* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download How to Manage UTI in the Elderley and Systemic Disease
African trypanosomiasis wikipedia , lookup
Neglected tropical diseases wikipedia , lookup
Human cytomegalovirus wikipedia , lookup
Sarcocystis wikipedia , lookup
Dirofilaria immitis wikipedia , lookup
Trichinosis wikipedia , lookup
Sexually transmitted infection wikipedia , lookup
Hepatitis C wikipedia , lookup
Hepatitis B wikipedia , lookup
Clostridium difficile infection wikipedia , lookup
Antibiotics wikipedia , lookup
Gastroenteritis wikipedia , lookup
Oesophagostomum wikipedia , lookup
Anaerobic infection wikipedia , lookup
Pathogenic Escherichia coli wikipedia , lookup
Carbapenem-resistant enterobacteriaceae wikipedia , lookup
Schistosomiasis wikipedia , lookup
Coccidioidomycosis wikipedia , lookup
Traveler's diarrhea wikipedia , lookup
Neonatal infection wikipedia , lookup
UTI in Elderly and Systemic Disease ewha univ. hosp. shim, bongsuk How to Manage UTI in the Elderly Aging & Infection UTI in the Elderly Recurrent UTI Asymptomatic Bacteriuria CAUTI Impact of Aging on Infections Aging increase risks of infection Immune changes drops with age Organ changes skin ; decrease protection bladder ; changes to increase UTIs Age-related diseases cancer, diabetes, dementia, voiding dysfunction, etc Physiologic changes hospitalized, institutionalization, medical procedures Department visits by Elderly Drach GW. AUA Update Series Vol 24 Lesson 33 2005 Infectious Disease in Elderly Yoshikawa TT. J Infect Dis 1997 UTI in the elderly extremely common most frequent infection among infectious diseases in the elderly risk factors for developing UTIs dementia, incontinence, decreased mobility asymptomatic bacteriuria is common 15-30% in men 25-50% in women Factors Associated with UTI men BPH Prostate Ca Prostate stone Urethral stricture Etc. both Coexisting diseases Diabetes mellitus Cerebrovascular accidents Dementia Increased hospitalizations Instrumentation Urinary catheters Alterations of immunity women Changes in bladder Introital G(-) bacteria colonization ↑ Vaginal glycogen ↓ Vaginal pH ↑ Kunin CM. 1987 Underlying Dis. in complicated UTI Causative Organisms of UTI Escherichia coli most common, 60~70%, but relatively low rate Proteus mirabilis Klebsiella pneumoniae enterococci more common than younger people Pseudomonas aeruginosa leukemia, aplastic anemia, after GI tract manipulation Staphylococcus rarely in elderly Melani PN. Clin Geriatr 2005 Clinical Presentation classic symptoms dysuria, frequency, urgency absent, masked or difficult to assess only 20% with new urinary symptoms upper UTI confusion (delirium), lethargy, agitation, collapse 15%, no fever and no leukocytosis deteriorate more rapidly from infection bacteremic UTI in the elderly often present respiratory symptoms, treated as ‘Pneumonia’ Barkham, et al. Age & Ageing 1996 Diagnosis history physical examination laboratories urinalysis ; 5-10 WBC/HPF urine culture & sensitivities ; >105 CFU/mL may diagnose acute uncomplicated cystitis based on history, P/E, and U/A alone, no need for culture to treat Therapy with Antibiotics 3-day course for simple acute cystitis 7-day course complicated by hospitalization instrumentation of the urinary tract diabetes immunosuppression failure of previous therapy more than three infections in the previous year symptoms lasting over 7 days Hooton TM. Med Clin North Am 1991 Stamm WE. N Engl J Med 1993 Antibiotics for UTI Adverse Effects of Antibiotics Melani PN. Clin Geriatr 2005 Acute Pyelonephritis (1) atypical clinical presentation fever, confusion, lethargy, nausea and vomiting often of little help in the diagnosis 15%, no fever or no leukocytosis Laboratories three sets of blood cultures and one urine culture Radiographic studies for urinary tract obstructive uropathy, calculous disease or abscess IVP, ultrasound or CT Acute Pyelonephritis (2) Treatments hospitalization : bed rest, adequate hydration, symptomatic care aminoglycoside (amikacin, gentamicin, tobramycin) + cephalosporin IV for 5~7 days oral antibiotics for more 2 weeks no response after 2-3 days : re-evaluation Follow-up repeat UC at least 6 months after treatment Preventing Recurrent UTI Increased fluid intake no evidence, but it may be helpful Antibiotic prophylaxis useful if >3 symptomatic UTIs/year risk of resistant organisms Topical estrogen improves atrophic vaginitis encourages lactobacilli growth Cranberry juice Asymptomatic Bacteriuria > 105 CFU/mL on 2 consecutive occasions no UTI symptoms more common in institutionalized or hospitalized patients prevalence 40 ~ 60 y.o ambulatory population 65~80 y.o Men Women 0.1% 5.0% 6% 18% nursing homes 23% hospitals 32% over 80 y.o 21% 25~50% Abrutyn E, et al. J Am Geriatr Soc 1988 Clinical Significance of Asymptomatic Bacteriuria in the past increased mortality routine treatment Nordenstam GR, et al. N Engl J Med 1986 no direct causal association with mortality rare proceeding to symptomatic UTI not recommend routine screening and treatment Baldassarre JS. Med Clin North Am 1991 Kunin CM, et al. Am J Epidemiol 1992 No Screening for or Treatment of Asymptomatic Bacteriuria pre-menopausal, non-pregnant women diabetic women older persons living in community elderly institutionalized subjects persons with spinal cord injury catheterized patients while the catheter remains in situ Boscia JA, et al. JAMA 1987 Nicolle LE, et al. Am J Med 1987 Abrutyn E, et al. J Am Geriatr Soc 1988 Screening for or Treatment of Asymptomatic Bacteriuria pregnant women suspicious obstructive uropathy before TURP before urological interventions before prosthetic device hip or cardiac valve Nicolle LE, et al. Am J Med 1987 Abrutyn E, et al. Ann Intern Med 1994 Catheter associated UTI incidence 27% under 65, 52% over 65 10-15% of hospitalized patients with indwelling catheter develop bacteriuria 3-5% per day of catheterization one-time catheterization ; 2% bacteriuria gram(-) bacteremia most significant complication of CAUTI greater antimicrobial resistance absence of symptoms no treatment Garibaldi RA. N Engl J Med 1981, Gleckman R. J Urol 1982 4,50대 세상에서 바로남자들에게 호랑이 제일 무서운 마눌님 물었습니다. 여자는? 입니다. . How to Manage UTI in the Diabetes DM and infection Immune System in DM UTI in the Diabetes Emphysematous Pyelonephritis Common UTIs in DM Infection and DM higher of incidence of infection complication & death - more frequent specific immunologic defects the risk factors of infection and resulting complication duration of illness severity of non-infectious complications concurrent illnesses level of glucose control degree of medical supervision Seymour A. Med J Aust 1963 Robbins SL. N Engl J Med 1994 Pathogenesis of Renal Failure in DM Diabetes and the Immune System (1) function of PMN leukocytes depressed chemotactic index – diminished response diminished phagocytosis diminished bactericidal activity Mowat AG. N Engl J Med 1971 Molenaar DM. Diabetes 1976 monocyte function decreased circulating monocytes impaired monocyte chemotaxis Geisler G. Acta Pathol Microbiol Immunol Scand 1982 Hill HR. Clin Immunol 1983 Diabetes and the Immune System (2) cell-mediated immunity decreased the transformation of lymphocytes decreased mitogenic response diminished release of migration-inhibition factor by T lymphocytes MacCuish AC. Diabetes 1974 Casey JI. J Infect Dis 1987 miscellaneous factors abnormalities in the microvascular circulation decrease tissue perfusion impair response to therapy McMillan DE. Mayo Clin Proc 1988 Infectious Diseases in DM Infections Mucormycosis Malignant external otitis Emphysematous Pyelonephritis Emphysematous Cholecystitis Infections strongly associated with diabetes possibly related to diabetes Urinary tract infections Fungal infections Staphylococcus aureus infections Soft-tissue infections Tuberculosis UTI in the Diabetes UTI more common more serious infections increased risk of complicated pyelonephritis asymptomatic bacteriuria is common cleared bacteriuria in short term but did not decrease number of symptomatic episodes or hospitalizations does not reduce complications in diabetes Harding, NEJM 2002 Common UTIs in DM Emphysematous Renal pyelonephritis or perirenal abscess Papillary necrosis Xanthogranulomatous Fourniere’s pyelonephritis gangrene Staphylococcus bacteremia Emphysematous Pyelonephritis (1) 85-100% of patients ; associated Michaeli J, et al. J Urol 1984 Zebbo A, et al. Urology 1985 with DM 10% of patient ; bilateral involvement glucosuria providing a substrate for production of gas by fermentation causative organisms E. coli, Klebsiella pneumoniae, Proteus mirabilis, Enterobacter aurogenes Candida species Emphysematous Pyelonephritis (2) Therapy potent antibiotics, for several weeks? relieve any obstruction undertake percutaneous drainage consider nephrectomy if clinical improvement does not occur mortality rate medical : 75%, surgical : 23% Lowe FC & Walther JM. Urology 1986 Renal Abscess twice frequency in DM Saiki J, et al. West J Med 1982 Plevin SN, et al. J Urol 1979 Pathogens E. coli, Klebsiella, Proteus Treatment antibiotic therapy alone ; resolve prompt drainage ; no clinical improvement within a few days, large collection, obstructive uropathy open incision and drainage ; no response to closed drainage Perinephric Abscess DM ; major contributing factor in perinephric abscess 14-75% of perinephric abscess ; DM Patterson JE. Infect Dis Clin North Am 1987 no symptoms resolving for pyelonephritis within 4-5 days prompt radiologic evaluation – CT scan Treatment drainage in combination with a prolonged course of antibiotics Renal Papillary Necrosis (1) Brauner DM increase risk of renal papillary necrosis patients with proteinuria in DM ; more infected with P-fimbrated strains of E.coli suspect A. Diabetes Res 1987 of renal papillary necrosis frequent relapsing or difficult-to-eradicate pyelonephritis fulminant presentation of pyelonephritis, accompanied by hematuria more than 3 times UTI ; higher risk of papillary necrosis Renal Papillary Necrosis (2) 30-50% of papillary necrosis Mujais SK. Semin Nephrol 1984 ; DM Treatment eradication of infection ; intensive antibiotics catheter drainage or PCN for obstruction and pyonephrosis appropriate duration of antibiotics ; not clearly established nephrectomy Fungal Urinary Tract Infection Candida albicans, Candida Roy JB, et al. Urology 1984 predisposing glabrata condition use of antibiotics, indwelling urinary catheter role of DM not clear precisely Treatment fluconazole orally Fournier’s Gangrene subclassification of necrotizing fasciitis around the male genitalia often in combination with DM, 40% bacteria a mixture of gram-negative bacteria, anaerobes, streptococci treatment wide surgical debridment of devitalized tissue mortality rate 40-50% even with aggressive management