Urinary Tract Infections (UTI) - 2024 PDF

Faculty of Medicine and Health Sciences Dr/ Samira Hameed Hanash professor in medical microbiology and immunology 2024 E.  UTI: Is an infection occurs when one or different micro-organism invade the UT and start multiply. The infection can occur at different po...

Faculty of Medicine and Health Sciences Dr/ Samira Hameed Hanash professor in medical microbiology and immunology 2024 E.  UTI: Is an infection occurs when one or different micro-organism invade the UT and start multiply. The infection can occur at different points in the urinary tract: Kidneys An infection of one or both kidneys is called pyelonephritis or a kidney infection Ureters The tubes that take urine from each kidney to the bladder are rarely the only site of infection Bladder An infection in the bladder is also called cystitis or a bladder infection Urethra: An infection of the tube that empties urine from the bladder to the outside is called urethritis  Re-infection: Occurs > 4 weeks after earlier UTI by different pathogens. More common in females due to short urethra, and E.Coli can invaid deeper tissues of UT, so this bacteria avoid destroyed by Abcs. Relapse UTI : Occurs within 2 weeks of TRT of an earlier UTI by the same pathogen  Pyuria : Presence of pus cell (WBCS) in urine. 1- Any leukocyte esterase on dipstick analysis 2-if 5 WBC/high power field in centrifuged urine sample 3 if 10 leukocytes/mm 3 in centrifuged urine sample Causes of pyuria include: Cystitis,prostatitis Bacterial and parasitic infection Tuberculosis Urinary tract stones Tumors in the urinary tract. Chyluria : Milky appearance of urine characterized by the abnormal presence of chyle, a milky white fluid comprising lymph and dietary fats in the urine lymphatic fluid leaks into the kidneys and turns the urine milky white (abnormal communication between the lymphatic and urinary systems) It is most commonly associated with the filariasis parasitic infection Wuchereria Bancrofti Injury to abdomen (abdominal trauma) Radiation Abscesses  Hematuria: RBCs in urine Occurs in these cases : ❖Bacterial infection ❖kidney/bladder stone ❖Schistosomiasis ❖Cancer ❖Kidney diseases (glomerulonephritis, inherited diseases) ❖Kidney injuries (as sickle cell anemia) ❖Some medications as Aspirin , heparin ❖Strenuous exercise : as trauma to the bladder , finally dehydration  Bacteruria Presence of bacteria in urine with or with out clinical symptoms : A- symptomatic bacteruria SBU B- asymptomatic bacteruria ASB ✓ ASB means the presence of bacteria in urine of patient who don’t have dysuria , urinary frequency, urgency, fever and flank pain ✓ Most ASB in elderly is associated with complicating factors such as : ❑ Hormonal – post menopausal women ❑ Anatomical – prostatic obstruction in men cystocele in women ❑ Metabolic factor – diabetic ❑ Functional-CNS diseases as dementia and P.D ❑ Instrumental- catheterization ❑ Immunological – increase in inflammatory mediators as cytokines, acute phase protein Note: Fever is a marker for serious infection and most important clinical indicator for ABCs , TRT  Asymptomatic bacteriuria isolation of a significant quantitative count of bacteria in an appropriately collected urine specimen from an individual without symptoms of UTI is the presence of bacteria in urine without any symptoms It s found during a urinalysis or a bacterial culture It is higher among females than males Asymptomatic bacteriuria is not harmful usually don t need to treat, these include diabetes, Catheterization, change of hormones level, Obstructive uropathy ( prostatic hypertrophy) Symptomatic bacteriuria is the presence of bacteria in urine with symptoms such as fever and flank pain Risk factors (predisposing factors for UTI) -insufficient fluid intake / dehydration -poor personal hygiene -incomplete bladder emptying -diabetic or immunosuppression -prostatic hypertrophy and vaginal atrophy (estrogen deficiency) -catheterization -lack of circumcision(colonized with ANO2 bacteria) -spinal cord injury -kidney stone -short female urethra -sexual intercourse Natural defense in urinary system flushing action of urine acidic PH of the urine secretory IgA high urea conc. Presence of antibacterial protein in the urine normal flora Flushing mechanism Several different microorganisms can cause UTIs, including bacteria, fungi and viruses and parasites, Bacteria are the major causative organisms and are responsible for more than 95 of UTI cases 1 bacteria.E.coli ,staphylococcus saprophyticus ,Neisseria gonorrhea M. Tubercle bacilli ,proteus , pseudomonas , klebsiella ( HAI ) liptospira – spirocheate / chlamydia / brucella,enterococcus Staphylococcus aureus. 2.Viruses Adenovirus, Herpes Simplex virus 3.Fungi Candida albicans 4.Parasites Trichomonas, Schistosoma haematobium and Enterobius Role of bacterial virulence in UTI : adhesion molecules flagella ( H Ag) capsular polysaccharide (K Ag )/glycocalyx layer (antiphagocytosis ) urease enzyme (urea to ammonia ) increase the PH in urine toxic to kidney formation kidney stone. haemolysin enzymes. destruction RBCs Routes of UTI : The hematogenous (descending) route The prevalence of UTI related to age groups : In 1st 3 months of life In pre-school groups of children In adults In old ages UTI in pregnancy : Physiological and anatomical changes UnTRT UTI during pregnancy leads to complicated outcome Normal microbiota of urinary system The predominant bacteria in the vagina are the lactobacilli. ✓These bacteria produce lactic acid, which maintains the acidic pH (3.8 to 4.5) of the vagina, inhibiting the growth of most other microbes. ✓Most vaginal lactobacilli produce hydrogen peroxide, which also inhibits growth of other bacteria. Estrogens (sex hormones) promote the growth of lactobacilli by enhancing the production of glycogen by vaginal epithelial cells. The glycogen quickly breaks down into glucose, which the lactobacilli metabolize into lactic acid. UTI common in pregnancy why ? Pregnancy and menopause are often associated with higher rates of urinary tract infections. 1-The reason is that estrogen levels are lower, resulting in lower populations of lactobacilli and therefore less vaginal acidity. 2-increase the progesterone leads to relaxation of urethral muscles which allow the bacteria to rise up in to the bladder leads to infection (Higher levels of progesterone decrease the muscles tone of the uterus , causing them to dilate in turn reducing the flow of urine.) 3-uterus growth leads to uncomplete empty of urine from bladder ---stagnant or stasis urine act as source of infection Clinical signs and symptoms Neonates and children younger than 2 years with UTIs usually have nonspecific symptoms Adults with uncomplicated lower UTIs present dysuria, frequency, urgency, suprapubic pain, and hematuria Acute complicated UTI presents with the same symptoms Pyelonephritis, present with flank pain, nausea, vomiting, fevers, chills, night sweats, and costovertebral angle tenderness. Cystitis Cystitis is typically caused by a bacterial infection of the urinary bladder. Women are more particularly susceptible than men due to short urethral length in females 95 % of cases, caused by Escherichia ,coli most common in UTIs in women, followed by Klebsiella Other common pathogens include Proteus, Staphylococcus saprophyticus and Enterococcus Symptoms fever, chills, nausea, pain in the upper back and Vomiting Nitrite and leukocyte estrase positive in cystitis  Acute pyelonephritis ❑ Pyelonephritis occurs as a complication of an ascending urinary tract infection that spreads from the bladder to the kidneys ❑ Escherichia coli is the most common, Proteus, Klebsiella and Enterobacter Symptoms fever, flank pain, nausea, vomiting, burning with urination Common in diabetic patient due to high level of sugar. Sample and diagnosis Pyuria is the most common in patients with acute pyelonephritis Nitrite production will indicate that the causative bacteria is E coli Proteinuria and microscopic hematuria may be present as well on urinalysis. Urinary Schistosomiasis Caused by Schistosoma haematobium ( trematodes ) Definitive host =human Intermediate host =snail Infective stage = cercaria Transmission by penetration of the skin or mucus membrane by cercaria During pathing or washing clothes with contaminated water. Symptoms With in 24 hrs after infection skin rash and intensive irritation is occurs at the sites of penetration  Maturation occurs at the blood vessels of the liver Migration of adult s. haematobium to the veins surrounding bladder Lay eggs after 12 weeks of infection (20- 200 egg/day ) terminal spine Sandy patches of bladder due to accumulation of died eggs &calcified )  Life cycle of schistosome. Free-swimming cercariae in water (1) penetrate unprotected skin. (2) During penetration, they lose their tails to become schistosomulae. (3) These migrate through the bloodstream via the lungs and liver to the veins of the bladder (Schistosoma haematobium) where they mature (4), to produce characteristic eggs within 6–12 weeks. 5 The eggs then penetrate the bladder or colon, to be passed in the urine (6). Eggs passed into fresh water release miracidia which penetrate snail intermediate hosts (7) where they mature into sporocysts (8). These release cercariae (1) into the water to complete the cycle Sample and diagnosis: presence of eggs in urine and RBCs. Normal Egg RBCs  Leptospirosis Definition: Leptospirosis is a disease that is caused by spirochete bacteria in the genus Leptospira. There are 10 pathogenic species, and more than 250 pathogenic serovars the important serotype called leptospira interrogans Transmission 1- Leptospires are spread by the urine of infected animals (rodents, dogs, livestock, pigs, horses and other wildlife animals ). 2- The bacteria can survive for weeks to months in urine- contaminated water and soil.  People can be infected through: Direct contact with the urine or reproductive fluids from infected animals Contact with urine-contaminated water (floodwater, rivers, streams, sewage) and wet soil Ingestion of food or water contaminated by urine or urine- contaminated water Transmission occurs through mucous membranes, conjunctiva, and skin cuts or abrasions. Human-to-human transmission is very rare but has been documented through sexual intercourse and breastfeeding. Transmission has also rarely occurred through animal bites. Bacterial morphology : Leptospires are typical spirochete bacteria marked by tight, regular, individual coils with a bend or hook at one or both end). Leptospira interrogansis the species that causes leptospirosis in humans and animals. Also tiny spiral bacteria , gram negative, dose not form spores ,aerobic bacteria motile bacteria , seen under dark field microscope with immunofluorescence Pathogenesis: -virulence factors 1-adhesion and invasion proteins 2-toxin ( c toxin ) 3-lipopolysaccharide ……inflammation when this bacteria gets in blood stream leptospira has two phases 1- immune phase( first phase) manifest fever and headache 2- weil disease (second phase ) which is more severe spread Leptospira interrogans, the agent of to different organs to lung, liver, kidney. , CNS leptospirosis. sign &symptoms : in 1st phase flu like illness, headache , fever.conjunctivitis ,chills, muscle pain. in 2nd phase liver( jaundice) ,in kidney ( renal failure ) in lung ( cough ,dysnea, hemoptysis, in meningitis (headache ,fever ,stiff neck). Risk of exposure: 1-farmer 2-fish workers 3-slaughter house workers 4-veterianarians 5-military persons Diagnosis by ELISA Dark field examination Agglutination test PCR test Treatment Penicillin g Doxycyclin ,amoxicillin , ampicillin, Prevention Wear protective foot wear &clothing Avoid swimming &wading in contaminated water Laboratory diagnosis of UTI: Specimen Collection: 1.Voided Midstream Specimen Collection (MSU) 2.Catheterized Specimen Collection (straight catheter or indwelling catheter) collect sample from upper part of catheter tube ,cleaning the tube with 70% alcohol. 3.Suprapubic Aspiration infants and patients with injury anaerobic culture Urine volume 10 mL significant pyuria 20 mL mycobacteria or fungi The number of specimens and timing of collection first morning Within 2 hours or add additives Not exceed 24 hours Maintain the original colony count Sodium borate 48h at 25Co preservative inhibit growth of N.F Culture 0.01ml vertical calibrated loop MA , BA & CLED agar Normal constituent of urine : 95% water /others are electrolytes (Na ,K,CL, Mg, Hco3 Abnormal constituent of urine: Protein –indicate destruction of glomeruli Glucose- ////// diabetic Ketones ////// starvation Bilirubin ////// hepatocellular disease RBCs ////// stone , Schistosoma ,bracterial infection Urobilinogen ////// hemolytic disease Galactose //////congenital disease ,lack of enzyme that break down this compound. Specimen Transport Urine is an excellent supportive medium for the growth of most uropathogens Rejection Criteria 24-hour urine specimens Foley catheter tips INTERPRETATION OF RESULTS INTERPRETATION OF RESULTS ❑ Specimens with multiple uropathogens (i.e., three or more) indicate probable contamination. ❑ One or two significant uropathogens present (i.e., 100000 CFU/mL or more) should routinely be identified. Susceptibility tests should be performed for inpatients. ❑ One or two uropathogens present in small numbers (i.e., 102 CFU/mL or more to less than 105 CFU/mL) should be routinely identified if the clinical situation warrants, such as in acute urethral syndrome or cases of previous antibiotic therapy Urine analysis Urine analysis Genital Infections and Sexually Transmitted Diseases Natural defenses in genital tract Synthesis of protective mucus sIgA PH value between 3 8 and 4 5 They support a defense system against infections Normal flora such as 1.Lactobacilli that are the most dominant 2. Coagulase negative staph 3-Corynebacterium spp 4-Streptococcus agalactiae(upto30%)is the normal flora of the female genital tract. *Streptococcus agalactiae causes disease in CNS such as meningitis ,and pneumonia in anew born’s first three months if transmitted from mother. Sexually transmitted diseases (STDs) Routes of infection Intimate person-to-person sexual contact Mother to child during pregnancy and childbirth Through blood products and tissue transfer STIs Exudative /discharge diseases (gonorrhea, chlamydia,vulvovaginitis and vaginosis ), Ulcerative (syphilis, chancroid, genital herpes), and HIV & warts disease (human papillomavirus) Venereal diseases (STDs) Venereal or sexually transmitted diseases are a group of contagious diseases transmitted mainly by sexual contact. Disease Causative organism -Syphilis Treponema pallidum -Gonorrhoea Nisseria gonorrhea -----GU -Chancroid (soft sore) Hemophilus ducreyii -Lymphogranulma Chlamydia trachmatis venereum --Non gonococcal U Chlamydia trachmatis Mycoplasma Trichmonas vaginalis -Herpes in genitalia HHV2 (60%), HHV1 (40%) -AIDS HIV -Venereal warts HPV  Urethritis Acute infection with dysuria and urethral discharge within 2 to 7 days 1. Mechanical injury (catheterization) 2. Chemical irritation (antiseptics) 3. Infectious disease Etiology Neisseria gonorrhoeae gonococcal urethritis (GU) G-ve intracellular diplococci Chlamydia trachomatis nongonococcal urethritis (NGU) Infectious and noninfectious etiologies Ureaplasma urealyticum and Mycoplasma genitalium Trichomonas vaginalis, herpes simplex virus (HSV), and adenovirus Coinfection  Gonorrhea in male (urethritis) Anterior urethritis: Incubation period 1- 4 days Acute: profuse green – yellow purulent urethral discharge leading to staining of under wears. The urinary meatus may be swollen and red. Chronic: Scanty discharge (morning drop). Posterior urethritis: ❑ -Dysuria, frequency & urgency ❑ -Asymptpmatic infection occurs in 5-10 % of cases (gonococcal carriers). Gonorrhea in Female ( URETHRITIS ▪ Gonorrhea affects cervix & present by vaginal mucopurulent discharge 50% of cases are asymptomatic ▪ Less common urethritis => burning micturition, frequency & urgency due to cystitis which occur early due to short urethra. Complication --P.I.D.(Pelvic inflammatory disease ( includes ectopic pregnancy, ovarian cyst rupture, lower abdominal pain, ovarian torsion and endometriosis in female but in male include prostatitis). It use pili to adhesion to epithelial cells Survive for 2 h in the surface Affect both male and female  Non sexual modes (uncommon) 1) Neonatal infection that causes ophthalmia neonatorum in the infant due to infection from his mother during delivery. 2) Childhood infection that causes vulvovaginitis in the female children due to contaminated towels and lavatory seats. Laboratory Diagnosis Purulent urethral discharge Passing a small swab a few centimeters into the urethra WBC > 5/HPF (urethral discharge) WBC > 10/HPF(first-void urine) Positive leukocyte esterase test Culture Gram stain of the lower sensitivity Serology Treatment Azithromycin and doxycycline are effective treatment Vulvovaginitis Symptoms Vaginal discharge, vulvar itching and irritation, and bad odor ,cheesy discharge (crude ) Due to decrease in lactobacilli. Vaginitis caused by trichomonas vaginalis( trichomoniasis ), and by c. albicans (candidiasis) V.vaginitis divided in to : Infectious motility is the diagnostic stage +white greenish discharge +itching Bacterial, fungal, viruses Non-infectious Chemical Bacterial Vaginosis Lactobacillus spp decrease leads to overgrowth of gardnerella vaginalis (normally found in vagina ) C/P –severe itching /excessive discharge /burning during urination /fishy odour pH between 3.8 and 4.5 Laboratory Diagnosis Presence of “clue cells,” which are vaginal squamous epithelial cells coated with G. vaginalis Lack of visible lactobacilli pH > 4.5 fishy odour (can be concentrate this odour by adding one drop of KOH In slide contain sample from v.swab.  Vaginitis by Candida albicans Germ tube Pseudohyphea Bacterial vaginosis Prostatitis Infection of prostate glands Causes of prostatitis : 1- recurrent catheterization 2-////////UTI 3-rectal intercourse 4-STD c/p : Lower abdominal pain ,lower back pain ,rectal pain and pain during intercourse P.S.A is important test done in case of prostatitis (PSA –cancer marker. Genital Ulcerative disease (syphilis, chancroid, and genital herpes) Syphilis :Syphilis is a sexually transmitted disease caused by the bacteria, Treponema pallidum. ( cause hard chancre ) Mode of transmission through : 1. Sexual intercourse 2. infected mother to their fetus (congenital syphilis) 3. Blood transfusion (survive in refrigerator for 24 to 36 hrs ) 4. Contaminated hand of physician & nurses Treponema pallidum. - General characters. Task -Virulence factors. Task Clinical stages of syphilis 1. Primary syphilis The primary stage is marked by the appearance of a single, painless sore, usually in the genital areas but may appear in the mouth (at the site of infection) Single lesion starting as a red papule and eroding into a painless ulcer. common sites include penis, anus, rectum, cervix, perineum, lips, tongue, swollen regional lymph nodes. The lesion heals spontaneously in 1 to 5 weeks 2. Secondary syphilis The secondary stage begins as the primary stage disappears generally Two to eight weeks after the chancre heals, with skin rash on the hands and feet that usually does not itch and clears on its own. ". A fever, sore throat, swollen glands, patchy hair loss Like primary syphilis, the signs & symptoms of secondary syphilis go away on their own 3-Latency syphilis (for many years), or hidden stage, the symptoms listed in 2nd syphili disappear,in this stage but can come back from time to time 4-Tertiary stage infection remains in the body, and It affects the brain and spinal cord can damage the brain, nerves, often causing mental illness and paralysis, It can also affect the heart causing inflammation of the aorta , eyes, blood vessels, liver, bones, and joint. Congenital syphilis : Result either abortion or stillbirth at term Saddle nose ,CNS anomalies , hutchinsons teeth,intrstitial keratitis Diagnossi: -detection of antibodies in clinical samples by -ELISA -PCR -VDRL -detection of bacteria by using dark field microscopy or by using immunofluorescence stain Treatment Tetracyclin ,erythromycin or pencillin G Chancroid chancroid is a sexually transmitted disease caused by the bacteria, haemophilus ducreyii. Gram. negative cocco- bacilli( cause soft chancre ) Symptoms Painful chancre ,bleeding easily Affect both male and female but male more affected than female. Chancroid associated with poor personal hygiene more commonly among men especially in Uncircumcised males but asymptomatic in women Diagnosis: By- ELISA PCR Treatment azithromycin Genital Herpes HERPES is a viral infection of the skin caused by the Herpes Simplex Virus (HSV). Classically, HSV-1 caused a mouth and lip rash while HSV-2 caused the genital herpes. 60% of genital herpes is caused by HSV-2 Herpes simplex virus (HSV), Double-stranded, linear DNA genome encased within an icosahedral capsid. Symptoms of primary genital herpes may include: fever, headache, pain when urinating, and muscle aches. classical rash small red bumps, blisters, or open sores on the penis, vagina lips where the infection occurred. Tender and swollen groin glands (lymph nodes) then develop about a week after the skin rash. The rash and pain usually completely goes away over 3 to 4 weeks.  Most HSV-2 infections, are acquired between the ages of 15 and 29 as a result of sexual activity, including oral sex. Active lesions are the usual source of infection, though asymptomatic carriers can shed HSV-2 through STD. Baby is infected at birth through contact with lesions in the mother’s reproductive tract.( Cesarian is recommended ) Also, mothers with oral lesions can infect their babies if they kiss them. Neonatal herpes infections can be very severe Neonatal herpes: Acquired from infected mother birth canal or their infected hands Cesarean section may be used to avoid infection Latent herpes: Recurrent herpes occurs as a result of ▪ Stress ▪ Immunosuppressed drugs ▪ Microbial infection ▪ Exposure to excessive sunlight or UV Diagnosis ELISA or immuonoflourescence test Treatment Acyclovir is used for all herpatic infections. Genital warts disease Sexual transmitted disease caused by humen papilloma virus ▪ DNA –non enveloped virus ▪ Genital serotype are 16 ,18, 31, 33 and 35 ▪ Affects the external genitalia or anus (condylomata acuminata) sexually transmitted papillomaviruses are strongly associated with cervical cancer.Over 180 subtypes of HPV have been identified Serotype 1 2 4 cause Cutaneous warts of the hands and feet The low risk serotypes 6 or 11 causing genital warts High risk serotypes 31 33 35 42 43 44 45 52 and 58 cause cervical cancer Viruses that cause genital warts invade the skin and mucous membranes of the penis , vagina, and anus during sexual intercourse Mode of transmission : - Direct contact - auto –inoculation - Affect both male and female - Diagnosis : - Serological diagnosis using ELISA &PCR TEST - Pap smear for detection malignant in cervix cells Treatment :Treated by surgical method or use cryosegoury at -196 co (liquid nitrogen ) or cauterization (burning), laser, or the use of corrosive chemicals. Surgical removal of warts and cancerous cells  Chlamydia It is a sexually transmitted infectious disease caused by Chlamydia trachomatis It is gram negative, anaerobic, intracellular obligates that replicate within eukaryotic cells It causes an ocular infection called Trachoma In females cause cervicitis, urethritis, pelvic inflammatory disease, perihepatitis, or proctitis, especially if untreated, increase the risk of infertility and ectopic pregnancy Infants born vaginally to mothers infected cause conjunctivitis and/or pneumonia In men, infection lead to urethritis, prostatitis and proctitis Serotype A,B,Ba,andC: Trachoma(cause blindness) SerotypeD-K:Genital tract infections,neonatal infections SerotypeL1-L3:Lymphogranuloma venereum(LGV),genital ulcer disease.. Diagnosis by serological test