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Transcript
Urinary Tract Infections UTI • UTI - common affliction for which patients seek medical attention • UTI can occur from infancy through old age • more common in females than males ~20% of all females will experience a UTI during their lifetime UTI Definitions The term “UTI” represents a wide range of clinical syndromes Bacteriuria: the presence of bacteria in urine - does not necessarily imply infection • Asymptomatic 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 procedures of the urinary tract UTI Definitions • 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 tract • Note: clinical criteria are notoriously inaccurate in identifying the actual anatomic site of infection UTI Definitions • 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 laboratory evidence of UTI -fever, nausea, chills, malaise, headache, etc UTI Definitions • Prostatitis: inflammation / infection of the prostate gland - may present as acute or chronic • Intrarenal abscess / perinephric abscess: collection of pus in the kidney or in the soft tissue surrounding the kidney UTI Definitions • Complicated infections - underlying abnormality that predisposes patient to UTI or makes UTI more difficult to treat effectively • Recurrent Infections Relapse - recurrence of infection by same organism after discontinuation of treatment Reinfection - recurrence of infection by a different organism after discontinuation of treatment UTI Pathogenesis • UTI usually due to patients own intestinal flora - ascending route of infection - organisms enter the urinary tract in a retrograde fashion via the urethra • Complicating factors such as catheters, nephrostomy tubes, surgery, urinary stones, etc - allow organisms to enter and persist in urinary tract - alter the typical spectrum of organisms - may have multiple etiologies UTI Pathogenesis • Elderly patients - incontinant - functionally impaired - postmenopausal changes - neurological alterations • Pregnant women - altered anatomy • Hematogenous route - endocarditis, bacteremias, tuberculosis - disseminated infections UTI Etiology • Majority of UTI are due to a single pathogen • The Enterobacteriaceae responsible for 90% of all UTI - gram negative bacilli - facultatively anaerobic - common intestinal flora • Escherichia coli most commonly isolated pathogen ~80% of all UTI Community-Acquired UTI E.coli S.epi & gm - enterics Enterococcus Proteus K.pneumoniae S.saprophyticus Uro-pathogens • E.coli, Klebsiella spp. -intrinsic gut organisms -highly motile -produce fimbriae (pili) >>attachment • Proteus, Morganella, Providencia -Urease producing organisms -increases urinary pH - leads to crystal formation >>biofilms >>colonization of catheter >>protects bacteria from host defenses & antibiotics Nosocomial UTI catheter associated Short Term Long Term E.coli Enterococcus Enterobacter E.coli Proteus Candida Proteus Providencia Morganella S.aureus Pseudomonas Pseudomonas Urinalysis • usually have increased numbers of WBC • leukocyte esterase test is often positive • nitrate 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? • Community 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 container • Collection 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 bladder • Indwelling catheters - urine obtained by inserting needle into 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 patient’s antibiotics • Specimens not received by lab in 1-2 hours MUST be refridgerated • Urines 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/Functional Predisposition to UTI – Impaired bladder emptying • • • • • Dysfunction Neuropathy VUR BOO Diverticulum Management of UTI • Anatomical/Functional Predisposition to UTI – Obstruction • Any level – VUR – Calculi • very difficult to eradicate if UTI and stones Management of UTI • Anatomical/Functional Predisposition to UTI – Intrarenal • • • • • • Renal scars Interstitial nephritis Papillary necrosis Medullary sponge kidney APKD Congenital calyceal obstruction Management of UTI • Anatomical/Functional Predisposition to UTI – Associated conditions • • • • Diabetes mellitus Pregnancy Immunosuppression Elderly Management of Female UTI • Bacterial Factors – Adherence • Adhesins • Fimbriae • Non-fimbrial Adhesins – Biofilms • Important in catheter UTI – Soluble Virulence Factor Production • Disrupt bladder protective mucus layer Management of Female UTI • Bacterial Factors – Iron Acquisition Mechanisms • Siderophores and Haemolysins • Allow growth – Serogroup and Serum R • O ag LPS outer G -ve • Prevent complement destruction – Capsules • K ag covers bacteria capsule • Protects v phagocytosis and complement attack Management of Female UTI • Bacterial Factors – Ig Proteases • Cleave gut IgA – Ureteric Paralysis • P. Fimbriae and endotoxin – Motility • Ascent of LUT – Urease Production • Hydrolyse urea and increases ammonia which increases bacterial adherence Management of Female UTI • Host Factors – Colonisation of vagina, introitus, urethra • • • • Biological predisposition Hormone deficiency vaginal atrophy Spermicidal jelly increases vaginal pH Antibiotics reduce vaginal lactobacilli and increase pH – Ascent to bladder • Sexual milkback • Catheterisation Management of Female UTI • Host Factors – Establishment of bacteria in bladder • Urine composition (extremes inhibit bacterial growth) • Reduced IgA and IgG • Reduced GAG layer in the bladder • Low urine flow • Incomplete emptying Management of Female UTI • • • • MSSU when symptomatic USS renal tract with post void residual KUB Targeted flexible cystoscopy (8% yield) – macroscopic haematuria – microscopic haematuria between UTIs – persistent UTI Management of Female UTI • 3 days oral antibiotics or x1 high dose if compliance poor • 14 days antibiotics if pyelonephritis • Address any underlying cause (rare) • General advice – increase fluid intake – cranberry juice – void before and after si Management of Female UTI • Hygiene – wash without soap – pat or air dry – cotton pants • 6 months low dose prophylactic antibiotics – alter gut flora – may affect COCP • Self-start antibiotic therapy Management of Male UTI • MSSU when symptomatic • USS renal tract with flow rate and post void residual • KUB • Flexible cystoscopy – macroscopic haematuria – microscopic haematuria – persistent UTI Management of Male UTI • UTI - 7 days oral antibiotics • Address underlying cause Management of Childhood UTI • History – – – – – fevers and rigors irritative LUTS incontinence change in voiding pattern bowel dysfunction • Examination – including neurology Management of Childhood UTI – TREAT IMMEDIATELY AFTER MSSU COLLECTED WITH THERAPEUTIC ANTIBIOTICS AND CONTINUE PROPHYLACTIC ANTIBIOTICS UNTIL INVESTIGATIONS COMPLETED – ONLY DISCONTINUE IF ALL INVESTIGATIONS NEGATIVE Management of Childhood UTI • MSSU/Suprapubic aspiration/Bladder catheterisation when symptomatic • USS renal tract with post void residual • DMSA/MAG3 (if hydronephrosis) • VCUG (if DMSA or MAG3 +ve) – at least 6 weeks post UTI • KUB (if ? SB/sacral agenesis) • MRI (if spinal anomalies) Management of Childhood UTI • UTI – 3-5 days antibiotics • Pyelonephritis – non-toxic/ > 3 months : im ab x1 + 10-14 days antibiotics – toxic/ < 3 months: iv antibiotics + 10-14 days antibiotics when stable • Asymptomatic bacteriuria: no treatment unless have VUR • Thank you!
