Transcript Urinary tract infection

Urinary tract infection
Dr. Mai Banakhar
UTI
• inflammatory response of urothelium to
bacterial invasion.
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Bacteriuria : bacteria in urine
Asymptomatic or symptomatic
Bacteriuria + pyuria= infection
Bacteriuria NO pyuria = colonization
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Pyuria :
WBCs in urine.
Infection
T.B
Bladder stone.
Complicated VS uncomplicated
• Un complicated UTI:
• UTI structurally &
functionally normal
urinary tract.
• Female.
• Respond to short
course of antibiotic
• Complicated UTI:
• Anatomical or
funtional abnormality.
• Male.
• Longer time to
respond to ttt
• Isolated UTI:
• 6 months between infections.
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Recurrent UTI:>2 infections in 6 months
3 UTI in 12 months.
Reinfection by different bacteria.
Persistence : same organism from focus within
the urinary tract.
Struvate stone.
Bacterial prostatitis.
Fistula
Urethral diverticulum.
atrophic infected kidney.
• Unresolved infection:
• in adequate therapy , bacterial resistance
to ttt.
Risk factors to bacteriuria
• Female
• Age
• Low estrogen (
menopause)
• Pregnancy.
• D.M
• Previous UTI.
• FC
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Stone
GU malignancy.
Obstruction.
Voiding dysfunction.
Institutionalized
elderly
Microbiology
Faecal-drived bacteria
Uncomplicated UTI
E.Coli, G-ve baccillus,
(85%- 50%)
Staph saprophyticus
Enterococ faecalis
Proteus
Klebsiella.
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Complicated UTI
E.coli 505
Enterococ faecalis.
Staph aureus
Staph epidermidis
Pseudomonas
aeruginosa
Route of infection
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Ascending
Short urethra
Reflux
Impair urteric
peristalisis.
Pregnancy
Obstruction
G-ve , Edotoxins
Organism P pili
Route of infection
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Haematogenous:
Uncommon.
Staph aureus.
Candida fungemia.
T.B
• Lymphatics:
• Rarely in
inflammatory bowel
disease,
reteroperitoneal
abscess
• Increase UTI risk
• Protect against UTI
• Increase bacterial
virulence
• Host defences
Factors increasing bacterial
virulence
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Adhesion factors
Toxins
Enzyme production.
Avoidance of host defense mechanisms
Factors increasing bacterial
virulence
• Adhesion factors
• G-ve bacteria, Pili
• Attachment to host
urothelial cells.
• Single type or different
types e.x E.coli
• Defined functionally be
mediating
hemagglutination (HA) of
specific erythrocytes
• Mannose –sensitive
• (type 1)
• Produced by all strains
E.coli
• Certain pathogenic types
of E.coli mannose
resistant pili
( pyelonephritis)
Factors increasing bacterial
virulence
• Avoidance of host
defense mechanisms
• E.coli
• Extracellular capsule
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Immunogenisity
• Toxins:
• E.coli cytokines,
pathogenic effect on
host tissues
phagocytosis
• M.Tuberculosis reisit
phagocytosis by
preventing
phagolysosome fusion
• Enzyme production:
• Proteus ureases
• Ammonia struvite
stone formation
Host defences
• Protective
• Mechanical (flushing of urine) antegrade flow of
urine
• Tamm-Horsfall protein (mucopolysaccharide
coating bladder prevent bacterial attachment)
• chemical : Low Urine PH & high osmolality
• Urinary Immunoglobulin I gA inhibit adherence
Lower UTI
• Cystitis: infection& inflammation of the
bladder
• Frequency, samll volumes, dysuria,
urgency, offensive urine SP pain,
haematuria, fever & incontinence.
Investigation
• Dipstick of MSU
• WBC ( pyuria )
• 75 -95% sensitivity
infection
• False –ve
• False +ve
• Other causes of
pyuria
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Nitrite testing:
Bacteriuria.
Specificity >90%
Sensitivity 35- 85%
+ test ------- infection
--------infection
Investigation
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Microscopy :
Bacteria :
False –ve low bacterial count
False +ve contamination (lactobacilli &
corynebacteria ) epithelial cells
• RBCs & pyuria
Investigation
Indications for further
investigations in LUTI.
• Symptoms of Upper
UTI.
• Recurrent UTI.
• Pregnancy
• Unusal infecting
organism ( proteus
suggest infection
stone)
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KUB
Ultrasound
IVU
cystoscopy
DD
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Non-infective cystitis:
radiation cystitis
Drud cystitis ( cyclophosphamide )
Haemorrhagic cystitis
Urethritis
Treatment
• Aim :
• Eliminate bacterial
growth from urine.
• Empirical ttt before
culture & sensitivity
for the most likely
organism.
• Adgusted according
to the culture &
sensitivity.
• Resistance :
• Intrinsic (proteus)
• Genetically
transferred between
bacteria by R
plasmids.
Recurrent UTI
• >2 in 6 months or 3 within 12 months
Reinfection
Bacterial persistence
Recurrent UTI
• Reinfection ( different • Bacterial persistance
bacteria)
( same organism
from a focus within
• After prolonged
tract) within short
interval with
interval
adifferent organism
• Reinfection in females • Functional or
anatomical problem.
• No anatomical nor
• The underlying
functional pathology
problem should be
• In males BOO,
treated
urethral stricture
Management Reinfection UTI
• Females
• KUB, Ultrasound, cystoscopy
• Simple Reinfection
TTT
Avoid spermicides
Estrogen replacement therapy
Low dose antibiotic prophylaxis
Female recurrent reinfection
• Prophylactic antibiotic:
• Reduce infection 90% at bed time 6-12
months
• Symptomatic reinfection
• Trimethoprim
• Nitrofurantoin
• Cephalexin
• Fluoroquinolones
Female recurrent reinfection
• Natural youghart
• Post-intercourse antibiotic prophylactic
• Self-started therapy
Management of bacteria
persistance
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Investigations:
Kub, renal ultrasound.
C.T, IVU
Cystoscopy
• Treatment :
• For the functional or anatomical anomaly
Antibiotics
• Empirical therapy.
• Definitive therapy.
• Bacterial resistance to drug therapy.
Acute pyelonephritis
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Clinical Dx:
Flank pain
Fever.
Elevated WBCs
• DD:
• acute cholecystitis.
• Pancreatitis.
Acute pyelonephritis
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Risk factors:
VUR
UTO
Spinal cord injury
D.M
Malformation
pregnancy
FC
Acute pyelonephritis
• Pathogenisis :
• Initially patchy
• Inflammatory bands from renal papilla to
cortex.
• 80% E.coli, others klebsiella, proteus&
pseudomonas.
Acute pyelonephritis
• Urine analysis & culture.
• CBC , U&E
• KUB & ultrasoundif no response with I.V
antibiotic for 3 days go for CTU
Perinephric abscess
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Pathogenesis.
Suspected??
C.T, ultrasound
PC drainage .
Open surgical
Pyonephrosis
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Infected hydronephrosis.
Pus accumulation
Causes
Ultrasound. C.T
Management: PCN, I.V antibiotic, I.V
fluids.
Emphysematous pyelonephritis
• Severe form of acute pyelonephritis
• Gas forming organism
• Fever, abdominal pain with radiographic
evidence of gas within the kidney.
• D.M
• Urinary obstruction.
• High glucose level-------fermentation,CO2
production
Emphysematous pyelonephritis
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Presentation: sever acute pyelonephritis
High fever & systemic upset
E.coli, commonly,
Klebsiella & proteus less frequent
Management
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KUB
Ultrasound, C.T
Patients are unwell
Mortality is high
Management
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Conservative ?
I.V antibiotic , IVF
PC drainage
Control D.M
• Sepsis is poorly controlled
• Nephrectomy
Xanthogranulomatous
pyelonephritis
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Severe renal infection
Renal calculi & obstruction.
Result in non-functioning kidney
E.coli & proteus common.
Macrophage full of fat deposit around the
abscess
• Kidney, perinephric fat
Xanthogranulomatous
pyelonephritis
• Acute flank pain
• Fever & tender flank mass
• C.T , Ultrasound
• Stone , mass ?? RCC
Xanthogranulomatous
pyelonephritis
• IV antibiotic ,
• Nephrectomy