Urinary Infection in Adults PDF

URINARY INFECTION IN ADULTS Dr. Taner Çamsarı  URINARY INFECTION Copyrights apply  UTI: Definitions Lower UTI: cystitis, urethritis, prostatitis Upper UTI: pyelonephritis, intra-renal abscess,perinephric abscess (usually late complications of pye...

URINARY INFECTION IN ADULTS Dr. Taner Çamsarı  URINARY INFECTION Copyrights apply  UTI: Definitions Lower UTI: cystitis, urethritis, prostatitis Upper UTI: pyelonephritis, intra-renal abscess,perinephric abscess (usually late complications of pyelonephritis) Uncomplicated UTI – Infection in a structurally and neurologically normal urinary tract. Simple cystitis of short (1-5 day) duration Complicated UTI – Infection in a urinary tract with functional or structural abnormalities (ex.indwelling catheters and renal calculi). Cystitis of long duration or hemorrhagic cystitis.  ASYMPTOMATIC BACTERIURIA isolation of a specified quantitative count of bacteria in an appropriately collected urine specimen from an individual without symptoms of urinary tract infection (UTI).  ASYMPTOMATIC BACTERIURIA ≥105 colony-forming units (CFU)/mL  SELECT INDICATIONS TO SCREEN/TREAT Pregnancy Patients undergoing urologic intervention Renal transplant recipients Patients with neurological or structural abnormality of the urinary tract Older patients Diabetes Mellitus  Clinical Symptoms and Presentation Cystitis in the adult: – Dysuria, urinary urgency and frequency, bladder fullness/discomfort – Hemorrhagic cystitis (bloody urine) reported in as many as 10% of cases of UTI in otherwise healthy women Pyelonephritis (upper UTI) in the adult: – Fever, sweating – Nausea, vomiting, flank pain, dysuria – Signs and symptoms of dehydration, hypotension A history of vaginal discharge suggests that vaginitis, cervicitis, or pelvic inflammatory disease is responsible for symptoms of dysuria (pelvic examination) – Important additional information includes a history of prior sexually transmitted disease (STD) and multiple current sexual partners.  Diagnosis of UTI U/A microscopic examination – WBC, RBC – Presence of bacteria Urine dipstick test: rapid screening test – leukocyte esterase test – Nitrate → nitrite test (+ in only 25%) Indications for urine culture – Pyelonephritis – Children, pregnant women – Patients with structural abnormalities of the urinary tract Indications for Evaluating the Urinary Tract Children – Ultrasound, IVP, CT scan Bacteremic pyelonephritis not responding to therapy – Ultrasound, IVP, CT scan Nephrolithiasis or Neurogenic Bladder – Ultrasound, CT, or IVP with post-voiding films Men with 1st or 2nd infection – Careful prostate examination – Ultrasound or IVP with post-voiding films  DIFFERENTIAL DIAGNOSIS Vaginitis Pelvic inflammatory disease Painful bladder syndrome(Interstitial cystitis) persistent pelvic or bladder pain frequency, urgency painfull sex. İntercourse exact cause unknown  Microbial Species Escherichia coli Enterobacteriaceae (such as Klebsiella spp and Proteus spp), Pseudomonas, Enterococci Staphylococci (methicillin-sensitive Staphylococcus aureus [MSSA] and methicillin-resistant S. aureus [MRSA]) Candida spp Microbial Species  Pathogenesis of UTI Hematogenous Route Ascending Route – Colonization of the vaginal introitus – Colonization of the urethra – Entry into the bladder UTI in Women: Factors Predisposing to Infection Short urethra Sexual intercourse & lack of post coital voiding Diaphragm, spermicide use Estrogen deficiency Host Factors Predisposing to Infection Extra-renal obstruction – Posterior urethral valves – Urethral strictures Renal calculi Incomplete bladder emptying Neurogenic bladder Immunocompromised individuals (e.g. DM, transplant recipients) Copyrights apply Copyrights apply Copyrights apply  Antibacterial Host Defenses Urine flow and micturition Urine osmolality and pH Inflammatory response (PMNs, cytokines) Inhibitors of bacterial adherence – Bladder mucopolysaccharides – Secretory immunoglobulin A  UTI: Upper Tract Disease Symptoms suggestive of upper tract disease (pyelonephritis): – Fever (usually greater than 380C), – Nausea, vomiting, and – Pain in the costovertebral areas – Urinary frequency, urgency and dysuria – Renal abscess: patients with urnary tract abnormalities, diabetic patients Evaluation: urine culture, +/- blood cultures, – Imaging if no improvement Microbiology: E.coli, and Citrobacter, Pseudomonas aeruginosa, Enterococci, Staphylococcus spp. Initial therapy: intravenous antibiotics for 10-14 days (perinephric abscess treat longer, +/- drainage)  Treatment: General Principles Quantitative cultures may be unnecessary before treatment of typical cases of acute uncomplicated cystitis. Culture urine in patients with upper UTI, complicated UTI, or with treatment failure. Susceptibility testing is necessary in all recurrent or complicated infections, perhaps not for uncomplicated cases. Identify or correct factors predisposing to infection – Obstruction, calculi – Diabetic patients who are at risk for recurrent infections, pyelonephritis and perinephric abscesses  Recurrent UTI Risk factors for recurrent uncomplicated UTI – P1 blood group positive; postmenopausal status; diabetes – Recent antimicrobial use – Behavioral risk factors (spermicide use, new partner, first UTI 2 symptomatic UTIs within six months or >3 over 12 months Postcoital prophylaxis vs. continuous prophylaxis vs. self-treatment  Empiric Antimicrobials Choice of antimicrobial agents – Primary excretion routes through the urinary tract – Achieve high concentration in urine and vaginal secretions – Inhibit E.coli, the primary pathogen in cystitis Short course (3-day) therapy for uncomplicated infections Longer duration (10-14 days) for complicated infection (e.g. pyelonephritis)  EMPIRIC THERAPY Acute simple cystitis Trimethoprim (with or without sulfamethoxazole). Nitrofurantoin Fosfomycin Ciprofloxacin  EMPIRIC THERAPY Acute simple cystitis Beta-lactam agents – amoxicillin-clavulanate (500 mg twice daily) – cefpodoxime (100 mg twice daily) – cefdinir (300 mg twice daily – cefadroxil (500 mg twice daily) – cephalexin (250 to 500 mg every six hours),  EMPIRIC THERAPY Acute complicated urinary tract infection Ceftriaxone (1 gram IV once daily) Piperacillin – tazobactam (3.375 grams IV every six hours) Fluoroquinolones (ciprofloxacin or levofloxacin) Imipenem 500 mg intravenously [IV] every six hours, Meropenem 1 gram IV every eight hours, or Doripenem 500 mg IV every eight hours) Vancomycin (for MRSA)  Bacterial Virulence Factors-I Enhanced adherence to receptors on uroepithelial cells – Type 1 fimbriae: mediate binding to uroplakins, mannosylated glycoproteins on the surface of bladder uroepithelial cells – P fimbriae: bind to galactose disaccharide on the surface of uroepithelial cells and to P blood group antigen ( D-galactose-Dgalactose residue) on RBCs 97% of women with recurrent pyelo are P1 blood group (+) Higher prevalence of P-fimbriated E.coli in cystitis-causing strains than in strains from asymptomatic persons (60% vs. 10%) Phase variation: – Type 1 fimbriae increase susceptibility to phagocytosis, P-fimbriae block phagocytosis – In strains that cause upper-tract infections: Type 1 down-regulated, Type P upregulated (PAP gene expression triggered by temperature, [glucose], concentration of certain amino acids)  Bacterial Virulence Factors-II Flagella- enhanced motility Production of hemolysin induces pore formation in cell membrane cell lysis (nutrient release) Production of aerobactin (a siderophore) iron acquisition in the iron-poor environment of the urinary tract