Urinary Tract Infection Cases PDF

NEPHROLOGY URINARY TRACT INFECTION DR. CORTEZ CASES ANTIBACTERIAL HOST DEFENSES IN THE URINARY A 24 y/o female consulted a physician for dysuria and urgency TRACT for 2 days. No vainal discharge. No fever. On PE, no abdomin...

NEPHROLOGY URINARY TRACT INFECTION DR. CORTEZ CASES ANTIBACTERIAL HOST DEFENSES IN THE URINARY A 24 y/o female consulted a physician for dysuria and urgency TRACT for 2 days. No vainal discharge. No fever. On PE, no abdominal 1. URINE tenderness. (-) KPT Osmolality What is the diagnosis? pH=acidic What laboratory exams to be requested? Expected Urea and organic acids findings? 2. URINE FLOW AND MICTURITION Antibiotics? Duration of treatment? 3. URINARY TRACT MUCOSA Bactericidal activity A 28 y/o femle was admitte for hig grade fever started 5 days Cytokine ago as dysuria and urgency. 3 days later develope high grade 4. URINARY INHIBITORS BACTERIAL ADHERENCE fever with chills and vague flank pain. PE: Temp 39.5 C, BP Tamm-Horsfall protein Bladder mucopolysaccharide 110/70, CR 108 beats/min. LMW oligosaccharide What is the diagnosis? Secretory immunoglobulin A What laboratory exams to be requested? Expected Lactoferrin findings? 5. INFLAMMATORY RESPONSE Treatment? PMN Neutrophils Cytokines A 58 y/0 female diabetic n hypertensive was admitted because 6. IMMUNE SYSTEM of 3 days fever. PPE: Conscious but incoherent, febrile, in Humoral Immunity Cardiorespiratory istress BP 80/60, CR 120 beats/min, RR Cell-mediated immunity 28cpm. Vesicular breath sounds, abomen was soft, (-) Miscellaneous tenderness, (+) KPT bilateral. No neuro deficit. o Prostatic secretions What is the diagnosis? o Hormones (maintain normal vaginal What laboratory exams to be requested? flora) Treatment? FACTORS PREDISPOSING TO UTI URINARY TRACT INFECTION Gender and Sexual activity Presence of microorgnism in the kidney and urinary Pregnancy tract Obstruction Occur as a reslt of intraction: Neurogenic Bladder Dysfunction o Bacterial virulence Vesicourethral reflux o Host biologi and behavioral factors ! HOST Urinary tract instrumentation DEFENSE MECHANISM Diabetes Mellitus Immunosuppression BACTERIAL VIRULECE FACTORS: Urinary tract abnormalities 1. ADHESINS/EPITHELIAL CELL RECEPTORS P fimbriae (MR) glycospingolipid globoseries BACTERIAL ETIOLOGY OF URINARY TRACT INFECTION gal-a 1-4 (P blood group antigens) Type I fimbriae (MS) –glucoproteins uroplakin I and II ORGANISM S/F/C fimbrieae (MR) –Sialyl a 2-3 Gram negative galactoside E.Coli 70-95 21-54 Proteus Mirabilis 1-2 1-10 Type I C (MR) Klebsiella Spp 1-2 2-17 G fimbriae (MR) –terminal N acetyl D Citrobacter Spp. /= 10 CFU bacteria/ ml C. ACUTE UNCOMPLICATED PYELONEPHRITIS IN Aymtomatic Individual on 2 consecutive specimen YOUNG WOMEN 5 >/= 10 CFU bacteria/ml D. COMPLICATED URINARY TRACT INFECTION Symptomatic patient Any growth of bacteria in suprapubic tap 1.Obstruction or other structural factor Cathetherized patient Urolitihiasis, malignancies, ureteral 2 >/= 10 CFU bacteria/ml and urethral structures, bladder calculi, renal cyst, fistulae, ileal LABORATORY CRITERIA FOR SIGNIFICANT PYURIA AND conduits and other urinary diversions BACTERURIA 2. Functional Abnormality Neurogenic bladder, vesicoureteral 1. Acute uncomplicated a. >/= 8 pus > 100cfu/ml reflux cystits cells/mm3 >1000cfu/ml 3. Foreign Bodies b. >/= 5 pus cells/ mm3 Indwelling catheter, ureteral stent, 2. Acute uncomplicated >/= 5 pus cells/ >/= 10 000 nephrostomy tube pyelonephritis hpf cfu/ml 4. Other conditions 3. Asymptomatic > 10 pus cells/ >/= 1000 000 Renal failure and transplantation, bacteuria hpf cfu/ml immunosuppression, multi-drug 4. Complicated UTI ------------- >/= 100 000 resistant uropathogens, hospital cfu/ml acquired (nosocomial) infection, (with few prostatitis-related infection, upper exceptions 5. UTI in males a. >/= 10 cells/ >/= 1000 cfu/ml tract infection in an adult other than a mm3 young healthy woman, other b. >/= 5 pus functional or anatomic abnormality of cell/hpf urinary tract E. ASYMPTOMATIC BACTERIURIA INTERPRETATION OF URINE CULTURE AND COLONY COUNT CLINICAL SYNDROMES OF UTI 1. Symptomatic women with pyuria and colony count of 2 2 10 to10 of E.coli, Klebsiella, Proteus or S. ACUTE UNCOMPLICATED CYSTITIS IN WOMEN Saprophyticus of midstream urine Acute onset of: dysuria, frequency, urgency and/or 2. Asymptomatic patient on 2 consecutive urine 5 suprapubic pain or gross hematuria specimens with colony count of 10 or more of single Without symptoms of: vaginal discharge or irritation species/ml pyelonephritis TRANSCOM | TEAM A1 3  NEPHROLOGY URINARY TRACT INFECTION DR. CORTEZ Without risk factors for complicated UTI: Post treatment follow- up: o Hospital acquired pneumonia o Routine post treatment urine culture and urinalysis not o Indwelling urinary catheter recommended in asymptomatic patients o Recent UTI o Patients whose symptoms worsen or not inproved should have urine culture and antimicrobials should be changed. o Recent urinary tract instrumentation in past 2 o Symptoms improved but not completely resolved should weeks extend treatment to 7-day course of same antimicrobial o Functional or anatomic abnormalities of urinary o Symptoms fail to resolve after 7-day treatment should be tract managed like as complicated UTI o Recent antimicrobial use in past 2 weeks o Symptoms for >7 days at presentation ACUTE UNCOMPLICATED PYELONEPHRITIS IN WOMEN o DM Suggested by: o Immunosuppression " fever (> 38C) " chills, nausea, flank pain Laboratory diagnosis: " CVA tenderness " With or without s/sx of lower UTI o Urine cultures are not necessary Mild illness to sepsi syndrome o Presence of significant pyuria: Laboratory findings: " >8 pus cells/mm3 uncentrifuged urine " significant pyuria " >5 pus cells/mm3 centrifuged urine " bacteriuria of > 10,000 cfu/ml " (+) LE and nitrite test " leukocyte casts- specific o Urine microscopy, LE and nitrite test not " leukocytosis prerequisite for treatment Urinalysis, urine gram stain & culture are recommended o Diagnostic test needed in those with unusual Blood cultures are not routinely recommended, unless: combination of symptoms 1. Patient present with sepsis= defined as any of the following Treatment 2. Temperture of > 38C or 90/min 5. Tachypnea RR> 20/min ORAL REGIMEN FOR ACUTE UNCOMPLICATED CYSTITIS 6. Hypotension SBP 40mmHg Drug Dose Interval Comment drop from the baseline (mg) Trimethoprim- 160/800 q12h Widely used in EMPIRIC TREATMENT REGIMENS FOR UNCOMPLICATED Sulfamethoxazole pregnancy, although ACUTE PYELONEPHRITIS not in approved use Trimethoprim 100 q12h Widely used in ANTIBIOTIC & DOSE FREQUENCY & DURATION pregnancy, although ORAL not in approved use Ofloxacin 400mg BID, 14 days Fluoroquinolones Avoid Ciprofloxacin 500mg BID, 7-10 days Ciprofloxacin 100-250 q12h fluroquinolones in Gatifloxacin 400mg OD, 7-10 days Levofloxacin 250 q24h possible pregnancy, Levofloxacin 250mg OD, 7-10 days Ofloxacin 200 q12h nursing mothers Cefixime 400mg OD, 14 days Trovafloxacin 100 q24h Cefuroxime 500mg BID, 14 days Cefpodoxiime 100 q12h Data are sparse Amoxicillin-clavulanate 625mg TID, 14 days (when gram stain shows gram Cefexime 400 q24h Data are sparse positive organisms) Nitrofurantoin Monohydrate/ 100 q12h Used in short PARENTERAL ( GIVEN macrocrystals courses. Avoid in UNTIL PATIENT IS (Macrobid) 50 q6h conditions other than AFEBRILE) Macrocrystals pregnancy with possible occult renal Ceftriaxone 1-2gm Q24h involvement Ciprofloxacin 200-400mg Q12h Levofloxacin 250-500mg Q24h Amoxicillin 250 q8h Used only when Gatifoxacin 400mg Q24h causative pathogen Gentamicin 3-5mg/kg BW (+/- Q24h is known to be ampicillin) susceptible or for Ampi-sulbactam 1.5gm (if with Q6h empiric treatment of gram positive organisms on mild cystitis in gram stain) Q6-8h pregnancy Piperacillin- sulbactam 2.35- Amoxicillin- 500/125 q12h 4.5gm Clavulanate TRANSCOM | TEAM A1 4  NEPHROLOGY URINARY TRACT INFECTION DR. CORTEZ TREATMENT Co-Amoxiclav OUT PATIENT VS. IN-PATIENT Caphalexin st rd Cotrimoxazole (not in 1 & 3 trimester) Indications for admission to hospital: o 7- day course is recommended inability to maintain oral hydration or take medicine o Follow-up culture should be done 1 week after concern about compliance treatment uncertainty about diagnosis Antibiotic must be initiated upon diagnosis of ASB in severe illness with high fever, severe pain, marked pregnancy debility and signs of sepsis # An initial parenteral dose of ceftriaxone may be given DRUGS: followed by oral antibiotics Nitrofurantoin # Duration of treatment is: 14 days Co-Amoxiclav # 7-10 days with selected flouroquinolones Cephalexin Cotrimoxazole (not in 1st and 3rd trimester) Work-up for urologic abnormalities # 7 day course is recommended # follow-up culture should be done 1 week after treatment Not recommended unless o patient remain febrile within 72 hours to rule- out nephrolithiasis, obstruction and perinephric B. ACUTE CYSTITIS IN PREGNANCY abscess characterized by urinary frequency, urgency, dysuria, o recurrence of symptoms and bacteriuria without fever and CVA tenderness. Gross hematuria may be present Post treatment urine culture not routinely done Pretreatment diagnostic test: recommended: Urine C&S of midstream clean catch urine specimen o patient whose symptoms initially points to sepsis In absence of urine C & S – it can be determined by: o patient whose s/sx not improve during treatment o >/= 8 pus cells/ mm3 of unspun urine o >/= 5 pus cells/ mm3 of spun urine Recurrence of symptoms o (+) LE and Nitrite test Re-treatment based on urine culture and sensitivity for 14 days Treatment should be instituted immediately to prevent Assess for underlying genito-urologic abnormality if urine spread of infection to kidney cultures show the same organism as initial infecting Antibiotics that will cover E. coli o TMP-SMX = kernicterus on 3rd trimester organism (re- tretment for 4-6 weeks) o FluOroquinolones o Both are teratogenic URINARY TRACT INFECTION IN PREGNANCY # 7-day course is recommended # post –treatment urine culture should be obtained to A. ASYMPTOMATIC BACTERIURIA confirm eradication of bacteriuria and resolution of Defined as > 100,000 cfu/ml of 1 or more uropathogens infection in pregnant women in 2 consecutive midstreamurine specimens or 1 catheterizd urine specimen in absence of syptoms in C. ACUTE PYELONEPHRITIS IN PREGNANCY pregnant women. All pregnant women must be screened for ASB on their st th th 1 prenatal visit (9-17 week AOG preferably 16 week CHARACTERIZED BY: AOG ) Shaking chills If untreated ASB in pregnancy: Fever 38celcius o Can lead to acute cystitis or pyelonephritis Flank pain, nausea and vomiting o Fetal complications (low birth weight, preterm With or without symptoms of lower UTI delivery) PE findings of CVA tenderness Screening Test: Standard urine culture test of choice Absence of urine culture: TREATMENT: – Gram stain of centrifuged urine - >6 of 12hpf alll pregnant with acute pyelonephritis should be – Urinalysis- >5 wbc/hpf hospitalized Urine dipsticks for LE and / or Nitrite tests or Any antibiotics use for acute uncomplicated PN can be Urinalysis alone - Not recommended screening test used except : Fluoroquinolones Aminoglycosides TREATMENT: In general, patients are hospitalized and given IV Antibiotic treatment must be initiated upon diagnosis of antibiotics until patient is afebrile after which oral ASB in pregnancy antibiotic therapy can be given to complete 10-14 days. DRUGS: Post treatment urine culture should be obtained to Nitrofurantoin confirm resolution of infection TRANSCOM | TEAM A1 5  NEPHROLOGY URINARY TRACT INFECTION DR. CORTEZ Patient should be monitored at intervals until delivery Low dose oral estrogen not recommended for to confirm urine sterility during pregnancy prevention of recurrent UTI Vaccine- insufficient evidence to recommend immuno- RECURRENT UTI IN WOMEN active E. Coli fractions (URO-VAXOM) for prevention Individual episodes of UTI should be treated with Defined as episodes of acute uncomplicated cystitis antibiotics used for acute uncomplicated cystits documented by urine culture occurring >2x a year Breakthrough infections during prophylaxis o initially treated with any antibiotics Prophylaxis for Reucrrent UTI is recommended recommended for acute uncomplicated When frequency of recurrence not acceptable to cystitis other than the one given for patient in terms of level of discomfort or interference prophylaxis urine C & S should be done. with activities of daily living URINARY TRACT INFECTION IN MEN Continous Prophylaxis Daily intake of low-dose antibiotics for ^-12 months A. UNCOMPLICATED CYSTITIS IN YOUNG MEN Post- Coital Prophylaxis Urinary tract infection in male generally considered complicated. Intake of a single dose of antibiotics after sexual st 1 episodes of symptomatic lower UTI in young(15 to intercourse 40y/o) healthy, sexually active without history of structural or functional urologic abnormality is Hormonal Treatment in Post- Menopausal Women considered uncomplicated. Application of intravaginal estriol cream at night for 2 weeks – 2x a week for 8 months Diagnostics: Pyuria INDICATIONS FOR SCREENING UROLOGIC o >/= 10 wbc/mm2 ABNORMALITIES o >/= 5 wbc/hbf Routine screening not recommended unless: o >/= 1000 cfu/ml of urine 1. Gross hematuria during episodes of UTI 2. Obstructive symptom 3. Clinical impression of persistent infection Tests: 4. Infection of urea-splitting bacteria Urinalysis 5. History of pyelonephritis Urine culture – should be done routinely in all men 6. History or symptoms suggestive of urolithiasis with UTI 7. History of childhood UTI # Routine urologic evaluation not recommended 8. Elevated serum creatinine - Combined renal UTZ and plain abdominal x-ray Treatment: 7 days [TMP-SMZ or Fluoroquinolone] PROPHYLAXIS FOR RECURRENT ACUTE UNCOMPLICATED CYSTITIS DRUG DOSE (MG) FREQUENCY THE NIH CONSENSUS CLASSIFICATION OF PROSTATITIS CONTINOUS PROPHYLAXIS CATEGORY CHARACTERISTIC/CLINICAL FEATURES TMP-SMX 40/200 Daily TMP-SMX 40/200 Thrice weekly I. Acute Acute infection of the prostate gland Trimethoprim 100 Daily Bacterial characterized by fever,chills, low back pain Nitrofurantoin 50/ 100 Daily Prostatitis and perineal pain. Irritative voiding Cefaclor 250 Daily symptoms(dysuria,frequency,urgency,noctur Cefalexin 125/250 Daily ia) re characteristic. Rectal examination Norfloxacin ( other 200 Daily reveals a markedly tender, swollen prostate. Fluoroquinolones are likely to be as II. Chronic Recurrent infection of the prostate caused effective) Bacterial by persistence of the same organism POST-COITAL Prostatitis despite treatment. Symptoms are irritative PROPHYLAXIS voiding and pain of varying degrees. Rectal TMP-SMX 40/200 examination reveals no characteristic TMP-SMX 80/400 finding. Trimethoprim 50/ 100 Nitrofurantoin 250 III. Chronic No demonstrable infection; primarily pain Ciprofloxacin 125 Prostatitis/CPP complaints, plus voiding complaints and Norfloxacin 200 S sexual dysfunction affecting men of all ages. Oloxacin 100 Usually cause is unknown. TRANSCOM | TEAM A1 6  NEPHROLOGY URINARY TRACT INFECTION DR. CORTEZ IIIA. Symptomatic patients without bacteriuria but Patients that should be screened and treated: Inflammatory with inflammation(wbc) in semen, expressed o Patients who will undergo GU Manipulation or subtype prostatic secretions(EPS) or post-prostatic Instrumentation st massage. o Post renal transplant up to 1 6 months IIIB. Non- No white cells in semen, EPS or post- o Patients with DM with autonomic neuropathy inflammatory prostatic massage. or azotemia subtype o All pregnant women IV. No subjective symptoms, inflammation o Neutropenic patients Asymptomatic detected either by prostate biopsy or the Inflammatory presence of white cells in EPS, or semen Periodic screening and treatment for ASB not Prostatitis during evaluation of other genitourinary recommended in the following: complaints. o Patients with DM with good glycemic control, no neuropathy or azotemia Treatment: o Elderly patients o Patients with indwelling catheter ACUTE BACTERIAL PROSTATITIS o Immunocompromised patients empiric treatment : o Other solid organ transplant patients o MP-SMX o HIV patients o oral Fluoroquinolones o Spinal cord injury patients modified base on urine C and S o Patients with urological abnormalities duration : 30days seriously ill patients require COMPLICATED UTI hospitalization & parenteral Significant bacteriuria in the setting of functional or antibiotics given: anatomic abnormalities of urinary tract and o aminoglycosides kidneys o Fluoroquinolones Urine gram stain and urine C&S must always be obtained before treatment CHRONIC BACTERIAL PROSTATITIS Initial antibiotics based on what uropathogen is most treatment guided by antimicrobial susceptibility likely the cause. Modification according to results of st 1 lune treatment is Quinolone urine culture and sensitivity. o Ciprofloxacin 500mg BID x 28 days or Duration of treatment : 7 days o Ofloxacin 200mg BID x 28 days or Post treatment urine culture should be done 1-2 o Norfloxacin 400mg BID x 28 days weeks after completion of medication. Alternatives: o Doxycycline 100mg BID x 28 days PATHOGENS IDENTIFIED IN COMPLICATED UTI o Minocycline 100mg BID x 28 days o Trimethoprim 200mg BID x 28 days Pathogens o TMP-SMX 160/800 mg BID x 28 days Catheter-associated E coli, P aeruginosa Men with recalcitrant chronic bacterial prostatitis can UTI Proteus mirabilis, enterbacter be treated with: TURP or total prostatectomy. Usually polymicrobial Symptomatic relief: Short term (1week) Providencia stuartii, Morganella o Anti-inflammatory agents morgagni o Prostatic Massage Citrobacter Long term, low dose suppressive therapy maybe Enterococcus, candida sp. required for patients who do not respond to full dose Anatomic E. Coli, Klebsiella pneumonia(37%), treatment. Abnormalities P. aeruginosa, Proteus mirabilis TMP-SMX 80/400mg OD is recommended 4 to 6 UTI in Diabetes E. Coli, Klebsiella pneumonia(37%), weeks. P. aeruginosa, Proteus mirabilis, Enterobacter, Enterococcus, Candida CHRONIC PROSTATITIS/ CPPS Renal Transplant E. coli (29-61%), Klebsiella Not recommended : antibiotics & alpha-adrenergic Recipients pneumonia & Proteus mirabilis (30%) blockers Gm(+) cocci(20%) Heat treatment maybe useful to relieve CPPS Enterobacter, Enterococcus, Serratia, o microwave thermotherapy Actinobacter, Citrobacter, P. Allopurinol for non bacterial prostatitis not aeruginosa recommended Neutropenic Patients Gram (-) bacilli esp. P. aeruginosa, staph. Aureus, candida ASYMPTOMATIC BACTEURIA IN ADULTS UTI in AIDS E. Coli, Enterobacter, Klebsiella pneumonia, P. aeruginosa, Presence of : Enterococcus, S. aureus, CMV, o 1 or more uropathogens adenovirus, toxoplasma, o >100,000 cfu/ml in 2 consecutive midstream pneumocystis carinii, blastomycoses or 1 catheterized urine specimen dermatidis, m. Tuberculosis o Absence of S/Sx attributable to UT TRANSCOM | TEAM A1 7  NEPHROLOGY URINARY TRACT INFECTION DR. CORTEZ CATHETER-ASSOCIATED UTI Urinalysis: pyuria or normal and little objective - 10-15% of hospitalized patient with catheter evidence of infection. - Risk of UTI is 3-5% day of catheterization Rule out STD - E. Coli, Pseudomonas, Proteus, Klebsiella, Serratia – Usually transient/ may subside without specific marked antimicrobial resistance therapy. - 2 routes : intraluminal and intrauretheral - Minimal symptoms - Gram (-) bacteremia 1-2% of cases URINARY TUBERCULOSIS (RENAL TB) - Most common source (30%) of gram (-) bacteremia $ May remain clinically silent for years while irreversible in hospitalized patients renal destruction takes place. $ Hematogenous seeding during Primary TB or late PREVENTION OF CATHETER-ASSOCIATED UTI reactivation and miliary disease. 1). Hand washing should be done before and after catheter $ Active lesions in the kidney may not become manifest care. clinically for many years -> there is a little evidence of 2). Limit catheter use to carefully selected patients. Avoid active pulmonary disease. unnecessary catheter use. Appropriate indications: For accurate and frequent measurement of urine output in critically ill patient To aid in urologic surgery or other surgery of contiguous structures. To relieve anatomic or functional UTO drainage. When urinary incontinence is present without obstruction in patient with sacral or perineal wound. Just before, during or just after prolonged surgical procedures with general or spinal anesthesia. 3). Catheters should be inserted using aseptic technique and sterile equipment. 4). Maintain sterile, closed catheter system at all times. 5). Urine specimen should be obtained aseptically without CLINICAL FEATURES OF URINARY TUBERCULOSIS opening the catheter collection junction. 6). Maintain unobstructed and adequate urine flow at all times. Asymptomatic 25 Detected during 7). Remove catheter as soon as possible. Incidence of autopsy, surgery or developing infection is 3-6% per day. during 8). Do not change catheter and drainage bags at arbitrary fixed investigations for interval. other diseases Asymptomatic 25 Persistent pyuria, Indications for change: urinary microscopic Malfunction or leakage abnormalities hematuria Catheter obstruction Lower UTI 80 Frequency, Contamination symptoms urgency, dysuria, Bacteriuria that require antibiotics (most common) incontinence, Concretions in catheter lumen that may proceed to its nocturia, suprapubic obstruction pain, perineal pain Candiduria Male genital 75 Epididymitis, tract hemospermia, 9). Daily meatal care is not recommended. involvement infertility, reduced 10). Irrigation of bladder with antimicrobial agents is not semen volume recommended. Female genital