typical symptoms, not belonging to any of therisk groups, is treated without laboratory investigations
– if the symptoms are atypical, a strip test urinalysis may be
carried out to support diagnosis – if the strip test is negative, the urine should be cultured and
other reasons for the symptoms should be considered
– First choices: – trimethoprim for 3-5 days
– nitrofurantoin for 5-7 days or
– pivmecillinam for 5-7 or 3 days
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Antimicrobial therapy in UTIs 2
Reserve drugs:
Quinolones (norfloxacin, ofloxacin or ciprofloxacin) for 3 days
– if first choice drugs are not suitable or
– if the infection has not responded to first choice drugs or
– recurrent infection within 4 weeks
– if there is a relapse, urine must be cultured and the treatment should becontinued for 7 days
In special cases:
– cefalexin or cefadroxil for 5 days (if the above are contraindicated)
– sulphatrimethoprim (SMZ-TM) for 3 days (particularly if the level ofinfection is unclear)
– amoxicillin for 5 days (particularly in enterococcal infections)
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Single-dose therapy
single-dose therapy is slightly less effective than conventional
therapy
effective in infections caused by E. co li , but less so in S.
saprophyticus infections
recommended particularly when practical reasons warrant its
use (e.g. self-care)
Preparations:
– phosphomycin 3 g – norfloxacin 800 mg
– ciprofloxacin 500 - 750 mg
– ofloxacin 200 mg as a single dose
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Treatment of pyelonephritis
Uncomplicated pyelonephritis:
A pyelonephritis patient who is not unduly ill
can be looked after at home (C)
Treatment with either a fluoroquinolone or
sulphatrimethoprim orally for 10-14 days
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Treatment of pyelonephritis 2
An unwell pyelonephritis patient with or without hightemperature should be admitted to hospital
in hospital the treatment is commenced with cefuroxime i.v.0.75-1.5g every 8 hours or with an fluoroquinolone orally
it is usually possible to change over to oral medication withfirst-generation cephalosporins in 2-3 days, when responseto treatment is obvious
third-generation cephalosporins are usually notrecommended for the treatment of uncomplicated
pyelonephritis, but ceftriaxone may be chosen as the initialtherapy, if either once a day or intramuscular administrationare considered beneficial
aminoglycosides have shown no additional benefits overother forms of treatment
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Treatment during pregnancy
Bacteriuria during pregnancy is associated withincreased risk of premature labour and pyelonephritis
– asymptomatic bacteriuria and cystitis are treated in thesame way
– single-dose treatment is not recommended
– drugs of choice
nitrofurantoin 75 mg twice daily for 5 - 7 days or
beta-lactamase (mecillinam, amoxicillin or first-
generation cephalosporins) for 5 – 7 days.
– due to foetal risk fluoroquinolones should be avoidedduring the whole of pregnancy, and SMZ-TM during the
latter part of pregnancy
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Lower UTIs in children
treatment principles are the same as for adults
little evidence to support short term treatment in children
(C)
drugs of choice
– nitrofurantoin 5 mg/kg/day or
– trimethoprim 8 mg/kg/day
– treatment to continue for 5 days (C)
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Probable lower UTI with generalised
symptoms in children
treated so that any possible infection of the kidney is alsocovered, i.e. with antibiotics with high tissue penetrability
oral medication acceptable
drugs of choice
– sulphatrimethoprim (trimethoprim 8 mg/kg/day)
– cefalexin 30 - 50 mg/kg/day in 3 divided doses
– cefuroxime axetil 20 mg/kg/day in 2 divided doses or
– mecillinam 20 - 40 mg/kg/day in 3 divided doses – treatment to continue for 7 days (C)
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Treatment of pyelonephritis in children
all infants with febrile UTI should be admitted to hospitaldrugs of choice
– cefuroxime (100 mg/kg/day in 3 divided doses) or
– ceftriaxone (80 mg/kg/day daily)
– intravenous therapy until obvious response
– when obvious response to treatment is observed,
medication is changed over to oral until the total course of
treatment, i.e. 10 days, is completed
follow-up treatment according to culture and sensitivity
results, with an antibiotic with good tissue penetrability (e.g.
sulphatrimethoprim or a cephalosporin)
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UTIs in men
a UTI in men can be associated with either acute or chronic
bacterial prostatitis
prostatitis or epididymitis may play a part particularly in
febrile UTI
it is advisable to palpate both the prostate and scrotum
chronic bacterial prostatitis, or at least the retention of
bacteria in the prostatic ducts, should be suspected in
relapses with the same causative bacteria
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UTIs in men 2
Afebrile lower urinary tract infection in men:
if the infection is not associated with urinary stricture or prostatitis,it is
treated with the same drugs as cystitis in women, but the treatment
should continue for 7 - 10 days
nitrofurantoin should not be used in men as adequate prostatic
concentrations are not achieved (D)
Febrile urinary tract infection in men is treated with
a long course of antibiotics with good prostatic and epididymalpenetration
first choice: a fluoroquinolone for 2 weeks
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UTIs in men 3
UTI in men associated with acute bacterial prostatitis treatment for 4 - 6 weeks (depending how quickly patient
responds to treatment)
to be followed up with low dose prophylaxis with e.g.
trimethoprim or nitrofurantoin
Chronic bacterial prostatitis
recurrent UTI’s and calcifications in prostate
oral quinolones for 2 – 3 months (D) to be followed up with prophylactic medication
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Treatment of UTI in diabetics
Cystitis in diabeticsdrugs of choice for initial treatment are same as for uncomplicated UTI
antibiotic treatment must always be based on the results of urine
culture
treatment to continue for 7 days
Acute pyelonephritis in diabetics
treatment is the same as for uncomplicated pyelonephritis
consider urological imaging earlier than normal, if there is no response to
appropriately chosen medication
the causative agents of recurrent UTI’s in diabetics are often unusual,
resistant microbes (species of pseudomonas, enterococci and
enterobacter) and various candida species.
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Prophylaxis of recurrent cystitis with
antimicrobial agents
prophylaxis should be considered when more
than 3 infections per year
prophylaxis to continue for 6 monthsif infections recur after prophylactic treatment,
the prophylaxis is re-commenced for 6 – 12
months (D)
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Drugs of choice in UTI prophylaxis
First choice:
trimethoprim 100 mg in the evenings
nitrofurantoin 50 - 75 mg in the evenings
Second choice:
methenamine hippurate 1 g twice daily
norfloxacin 200 mg daily or on 3 evenings per weeknitrofurantoin (not if serum creatinine is above 150 μmol/l)
quinolones (in cases where there is no response with other
prophylactic medication or tolerance to other medications is poor)
During pregnancy:
nitrofurantoin 50 mg daily or
methenamine hippurate 1 g daily for the rest of the pregnancy
particularly if recurrent bacteriuria is diagnosed in early pregnancy
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Medication to be taken after intercourse
A single-dose prophylaxis taken after intercourse iseffective in women whose UTI’s are clearly associated with
sexual intercourse (A)
First choice:
– trimethoprim 100-300 mg as a single dose
– nitrofurantoin 50-75 mg as a single dose
Second choice:
– norfloxacin 200 mg, ofloxacin 100 mg or ciprofloxacin
100-250 mg
– sulphatrimethoprim (1 single-strength tablet)
Th i lit it i f th
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The main quality criteria for the
treatment of UTI’s
urine sample to be collected appropriately when
infection is suspected
unnecessary culturing of urine samples to be
avoided
the investigation and treatment of asymptomatic
bacteriuria to be reserved for risk groups
diagnosing structural anomalies of the urinary tractin children
rational use of antibiotics
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Antimicrobial therapy in association with
a urinary catheter 1
the treatment of UTI in a catheterisedpatient should always be based on theidentity and sensitivity of the causative
microbethe catheter should always be removed, atleast for the duration of treatment, asotherwise the bacteria will not be eradicated
if this is not feasible, the recommendation isto continue treatment for 7 - 10 days evenin lower UTI’s
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Antimicrobial therapy in association with
a urinary catheter 2
In the following patient groups antibiotics can prevent serious
infective complications caused by long-term catheterisation :
after renal transplant (for 3 months)
granulocytopenic patients and
possibly in diabeticsit is recommended that drugs which could be of benefit in serious
infections (beta-lactamases and fluoroquinolones) are not used for
prophylaxis
Antibiotic prophylaxis is not recommended:
for repeat catheterisationsfor the insertion of long-term catheter
for pyuria and bacteriuria in a patient with a long-term catheter but no
obvious infection
Antimicrobial therapy in association with a urinary
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Antimicrobial therapy in association with a urinary
catheter 3
Fungal bladder infection in a catheterised patient:
systemic fluconazole is slightly more effective than
topical amphotericin B
removal of the catheter will improve the eradication of themicrobe during therapy
Suprapubic catheter:
its use is associated with a lower incidence of bacteriuria inpostoperative care
any infections are treated as any other infections
associated with urinary catheters