L2 Urinary Tract Infection PDF

L2 URINARY TRACT INFECTION DR. Foaad Alfertosy bacterial colonisation is confined to the lower end of the urethra and the remainder of the urinary tract is sterile.  The urinary tract can become infected with various bacteria nee but ne the most c...

L2 URINARY TRACT INFECTION DR. Foaad Alfertosy bacterial colonisation is confined to the lower end of the urethra and the remainder of the urinary tract is sterile.  The urinary tract can become infected with various bacteria nee but ne the most common is E. coli derived from the gastrointestinal tract.  presentations of urinary tract infection 1.Asymptomatic bacteriuria 2. Symptomatic acute urethritis and cystitis 3. Acute pyelonephritis 4 Acute prostatitis. 5 Septicaemia (usually Gr-ve bacteria)  In woman more than man Urinary tract infection (UTI) The prevalence of UTI in women is about 3% at the age of 20, increasing by about 1% in each subsequent decade. In males, UTI is uncommon, except in the first year of life and in men over 60, when it may complicate bladder outflow obstruction. In women, the ascent of organisms into the bladder is easier than in men; the urethra is shorter and the absence of bactericidal prostatic secretions may be relevant..  Pathophysiology : urine is an excellent culture medium for bacteria; in addition, the urothelium of susceptible persons may have more receptors, to which virulent strains of E. coli become adherent Risk Factors for UTI 1.Incomplete bladder emptying ; includes a Bladder outflow obstruction( BPH, Prostate cancer, Urethral stricture, Vesico-ureteric reflux) b Uterine prolapsed. c Neurological problems includes ;Multiple sclerosis, Spina bifida, Diabetic neuropathy lead to atonic bladder. 2.Foreign bodies includes; a Urethral catheter or ureteric stent b Urolithiasis 3.Loss of host defences includes; a Atrophic urethritis & vaginitis in post-menopausal women b Diabetes mellitus. C/F of cystitis and 1-urethritis urethritis ( lower UTI ): 2-Cystitis 1 frequent micturition and urgency. 2 scalding pain in the urethra during micturition (dysuria) 3 suprapubic pain during and after voiding. 4 intense desire to pass more urine after micturition, due to spasm of the inflamed bladder wall (strangury) 5 cloudy urine & or unpleasant odor. 6 microscopic or visible haematuria.  Pain of stone is called collicy C/F pyelonephritis or Upper UTI Dol pain and fever presents as a classic triad of loin pain, fever and tenderness over the kidneys. rigors, vomiting, hypotension and loin pain, guarding or tenderness, and may be an indication for hospitalisation. Rarely, acute pyelo- nephritis is associated with papillary necrosis. Fragments of renal papillary tissue are passed per urethra and can be identified histologically. They may cause ureteric obstruction and, if this occurs bilaterally or in a single kidney, it may lead to AKI. challs‫ و ال‬rigar ‫لبفرق بني‬  Predisposing factors include diabetes mellitus, chronic urinary obstruction, analgesic nephropathy and sickle cell disease. A necrotising form of pyelonephritis with gas formation, ‘emphysematous pyelonephritis’, is occasionally seen in patients with diabetes mellitus. Xanthogranulomatous pyelonephritis is a chronic infection that can resemble renal cell cancer. It is usually associated with obstruction, is characterised by accumulation of foamy macrophages and generally requires nephrectomy. Investigation of UTI All patients 1 Dipstick urine estimation of nitrite, leucocyte esterase & glucose. 2 Microscopy: clean-catch MSU for microscopy. Growth of urinary pathogen≥100.000cfu/ml urine (standard method) 3 Urine culture Infants, children, and anyone with fever or complicated infection 1.Full blood count; urea, electrolytes, creatinine 2 Blood cultures Pyelonephritis; males; children; women with recurrent infections 1 Renal tract ultrasound or CT. 2 Pelvic examination in women, rectal examination in men. Continuing haematuria or other suspicion of bladder lesion indication for Cystoscopy. Typical organisms causing UTI in the community include E.coli derived from the gastrointestinal tract (about 75% of infections), Proteus spp., Pseudomonas spp., streptococci and Staphylococcus epidermidis. In hospital, E. coli still predominates, but Klebsiella or streptococci are more common. Management Antibiotics are recommended in all cases of proven UTI. If urine culture has been performed, treatment may be started while awaiting the result. For infection of the lower urinary tract, first choice trimethoprim (between 10& 40% of UTI are resistant to trimethoprim), second choice Nitrofurantoin, quinolone antibiotics such as ciprofloxacin and norfloxacin, and levofloxacin Treatment for 3 days is the normal Penicillins and cephalosporins are safe to use in pregnancy but trimethoprim, sulphonamides, quinolones and tetracyclines should be avoided. For pyelonephritis specially seriously ill patients may require intravenous therapy with a cephalosporin, quinolone or gentamicin for a few days , later switching to an oral agent. Antibiotics should be continued for 7–14 days. Intravenous rehydration( at least 2 L/day) may be needed in severe cases. renal tract ultrasound performed to exclude urinary tract obstruction or a perinephric collection. Asymptomatic bacteriuria This is defined as more than 100.000 organisms/mL in the urine of apparently healthy asymptomatic patients. Approximately 1% of children under the age of one year, 1% of schoolgirls, 0.03% of schoolboys and men, 3% of non pregnant adult women and 5% of pregnant women have asymptomatic bacteriuria. It is increasingly common in those aged over 65. There is no evidence that this condition causes renal scarring in adults who are not pregnant and have a normal urinary tract. However, up to. 30% will develop symptomatic infection within 1 year. Indications of Treatment of a symptomatic bacteriuria are : infants, pregnant women ,D.M and those with urinary tract abnormalities. Persistent or recurrent UTI If the causative organism persists on repeat culture despite treatment, or if there is reinfection with any organism after an interval, In women, recurrent infections are common and investigation is only justified if infections are frequent (three or more per year) or unusually severe. Recurrent UTI, particularly in the presence of an underlying cause, may result in permanent renal damage, If an underlying cause cannot be treated, suppressive antibiotic therapy can be used to prevent recurrence and reduce the risk of septicaemia and renal damage. simple measures may help to prevent recurrence includes Fluid intake of at least 2 L/day Regular complete emptying of bladder Good personal hygiene Emptying of bladder before and after sexual intercourse Cranberry juice may be effective) Catheter-related bacteriuria In patients with a urethral catheter, bacteriuria increases the risk of Gram-negative bacteraemia fivefold. Bacteriuria is common, however, and almost universal during longterm catheterisation. Treatment is usually avoided in asymptomatic patients, as this may promote antibiotic resistance. THANKS