Download Urinary tract infection

Urinary Tract Infection
J.Pudji Rahardjo, Sp.PD-KGH
Jakarta
Kidney (s)
• Important body organ :
• 1/200 BW in 60-70 kg (300 gram each)
• Its rule / function :
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Regulate fluid / electrolyte balance
Regulate water balance
Excrete waste products
Pruduce hormon that control
• Blood hemoglobin
• Blood pressure
EFFECTS of kidney
disturbances AT GLANCE
 Disturbance of :
Excretion of water `: edema : legs or whole body
Excretion of electrolyte : heart rhythm, hypertension
Waste / toxin excretion : ay or all body’s system
Diseased kidney : e.g.
reduce hormon production  anemia,
Stimulate hormon production  hypertension
Symptoms and signs at presentation of
patients with renal disease
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Easy fatigbility
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Flank pain, mostly unilateral
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Decreased appetite
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Mental status changes eg, confusion
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Nausea vomiting
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Pallor
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Generalized pruritus
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Weight loss or pain
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Shortness of breathsleep disturbances
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Lower extremity pitting edema
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Urinary hesistancy, urgency , or frequency
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Ascites
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Microscopic or gross hematuria
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Ulmonary edema or congestion
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Proteinuria
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Pleural or pericardial effusion
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Frothy appearance of urine
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Pericarditis
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Uncontrolled hypertension
Assessing renal function
(eGlomerular Filtration Rate)
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Cockroft-Gault Formula
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MDRD Formula
Creatinine Clearence =
GFR =
(140 –Age in years) X Body weight (kg)
175 X Serum creatinine* X Age** X
(0.742 if female) X (1.21 if black
plasma creatinine
Female : due to less muscle mass x
* - 1.151
** - 0.203
Urinary tract infection
• Some of the most common experienced by humans,
exceeded in frequency among ambulatory patients
only by respiratory and gastrointestinal infections
• USA : the most common cause of both communityacquired and nosocomial infections for patients
admitted to hospital
Urinary tract infection
• Definition :
• The microbial invasion of any of tissues extending
from the urethral orifice to the renal cortex
• The presence of bacteria in the urine (bacteriuria)
places the entire urinary system at risk of invasion by
bacteria
Definitions (1)
• Significant bacteriuria :
• The presence of 100.000 CFU/ml of urine
• Smaller count for young women : 1000 CFU/ml urine
may be associated with cystitis or acute urethral
syndrome
• Recurrent UTI :
• Reinfection : a recurrent infection due to different
microorganism, which is drug susceptible
• Relaps : a return of infection due to the same
microorganism, which often is drug resitant
Definitions (2)
• Complicated and uncomplicated UTI
• Uncomplicated UTI: infection of urethral and bladder
mucosae in the absence of upper tract disease, sequale
are rare, mostly in women
• Complicated UTI : infection that occurred in diabetes,
pregnancy, immunosuppression, structural abnormality
of the UT, symptoms usually last more than 2 weeks,
young women frequenly excepted
Definitions (3)
• Clinical classification :
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Asymptomatic bacteriuria
Acute uncomplicated cystitis in women
Recurrent infections in women
Acute uncomplicated pyelonephritis in women
Complicated UTIs in both sexes
Catheter-associated UTIs
Risk factors and pathogenesis
• The prevalence of UTI in female is increasing accompanies
aging, start from 2% in infancy , stable until teens, and
increases again in adultery, there after in older age. Male
stable at 1% until old age than increase sharply when
prostatism exist
• Risk factors for UTI : age, pregnancy, sexual intercourse, use
of diaphragm, condoms, spermicides, delayed poscoital
micturation, menopause, a history of recent UTI.
• Factors that do not increase : diet, tampons, clothing,
personal hygiene.
Risk factors for urinary tract infection
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Female sex
Previous UTI
Sexual intercourse
Lack of circumcision
Vesico-ureteric reflux
Urologic instrumentation or
surgery
Urinary tract obstruction
Neurogenic-bladder
Polycystic kidney disease
Renal transplantation
Lack of urination after
intercourse
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Spermicide use
Diaphragm use
Pregnancy
Lower socioeconomic group
Diabetes
Sickle cell trait in pregnancy
HIV with with high viral load
Neurologic disease
Older age
Estrogen deficiency
Bladder prolapse
Acute Uncomplicated Cystitis
General Consideration :
 A classic example : infection of the bladder,
commonly affects women the reproductive group
 50-60% adult women will have once experience of
this symptoms during their lifetime
 Risk factors: increased frequency of sexual
intercourse, recent use of diaphragm / spermicidal
agent, delayed postcoital micturation, history of
recent UTI
Essential of Diagnosis
• Triad of dysuria, frequency, and urgency
• Suprapubic or low back pain
• Afebrile
• Positive urinalysis
Laboratory findings
Diagnosis :
 Often on patients history alone : dysuria, frequency of
urination without vaginal discharge : 96%
 Pyuria > 5wbc/HPF, and positive bacteria (85-95 specific
for infection)
 Dipstick test : fast and confinient
 Urine culture sensitive in only 50%, diagnostically
positive :100.000 CFU/ml, 1000 CFU/ml in young
women
Special test
• Not necessary for : healthy, nonpregnant women
with strongly positive history of Auc Cystitis,
presumptive therapy can initiated soon
• No symptom / history UTI : appropriate test :
urinalysis and microcopy, dipstick : negative  urine
culture
• DD/ : cervicitis or vaginitis
Treatment
• Short course : 3 days AB
• Intolerance / resistance : UTI in the past 6 months,
older age, recurrent UTI : 7 – 14 days treatment
course
• Recurrent infection, esp. women : need prophylaxis
agent, low dose for 6 months to 1 year, or postcoital
Oral regimen for acute uncomplicated cystitis
Antimicrobial agent
dosage
Duration
(days)
US FDA
pregnancy
category
Adverse effects
TMZ
1 tab q 12h
3
C
Anorexia,vometing, nausea, rash,
blood dyscrasia, Steaven JS
Trimethoprim
100mg q 12h
3
C
Diarrhea, rash, blood dyscrasia,
hypersensitivity, taste change
Ciprofloxacin
250mg q 12h
3
C
Headache, dizziness, nausea, diarhea,
psychosis, tendon rapture
Levofloxacin
250mg q 24h
3
C
idem
Gatifloxacin
400mg q 12h
3
C
idem
Nitrfurantoin MM
100mg q 12h
7
B
Anorexia,nausea, vomiting,
headache, hemolytic anemia,
pulmonary hypersensitivity
Amoxicillin
clavulanate
500/125mg q 12h
7
B
Nausea, diarrhea, rash, blood
dyscrasia
Cephalexin
250mg q 8h
7
B
Nausea, diarrhea, rash, blood
dyscrasia
Acute Pyelonephritis
• Infection of the upper urinary tract : the kidney
• Most episodes are generally considered to be
uncomplicated
Acute pyelonephritis
• Essentials of diagnosis :
• Fevers . 38 *C
• Chills
• Flank pain or costovertebral angle
tenderness
• Positive urine culture
Symptoms and signs
 Mostly : Leucocytosis, severe urosepsis : leucopenia
 Gram stain bacteria for guiding immediate empiric
AB, but pretreatment urine culture is a must
 Blood culture needed in severe cases and
hospitalized women
 DD/. : renal calculus, gallbladder disease,
appendicitis, but with catheter diagnosis is difficult
Treatment
• Healthy, nonpregnant women with uncomplicated
PN can be managed in out patient setting
• Oral hydration is important
• Duration of treatment : 7 days for mild, 14 days for
severe / toxic condition
• Severe cases : hospitalization
Prognosis
• Uncomplicated : usually respond within 48=72
hours
Complicated UTI
• UTI + a structural or functional abnormality
• Increased risk for bacteremia, sepsis, abscess
UTI in men
• Risk factors : anal intercourse, lack of circumcision,
sexual partner have e,coli infection
Thank You