Urinary Tract Infections: Diagnosis, Treatment & Prevention

Gloria Rebecca Jové MD, MPH & TM,FACP Infectious Diseases I Course MIC 643 Microbiology Division [email protected] SCHOOL OF BEHAVIORAL AND BRAIN SCIENCES Revised 2023  Learning Obj...

Gloria Rebecca Jové MD, MPH & TM,FACP Infectious Diseases I Course MIC 643 Microbiology Division [email protected] SCHOOL OF BEHAVIORAL AND BRAIN SCIENCES Revised 2023  Learning Objectives Describe Describe the most common etiologic agents of UTI. Discuss Discuss the pathogenesis of Upper and Lower UTI. Recognize the clinical manifestations of cystitis, pyelonephritis and Recognize complications of those cases. Recognize the clinical differences of UTI in special populations of patients : Recognize DM, Pregnancy, Transplant patients, etc. Name Name the diagnostic methods use for UTI. Recognize Recognize the treatment modalities for cases of UTI.  UTI is the most common bacterial infection encountered in the ambulatory care setting in the U.S. Up to 60% of women have symptomatic UTIs during their lifespan, and 10% of women have UTIs each year.  Self Assessment 1 A 45-year-old woman presents to the ER with intense right flank pain, fever and a burning sensation in the urine. Abd/pelvic CT scan showed right nephrolithiasis. A urine culture was taken and plated on MacConkey agar. Gram-negative rods that did not ferment lactose were identified. Which virulence factor of the causal agent is most important to pathogenesis of this illness? A) Coagulase + B) Production of Urease C) Exotoxin release D) Catalase + E) Presence of Capsule MacConkey BA-swarming  Terminology Significant Bacteriuria : 105 cfu/ml 2100 000 coloniamL , Asymptomatic Bacteriuria 2100 colonias pero asintomatico , 000 Cystitis vs Urethritis Acute Pyelonephritis Complicated vs Uncomplicated UTI Intrarenal and perinephric abscess In: Mandell GL, Bennett JE, Dolin R (eds). Principles and Practices of Infectious Disease. Philadelphia, PA: Churchill Livingstone.  Recurrent UTI ACP Board Prep Curriculum  Complicated Cystitis Defined by any one of the following: Pregnancy Male sex Recent abx exposure Healthcare –acquired Uninary catheter Immunosuppression ( Including DM) CKD, neurogenic bladder, urinary obstruction  Pathogenesis Ascending Route (95%): Colonization Colon Vaginal Uretral Perirectal · muchas veces de aquivienen las bacterias Vestibule Hematogenous Route ( 105 bacteria / ml 1,2 100 000 colonias/mL , Adequate methods for urine collection: 1.Midstream clean catch 2.Catheterization 3.Suprapubic aspiration UTI is most common source of GNR bacteremia Bacteremia in 60% of elderly males with pyelonephritis. 1 Rubin UH, shapiro ED. CID 1992;15:S216-27. 2 Hooton TM. Infect Dis Clin N Amer 2003;17:303-332. Proteus spp Micro Lab  Diagnosis Radiologic Non-contrast CT scan B-mode Ultasonography Plain Abdominal XR Radiopaedia.org  Treatment Uncomplicated Cystitis Pyelonephritis First Line: FQ or Ceftriaxone, TMP/SMX FForoquinoearazadas IV antibiotics Persona que llega solo con la queja de "ardor al orinar" · Avoid FQ in Pregnancy. Treat Pyelo for 10-14 days  Risk factors for multidrug-resistant gram- negative urinary tract infections A previous MDRO urinary isolate In-patient stay at a health care facility (eg., hospital, nursing home, long-term acute care facility) Use of a fluoroquinolone, trimethoprim-sulfamethoxazole, or broad-spectrum beta-lactam (eg., third or later generation cephalosporin) Travel to parts of the world with high rates of multidrug-resistant * organisms *India, Mexico, Israel, Spain  Self Assessment A 22-year-old woman presents to her family physician with a second episode consistent with acute cystitis in the past 6 months. The previous episode responded promptly to empirical short-term antimicrobial therapy. She is sexually active in a stable monogamous relationship. What advice should she be given with respect to behavioral modification to decrease her risk of subsequent recurrent infection? A. Use oral contraceptives high in estrogen levels. B. Discontinue use of spermicide birth control method. C. After bowel movements, she should wipe herself from front to back. D. Increase her intake of cranberry juice. E. Use showers rather than baths for personal hygiene Prevention of UTI Post-Menopausal women: intravaginal estrogen lo unico que esta demostrado que disminuye UTI : risk. Cranberry Juice (>4L) ??? Probiotics, Lactobacillus acidophilus ??? Avoid spermicides ??? Chronic Abx suppression ??? Post-coital voiding Mear despues de chingar :  Who should be treated in Asymptomatic Bacteriuria Pregnant female Traumatic Urologic procedure : Transurethral prostatectomy, percutaneous lithotomy, etc.  UTI Complicating Pregnancy Asymptomatic bacteriuria : 5-10 % ↑progesterona disminuye el tono muscular de (If untreated 20-30% develop pyelonephritis) la vejiga Recurrent asymptomatic bacteriuria Cystitis : 0.3-1.3% Pyelonephritis : 1-2 % (Millar LK, Cox SM et al.Infec Dis Clinic North Amer 1997;11:13-26)  Pathogenesis of UTI during Pregnancy Dilatation of ureters and renal pelvis Decreased ureteral peristalsis Pregnancy-induced glucosuria and aminoaciduria Reduced bladder tone gracias aprogesterona (Millar LK, Cox SM et al.Infec Dis Clinic North Amer 1997;11:13-26) Complications in Pregnancy Respiratory insufficiency Sepsis syndrome Renal dysfunction Anemia (Hemolysis) Preterm birth and low birth weight 1 Millar LK, Cox SM et al. Infec Dis Clinic North Amer 1997;11:13-26 2 Polivka BJ et al. J Obstet Gynecol Neonatal Nurs 1997;26:405-13 Clinical Presentations of UTI in Diabetics Acute pyelonephritis : -Fivefold higher rate than non-diabetics -Bilateral involvement -15-20% positive blood cultures - More common in women  Clinical Presentations of UTI in Diabetics Complicated UTI : 1. Renal cortical abscess 2. Xanthogranulomatous pyelonephritis 3. Emphysematous cystitis: pneumaturia 4. Perinephric abscess 5. Fungal infection 6. Resistant organism (Patterson et al. Infect Dis Clin North Amer 1995;9:25.) Emphysematous pyelonephritis : Aire dentro del rinon  Renal Abscess 69-year-old alcoholic male with Klebsiella pneumoniae bacteremia and renal abscess. Hospital de la Concepcion 2011 Xanthogranulomatous Pyelonephritis Diffuse parenchymal destruction Predisposing factors : obstruction (staghorn calculi) and infections E.coli and Proteus spp Adults > 40 yrs Males > females Unilateral Dx: Ct scan or biopsy Treatment : nephrectomy  Self Assessment 3 Four weeks after his arrival from Africa, a 24-year-old graduate student presents with blood in his urine. Microscopic examination of his urine reveals the presence of eggs with terminal spines. In the interview he admits that he has been working on his family's rice field occasionally since his early childhood. The most likely etiologic agent of his complaint is: A) Schistosoma haematobium B) Fasciolopsis buski C) Schistosoma mansoni D) Entamoeba histolytica E) Schistosoma japonicum  # Key points UPEC virulence factors increased risk of UTI Structural , genetic and behavioral factors increased risk of UTI Tx ASB: Pregnancy and GU procedures ASB asymptomatic = bacteremia Tx cystitis short term vs Pyelo 14 d Intravaginal estrogen for Post-menopausal females www.psm.edu ü Library ü Athens ü Clinical Key ü Search: Mandell , Principles and Practice of Infectious Diseases