UTI (Urinary Tract Infection) - PDF

 UTI: ASYMPTOMATIC BACTERIURIA CYSTITIS PROSTATITIS PYELONEPHRITIS UTI : EPIDEMIOLOGY ETILOGY RISK FACTOR PATHOPHYSIOLOGY CLINICALFEATURES DIFF. DIAG MANAGEMENT COPLICATION  EPIDEMIOLOGY - Female 1 year --- 50 years of age 50-- 80% women once uti lifeti...

 UTI: ASYMPTOMATIC BACTERIURIA CYSTITIS PROSTATITIS PYELONEPHRITIS UTI : EPIDEMIOLOGY ETILOGY RISK FACTOR PATHOPHYSIOLOGY CLINICALFEATURES DIFF. DIAG MANAGEMENT COPLICATION  EPIDEMIOLOGY - Female 1 year --- 50 years of age 50-- 80% women once uti lifetime ASB ~5% among women ages 20 and 40 40--50% elderly women and men 20--30% of women one episode UTI have recurrent episodes  EPIDEMIOLOGY single catheterization causes UTI 1% of ambulatory Persons single catheterization of hospitalized patients, occurs in at least 10% lower socioeconomic groups African-American women with sickle cell trait  ETILOGY COMPLICATE UNCOMPLICATED UTI UTI Multiple organisms 95% singl bacterial antibiotic-resistant isolates E. coli Ecoli 75--90% Pseudomonas Staphylococcus Klebsiella saprophyticus 5--15% Proteus Klebsiella, Proteus Citrobacter Enterococcus Acinetobacter Citrobacter species. enterococci Staphylococcus aureus yeast  ETIOLOGY Anaerobic organisms are rarely pathogens Coagulase-positive staphylococci most often invade the kidney from the hematogenous route Fungi particularly Candida spp Adenoviruses (particularly type 11 RISK FACTOR PATHOGENESIS OF URINARY TRACT INFECTION Ascending Route Hematogenous Route Spread from contiguous structures  UTI HOST INFECTION ORGANISM ENVIROMENT  MICROORGISM (VIRULACE FACTORS) serogroups of E. coli 01,02, 04, 06, 07, 08, 075, 015 018ab O, K,H serotypes Motile bacteria Capsular polysaccharide(by countering lytic effects of complement and phagocytes. α-hemolysin inhibits protective cytokine production Indoleamine 2,3-dioxygenase Adhesins(pili or fimbriae) ANTIBACTERIAL HOST DEFENSES Colonization due to : loss of vaginal Lactobacillus species diaphragm and spermicide use Uro virulence factors PATHOGENESIS  UTI Uncomplicated urinary complicated tract infection refers: urinary acute cystitis or tract infection pyelonephritis in non pregnant outpatient women without anatomic abnormalities or instrumentation of the urinary tract;  CLINICAL SYMTOMS Asymptomatic Bacteriuria: ≥10 5 CFU/mL or ≥10 8 CFU/L Screened or Treated: pregnancy ,4–7 days antimicrobial treatment renal transplant recipients have had renal transplant surgery >1 month prior Undergoing Endourological Procedures 1– 3% among healthy premenopausal women, 15% or greater in women and men age 65-80 years two consecutive specimens with same bacteria species in female men, a single specimen with isolation of one bacteria species  CLINICAL SYMTOMS lower tract symptoms : frequent painful urination turbid urine. Suprapubic heaviness or pain grossly bloody bloody tinge at the end of micturition dysuria nocturia. Fever(-) managed on the basis of history No need U/A OR U/C SIMPLE CYSTITIS TRETMENT  CLINICAL MANIFESTATIONS OF PYELONEPHRITIS Fever worsening of cognitive Chills impairment flank pain Delirium frequency fall Urgency Dysuria Nausea vomiting Flank tenderness  LAB TEST methods for urine collection include 1– mid stream clean- catch 2-“in and out ” catheterization 3— suprapubic aspiration.  LAB TESTS Urinalysis: urine should be analysed In 30to 60 mins WBC.>10 RBC=2-3 nitrite( staph saprophyticus does not nitrate) leukocyte esterase White cell casts Proteinuria Diagnostic gold standard is U/C  D.D Vulvovaginitis Viral cystitis enterbiasis Calculi STD Epididymitis  MANAGMENT hydration and acidification of the urine no evidence to support the efficacy Clinical response occur within 24 hours with treatment of cystitis pyelonephritis, response should occur 48 to 96 hours  MANAGMENT Bacteriologic Cure : negative u/c on antimicrobial thrapy AND follow up 1—2 WEEK Bacteriologic Persistence: (1) persistence of significant bacteriuria after 48 hours of treatment(resistant organism ,not taking the agent, insufficient dosage, poor intestinal absorption, or poor renal excretion) (2) persistence of the infecting organism in low numbers in urine after 48 hours(persistence in the urinary tract or contamination from the urethra or Vagina)  MANAGMENT Bacteriologic Relapse : occurs within 1 to 2 weeks after the cessation of chemotherapy renal infection, structural abnormalities of the urinary tract, chronic bacterial prostatitis Reinfection :After initial sterilization of the urine occur during the administration of chemotherapy  UNCOMPLICATED CYSTITIS IN WOMEN nitrofurantoin (100 mg every 12 hours for 5 days) fosfomycin (a single dose of 3 g , TMP-SMX (1 double-strength tablet every 12 hours for 3 days). Clearly one of the Pivmecillinam (400 mg twice daily for 3–7 days) fluoroquinolones such as ciprofloxacin, ofloxacin, and levofloxacin given for 3 days β-lactams should be considered only if nitrofurantoin, fosfomycin, and TMP-SMX cannot be used  MANGMENT severely ill with pyelonephritis should be hospitalized in pyelonephritis have made fluoroquinolones the first-line therapy for acute uncomplicated pyelonephritis Uncomlicated pyelonephritis: oral thrapy levofloxacin 750 , 5 days Ciproflox 500 ,7 day additional, single dose ifluoroquinolone resistanceis greater than 10% fluoroquinolonef(ceftri or aminoglycosid agent other than a fluoroquinolone, 14 days of therapy Cotrimoxazol 2tablet bid 14 day Beta lactam agent is used initial dose of ceftriaxone, ertapenem, or aminoglycoside  TREATMENT UNCOPLICATED PYELONEPHRITIS Parenteral Therapy : fluoroquinolone ceftriaxone or piperacillin- tazobactam with or without an aminoglycoside initially, carbapenem severe sepsis or septic shock, initial therapy with a carbapenem Susceptibility pattern of the infecting organism is known, therapy can be altered accordingly Responded clinically, oral therapy should be substituted for parenteral therapy COMPLICATED URINARY TRACT INFECTION Men ,stone , urinary LAB TEST obstruction,, drainage device,, U/c ,,B/c RENAL failure Imaging by ultrasound, CT scan, and/or MRI Fever with symptoms of cystitis Escherichia coli and Klebsiella pneumoniae Resistant bacteria Imaging indicated  COMPLICATED URINARY TRACT INFECTION TREATMENT Ceftazidime ± aminoglycosides Carbapenems fosfomycin 3g IV three doses  EMPHYSEMATOUS PYELONEPHRITIS Older female diabetic patients chronic urinary infections ,, renal vascular disease high mortality rate production of gas in renal and perinephric tissues E. coli or Klebsiella Lethargy , Evidence of kidney dysfunction on blood tests , Shock, dysuria, flank pain Treatment: antibiotic and Nephrectomy or percutaneos drainage URINARY TRACT INFECTION IN PREGNANCY Dilation of the ureters and renal pelves, with markedly decreased ureteral peristalsis bladder decreases in tone incidence of bacteriuria during pregnancy is similar non pregnant women 25% of those with bacteriuria of pregnancy, develop infection in the later trimesters. 40% patients with untreated bacteriuria early in pregnancy develop acute symptomatic pyelonephritis later in pregnancy COPLICATION OF UNTREATED ASB preterm birth low birth weight, increased risk of pyelonephritis  URINARY TRACT INFECTION IN PREGNANCY screened at 12 to 16 weeks’ gestation or at the first prenatal visit treatment of asymptomatic bacteriuria and cystitis: single-dose fosfomycin 3 g cephalexin 500 mg four times a day for 3 to 5 days 7-daycourse of nitrofurantoin ( NOT FIRST TRIMESTER) TMP-SMX for 3 days(NOT FIRST TRIMESTER) Acute pyelonephritis: third- generation cephalosporins for 14 days. cefixime can be given for 14 days with close follow-up  URINARY TRACT INFECTION IN PREGNANCY Follow up: u/c 1to 2week after discontinuing therapy and at regular intervals (monthly) for the remainder of the pregnancy If relapses or multiple reinfections occur during pregnancy, an imaging evaluation should be Considered postpartum RECOMMENDATIONS FOR INITIAL THERAPY OF URINARY TRACT INFECTION IN ADULTS  CANDIDURIA Indwelling catheterization patients in ICU Taking broad- spectrum antimicrobial drugs Diabetes mellitus >50% urinary Candida isolates to be non -albicans species  CLINICAL PRESENTATION LABORATORY FINDING WITHOUT SYMPTOMS PYELONEPHRITIS SEPSIS  CANDIDA UTIS TREATMENT Removal of the urethral catheter cure of 30% to 40% Asymptomatic infection IS NOT NEED FOR TREATMENT EXCEPCTION Neutropenia undergoing urologic manipulation who are clinically unstable low –birth -weight infants. CYST I T IS CANDIDA : oral fluconazole 200 mg daily for 14 days Candida glabrata and C. krusei symptomatic treated with systemic or amphotericin B irrigation AmB deoxycholate, 0.3–0.6 mg/kg daily for 1–7 days Pyelonephritis : due to azole-resistant Candida glabrata and Candida krusei should be managed with systemic amphotericin B desoxycholate, with or without oral flucytosine.  IMAGING STUDIES severely ill or immunocompromised patients pyelonephritis who fail to improve after 72 hours of appropriate antibiotic therapy Child < 5years with first uti Men with first uti complications Corynebacterium urealyticum  PREVENTIVE STRATEGY Continuous postcoital patient-initiated therapy  CATHETER-ASSOCIATED UTI (CAUTI) Presence of significant bacteriuria in a catheterized or Recently catheterized patient with symptoms or signs referable to the urinary t ract 75% of UTIs acquired in the hospital are associated with urinary catheters Bacteriuria associated catheterization with a closed drainage system is approximately 3% to 8% per day CAUTI Risk Factors: female sex meatal colonization with uropathogens, colonization of the drainage bag catheter insertion outside the operating room, rapidly fatal underlying illness older age diabetes mellitus, elevated serum creatinine at the time of catheterization  CATHETER-ASSOCIATED UTI Less than one -fourth of patients with catheter -associated bacteriuria develop UTI symptoms MICROBIOLOGY: in short-term catheterized patients single organisms, gram- negative bacilli and enterococci Bacteriuria in long- term catheterized patients is usually polymicrobial INDICATIONS FOR URINARY CATHETERS  SIGNS AND SYMPTOMS CAUTI Altered mental status Flank pain Costovertebral angle tenderness Rigors Pelvic discomfort Malaise or lethargy Suprapubic pain or tenderness Increased spasticity Autonomic dysreflexia Sense of unease DIAGNOSIS TREATMENT CAUTI