Download Dysuria, frequency

Urinary Tract Infection
(UTI)
Urethral Terrorist Incident?
鲍一歌
四川大学华西医院
UTI: a quick view
• Definition of UTI
• Presence of pathogen in the urinary tract and
invasion and reaction of the urinary tract to the
disease producing organisms and their toxins. The
reaction usually includes inflammation of the
involved organ.
• Key: Bacteria + inflammation
UTI: a quick view
• The inflammation cause by pathogenic
microorganism involving any parts of genitourinary
tract.
• These infections can spread from a given locus to
any or all of the others.
UTI sites
Necrotizing papillitis
Renal abscess
Renal carbuncle
Perinephric abscess
• Pyelonephritis
Pyonephrosis
• Cystitis
Prostatitis
Epididymitis
Urethritis
Pathways of pathogen infect urinary tract:
1. Ascending route
Most common cause
2. Hematogenous spreads
To kidney, prostate, testis
Usually are straptococcus
3. Lymphatogenous spreads
Through the lymphatic channels
from the neighbor infection
4. Direct extension from another organ
Intraperitoneal abcesses like
Appendiceal abcess.
UTI: a quick view
• UTIs are the most common infections just
secondary to those involved respiratory system.
• Women are especially prone to UTIs, One woman
in five develops a UTI during her lifetime. Why?
• UTIs in men are not so common, but they can be
very serious when they do occur. Why?
UTI in a nutshell
• Typical clinical scenario
• Young female
• Dysuria, frequency
• Urianalysis
• WBC +++
• Nitrite +ve
• Urine C&S
• Escherichia coli growth
• Resistant to all beta lactams and beta lactamase inhibitor except
carbapenems
• Rx
• Levofloxacin 500 mg qd po x 3d
UTI in a nutshell
• Typical clinical scenario
• Young female
• Dysuria, frequency
• Urianalysis
• WBC +++
• RBC +
• Nitrite +tive
• Urine C&S
• Escherichia coli growth
• Resistant to all beta lactams and beta lactamase inhibitor except carbapenems
• Rx
• Levofloxacin 500 mg qd po x 3d
1. Female UTI: more common and
more recurrence
• Short urethra
• Shorter route for bacteria to enter the bladder
• Antimicrobial effect of urine
• Close to vagina & anus
• Reservoirs
• Men are less common in UTI, but more likely to
have recurrence after the 1st episode. Why?
UTI in other population: more
complicated
• Pregnancy: asymptomatic bacteriuria (5%). Risk of
pyelonephritis and miscarriage. Screen at 1st
trimester
• Senior male: asymptomatic bacteriuria,
intertwisted with BPH
• Pediatric: more likely to become pyelonephritis,
screen for congenital abnormalities (VUR etc)
UTI in a nutshell
• Typical clinical scenario
• Young female
• Dysuria, frequency
• Urianalysis
• WBC +++
• Nitrite +ve
• Urine C&S
• Escherichia coli growth
• Resistant to all beta lactams and beta lactamase inhibitor except
carbapenems
• Rx
• Levofloxacin 500 mg qd po x 3d
Clinical Manifestation of UTIs:
Could be asymptomic in some chronic infections.
• Abnormal urination:
Vesical irritability: frequency, urgency, burning
Difficulty of urination
• Abnormal urine:
Reddish urine, Bloody urine, Hematouria
Milky, cloudy urine, pyauria, bacteriuria
• Pain:
Local pain and referred pain
• GI tract symptoms:
Nausea, vomitting, etc.
• Systematic symptoms:
Fever, chills, headache, etc.
Bacteremia, toxicemia, sepsis, infectious shock
Cystitis vs. pyelonephritis:
manifestation
Cystitis: localized
Pyelonephritis: generalized
• Bladder irritation/
lower urinary tract
symptoms (LUTS)
• Dysuria
• Frequency, urgency
• Fever, chills, nausea
and vomiting
• Myalgia and malaise
• Risk of urosepsis
• Local: flank pain, CVA
tenderness, dysuria and
frequency
LUTS vs. bladder irritation symptoms:
Very similar
LUTS: sphincter/detrusor
dysfunction
Bladder irritation:
inflammation
• Core symptom: difficult
urination
• Core symptom: dysuria
storage symptoms: frequency, urgency, dysuria
voiding symptoms: hesitancy, post-void dribbling
other: suprapubic pain, hematuria, foul-smelling
urine
Clinical manifestations
• 3 components: symptoms, bacteriuria, pyuria
• Symptoms + bacteriuria + pyuria = Symptomatic
UTI
• (location? Acute or chronic/recurrent?)
• Bacteriuria only = Asymptomatic bacteriuria
• Pyuria only = healthy or stone or cystitis or bladder
cancer etc.
• Symptom only = interstitial cystitis etc.
UTI in a nutshell
• Typical clinical scenario
• Young female
• Dysuria, frequency
• Urianalysis
• WBC +++
• Nitrite +ve
• Urine C&S
• Escherichia coli growth
• Resistant to all beta lactams and beta lactamase inhibitor except
carbapenems
• Rx
• Levofloxacin 500 mg qd po x 3d
Urianalysis 尿常规
• Look for evidence of
pyuria (WBC counts)
• Hematuria
• And bacteriuria
• Nitrite
• Bacteria in urine pellets
Bacteriuria or contamination?
Bacteriuria
Contamination
• > 105 CFU/ml on voided
samples
• > 102 CFU/ml on
catheterized/
suprapubical aspiration
• 103 – 105 CFU/ml:
suspicisous
• Microbes from external
genitals during sample
collection
• S. aureus, S.
epidermidis, mixed
flora
• < 103 CFU/ml
• Common microbes:
E.coli, enterococcus
UTI in a nutshell
• Typical clinical scenario
• Young female
• Dysuria, frequency
• Urianalysis
• WBC +++
• Nitrite +ve
• Urine C&S
• Escherichia coli growth
• Resistant to all beta lactams and beta lactamase inhibitor except
carbapenems
• Rx
• Levofloxacin 500 mg qd po x 3d
What bacteria causes UTI?
• Common pathogens for cystits
• These bugs “KEEPS” you busy
• Klebsiella sp.(克雷白杆菌属)
• E. coli (most common), other Gram-negatives
• Enterococci (肠球菌属)
• Proteus mirabilis (奇异变形杆菌), Pseudomonas (假单
胞菌属)
• S. saprophyticus (腐生葡萄球菌)
Special pathogens
• Tuberculosis (TB)
• Chlamydia trachomatis
• Mycoplasma (Ureaplasma urealyticum)
• Fungi (Candida)
What bacteria causes UTI?
Community-acquired UTI
Hospital-acquired UTI
• Most common: E.coli
(85%)
• Klebsiella (克雷白杆菌属)
• Enterococcus fecalis (粪
肠球菌)
• Staphylococcus
saprophyticus (腐生葡
萄球菌)
• Proteus mirabilis (奇异变
形杆菌)
• Most common: E.coli (3050%)
• Enterococcus (肠球菌属)
• Klebsiella (克雷白杆菌属)
• Citrobacter (柠檬酸细菌
属)
• Seratia (赛氏杆菌属)
• Pseudomonas (假单胞菌
属)
Hospital acquired UTIs
• 35~50% in total hospital acquired infection, again
just secondary to respiratory infection.
• Among them, 75~80% caused by catheterization
• Bacteria usually have high resistance to antibiotics,
so the infection could be very severe.
• Catheter Care:
• Choice of catheter: appropriate size
• Drainage system: closed, not open drainage
• Clean or sterile of urethral openning.
How do bacteria enter the
bladder?
• Rectum -> vagina ->
periurethral perineum ->
urethra
• Activities that increase the risk
• Simple movement of
underwear
• Wiping from back to front
after a bowel movement
• Sexual intercourse
• diaphragm with a spermicide
• delayed postcoital micturition
Reservoir: war trench for bugs!
Bacterial invasion, adhesion, and colonization
Host defence mechanism
• Urine flushing
• Shedding of urothelia
Bacterial colonization mechanism
• Adhesion to surface
• Form intracellular bacterial
community
Factors promoting host
defence
• Increased water intake
• Frequent urination
Factors promoting bacterial
colonization
• Foreign body
• Anatomical abnormaly
• Urinary
stasis/obstruction/reflux
Host defence: Urine
• Osmaolarity
• Urea concentration
• Organic acid concentration
• Acidic pH value
Bacterial invasion, adhesion, and
colonization
• Uropathoge
nic E.coli
expresses
fimbrae (or
pili) to
adhere to
urothelia
Factors promoting bacterial
colonization
Bacteria adhering to foreign
body (ureteral stent and stone)
A patient with anatomical abnormaly
(Ureteral duplication)
Some bacteria could form
intracellular bacterial community (IBC)
• By hiding inside the
cells, the bacteria are
able to escape from
host immune defence
and luminal antibiotics
IBC
UTI: the natural history
No recurrences
Infection resolved
Initial UTI
Reinfection
Relapse
Unresolved UTI
Chronic UTI
Classification of UTI: simple,
complicated and recurrent
Simple/ uncomplicated
• lower UTI in a setting of
functionally and
structurally normal urinary
tract
Chronic
• Recurrent: ≥3 UTIs/12 mo
• Unresolved, reinfection and
relapse
Complicated: with risk
factors!
• Structural and/or functional
abnormality
• Immunocompromised
• Iatrogenic complication
• Pregnancy
• Pyelonephritis
• Catheter-associated
Recurrent UTI
Reinfection (common, 80%)
• Different strains of
pathogen, re-enter the
urinary tract
• Usually >= 2 weeks (for
same pathogen
cultured)
• Any organism with an
intermittent sterile
culture
Relapse (less common but
difficult)
• Same strains of
pathogen, persists
within the urinary tract
• Usually <= 2 weeks
• Despite sensitivitybased therapy
Recurrent UTI
Cause of reinfection:
extraurinary Reservoirs!
• Poor personal hygene
• Bacterial vaginosis
• Multiple sexual
partners
Relapse: ~ complicated UTI
•
•
•
•
•
•
•
•
Infection stones
Chronic bacterial prostatitis
Foreign bodies
Urethral diverticula and infected
periurethral glands
Nonrefluxing, normal-appearing,
infected ureteral stumps after
nephrectomy
Infected urachal cysts
Infected communicating cysts of
the renal calyces
Papillary necrosis
Discussion on diagnosis of UTIs:
• Typical simple UTI:
symptom + sign + routine test of urine
• Recurrent or persistent infection:
Relapse, Reinfection, persistent
Need to check both offense and defence side:
• Microscopy and culture of urine (MSU):
Before treatment + One week after treatment
Clean catch of midstream of fresh urine
• Bacteriuria with clinical significance:
>105 cfu(colony forming unit) per ml of urine
<103 cfu/ml = contaminant, 103~104cfu/ml = suspected
Should combined with symptom, strain of bacteria, etc.
• Sensitivity test of antibiotics:
UTI in a nutshell
• Typical clinical scenario
• Young female
• Dysuria, frequency
• Urianalysis
• WBC +++
• Nitrite +ve
• Urine C&S
• Escherichia coli growth
• Resistant to all beta lactams and beta lactamase inhibitor except
carbapenems
• Rx
• Levofloxacin 500 mg qd po x 3d
Treatment: antibiotics based
therapy
Cystitis
Pyelonephritis
• Oral Abx: empirical
• Urine culture/no
culture
• Intavneous ABx -> oral
Abx
• Blood culture/urine
culture, needs follow up
• All patients needs to rule
out risk factors
(abnormalities? Foreign
body? Immune
compromise?)
Treatment of UTIs:
• Principle:
To offense side: sensitive, effective antibiotics
To defence side: primary lesion, complication
Supportive approach, symptomatic treatment.
• Route uncomplicated infection:
Single antibiotics, short-term rather than long term
full course of treatment.
• Severe or complicated infection:
Chose antibiotic by sensitivity test, Stop drugs one week after
symptom disappear, MSU one week after treatment.
• Recurrent uncomplicated infections, especially in Women:
low doses antibiotic daily for 6 months or longer
single dose of an antibiotic after sexual intercourse
short course (1 or 2 d) antibiotics at symptoms appear
What ABx to choose?
TMP-SMX
Nitrofurantonin
Simple,
Uncomplicated
UTI
√
Prevention for
recurrence
√
Ceftriaxone
Ampicillin
√
Ciprofloxacin
±
Complicated
UTI
√
√
√
Pyelonephritis
√
√
√
ABx of note:
Fluoroquinolones
Forsfomycin
Indications for investigations
•
•
•
•
•
•
pyelonephritis
persistence of pyuria/symptoms following adequate therapy
severe infection with an increase in Cr
recurrent/persistent infections
atypical pathogens (urea splitting organisms)
hx of structural abnormalities/decreased flow
• Investigations:
•
•
•
•
•
U/A, urine C&S
UA: leukocytes ± nitrites ± hematuria
C&S: midstream, catheterized, or suprapubic aspirate
if hematuria present and persistent need hematuria workup
CT scan if indicated
Summary
• Adult female are most vulnerable (Pediatric? Senior
male? Pregnancy?)
• Short urethra, vagina as reservoirs (in recurrent patients)
• Host defense mechanisms: urine flush, urothelial
shedding and more
• Uropathogenic E.coli are most common pathogen
(community vs. iatrogenic?)
• Invasion mechanisms: adhesion, intracellular bacterial
community
• Factors that increase and decrease risk of UTI (urine
flush, bacterial adhesion, reservoir, host immunity)
Summary
• Risk factors of UTI (complicated UTI, recurrent UTI)
• stasis and obstruction:
• residual urine due to impaired urine flow e.g. PUVs, reflux,
medication, BPH, urethral stricture, cystocele, neurogenic bladder
• foreign body
• introduce pathogen or act as nidus of infection e.g. catheter,
instrumentation (stone)
• decreased resistance to organisms:
• DM, malignancy, immunosuppression, spermicide use, estrogen
depletion, antimicrobial use
• other factors:
• trauma, anatomic abnormalities, female, sexual activity, fecal
incontinence
Summary
• Typical presentation of UTI:
• Dysuria, frequency
• Bacteriuria
• Pyuria
• Mainstay of Abx
• Quinolones for E.coli, ampicillin for enterococcus
• Forsfomycin as a new option
Summary
• Prevention of UTI
• Maintain good hydration (especially with cranberry
juice)
• Wipe from front to back to avoid contamination of the
urethra with feces from the rectum
• Avoid feminine hygiene sprays and scented douches
• Empty bladder immediately before and after intercourse
Urinary Tuberculosis
Clinical case
• 37-year-old female patient
• Experienced vesical irritability for 5 yrs. Five years
ago she had the symptom every 3 to 4 months,
which was released by the antibiotics every time.
• In recent 2 years, vescial irritability did not disturb
her any more, but she felt mild dull pain on her
left lumbar area and frequency of urination. She
worried about there was something wrong, so
came to see the doctor.
• what is your consideration and how to make the
diagnosis?
• B-Ultrasound image of this patients, left kidney
Urinary Tuberculosis:
1. How does TB occurs in urogenital system?
2. What are the differences between pathological renal
TB and clinical renal TB?
3. What are the basic pathological changes of urinary TB,
and what are characteristic pathological changes of
kidney, ureter, bladder and urethera?
4. What are the pathophysiological results of TB disease
in urinary tract?
5. How to diagnose urinary TB, what kind of diagnostic
approaches do you like to orderly chose?
6. After the diagnosis, how could you select the different
treatments?
Etiology of Urinary TB
• Pathogen: Tubercle bacilli,
mycobacterium tuberculosis
• Immunity of human to TB:
lack natural immunity
Pathogenesis of Urinary TB:
• Secondary to the primary tuberculosis in lung.
• Spreads from lung to urinary system by hematogenous
route.
• Kidney (and possibly the prostate) is the primary sites
of genitourinary tract TB, and then involve other sites by
descent route.
Pathological kidney TB:
• Renal cortex of both kidney involved
• Granulomatous tubercule formed in cortex
• TB may be destroyed by normal tissue defense
• Recovery without symptom, found by autopsy
Clinical kidney TB:
• Renal medullar of unilateral kidney involved
• Tubercule formed, and then the destructive and
proliferative changes occur.
• TB destroyed the parenchyma and enter the collective
system, clinical symptom appears.
Basic pathologic change of urinary TB:
Destructive
Changes
Caseous Necrosis
Caseous abscess
Caseous cavity
Scars formation
Parenchyma
Of kidney
Calcification
Tubercle
Fibrosis
Proliferative
Changes
Mucosa of
Urinary tract
Caseous ulcer
Stenosis
Stricture
Pathological change of various urinary organs:
Contralateral
Hydronephrosis
Caseation
Abscess, Cavity
Tubercular nephritis
Calic-pelvis stenosis
UPJ stricture
Multiple
sites involved
Hydronephrosis
Thicken,
Ureterstraight
dilationwall
Segmental
stenosis
Autonephrectomy
Stenosis
Ureteral reflux
White yellow nodules
Deep, ragged ulcer
Fibrosis
Vesical contracture
Pathological change of various urinary organs:
Contralateral
Hydronephrosis
Caseation
Abscess, Cavity
Tubercular nephritis
Calic-pelvis stenosis
UPJ stricture
Pathophysiological results of urinary TB:
sites involved
Unilateral renal function Multiple
Hydronephrosis
Thicken,
straight
wall
Total renal function
Ureter
dilation
stenosis
Bladder urinating funtion Segmental
Autonephrectomy
Antireflux function of ureter orifice
Stenosis
Ureteral reflux
White yellow nodules
Deep, ragged ulcer
Fibrosis
Vesical contracture
Diagnosis of urinary tuberculosis:
•
Genitourinary tuberculosis should be considered:
1. Chronic cystitis not responds to adequate therapy
2. ‘Sterile’ pyuria ( finding of pus without bacteria )
3. Positive sign found at epididymis, prostate, etc.
•
Four aspects of diagnosis:
1. Etiology
Structure
2. Pathology
Symptom
Pathogen
3. Pathophysiology
4. Symptom
Function
Principle of urinary TB treatment:
1. Treatment of Pathogen
2. Protect the function
3. Reconstruct the structure
Remove the destroyed organ
4. Symptomatic treatment