Post on 22-Dec-2015
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• Bacteriuria : bacteria in urine
• Asymptomatic or symptomatic
• Bacteriuria + pyuria= infection
• Bacteriuria NO pyuria = colonization
Complicated VS uncomplicated
• Un complicated UTI:• UTI structurally &
functionally normal urinary tract.
• Female. • Respond to short
course of antibiotic
• Complicated UTI:• Anatomical or
funtional abnormality.• Male.• Longer time to
respond to ttt
• Recurrent UTI:>2 infections in 6 months• 3 UTI in 12 months.• Reinfection by different bacteria.• Persistence : same organism from focus within
the urinary tract.• Struvate stone.• Bacterial prostatitis.• Fistula• Urethral diverticulum.• atrophic infected kidney.
Risk factors to bacteriuria
• Female• Age • Low estrogen
( menopause)• Pregnancy.• D.M• Previous UTI.• FC
• Stone • GU malignancy.• Obstruction.• Voiding dysfunction.• Institutionalized
elderly
Microbiology
Faecal-drived bacteria
Uncomplicated UTI
E.Coli, G-ve baccillus, (85%- 50%)
Staph saprophyticus
Enterococ faecalis
Proteus
Klebsiella.
• Complicated UTI• E.coli 505• Enterococ faecalis.• Staph aureus• Staph epidermidis• Pseudomonas
aeruginosa
Route of infection
• Ascending • Short urethra• Reflux• Impair urteric
peristalisis.• Pregnancy• Obstruction• G-ve , Edotoxins• Organism P pili
Route of infection
• Haematogenous:• Uncommon.• Staph aureus.• Candida fungemia.• T.B
• Lymphatics:• Rarely in
inflammatory bowel disease, reteroperitoneal abscess
Factors increasing bacterial virulence
• Adhesion factors
• Toxins
• Enzyme production.
• Avoidance of host defense mechanisms
Factors increasing bacterial virulence
• Adhesion factors• G-ve bacteria, Pili• Attachment to host
urothelial cells.• Single type or different
types e.x E.coli• Defined functionally be
mediating hemagglutination (HA) of specific erythrocytes
• Mannose –sensitive • (type 1)• Produced by all strains
E.coli
• Certain pathogenic types of E.coli mannose resistant pili
( pyelonephritis)
Factors increasing bacterial virulence
• Avoidance of host defense mechanisms
• E.coli• Extracellular capsule
• Immunogenisity phagocytosis
• M.Tuberculosis reisit phagocytosis by preventing phagolysosome fusion
• Toxins:• E.coli cytokines,
pathogenic effect on host tissues
• Enzyme production:• Proteus ureases• Ammonia struvite
stone formation
Host defences
• Protective • Mechanical (flushing of urine) antegrade flow of
urine• Tamm-Horsfall protein (mucopolysaccharide
coating bladder prevent bacterial attachment)• chemical : Low Urine PH & high osmolality• Urinary Immunoglobulin I gA inhibit adherence
Lower UTI
• Cystitis: infection& inflammation of the bladder
• Frequency, samll volumes, dysuria, urgency, offensive urine SP pain, haematuria, fever & incontinence.
Investigation
• Dipstick of MSU• WBC ( pyuria )• 75 -95% sensitivity
infection• False –ve • False +ve• Other causes of
pyuria
• Nitrite testing:• Bacteriuria.• Specificity >90%• Sensitivity 35- 85%• + test ------- infection• - --------infection
Investigation
• Microscopy :
• Bacteria :
• False –ve low bacterial count
• False +ve contamination (lactobacilli & corynebacteria ) epithelial cells
• RBCs & pyuria
Investigation
Indications for further investigations in LUTI.
• Symptoms of Upper UTI.
• Recurrent UTI.• Pregnancy• Unusal infecting
organism ( proteus suggest infection stone)
• KUB• Ultrasound• IVU• cystoscopy
DD
• Non-infective cystitis:
• radiation cystitis
• Drud cystitis ( cyclophosphamide )
• Haemorrhagic cystitis
• Urethritis
Treatment
• Aim :• Eliminate bacterial
growth from urine.• Empirical ttt before
culture & sensitivity for the most likely organism.
• Adgusted according to the culture & sensitivity.
• Resistance :• Intrinsic (proteus)• Genetically
transferred between bacteria by R plasmids.
Recurrent UTI
• Reinfection ( different bacteria)
• After prolonged interval with adifferent organism
• Reinfection in females• No anatomical nor
functional pathology• In males BOO,
urethral stricture
• Bacterial persistance ( same organism from a focus within tract) within short interval
• Functional or anatomical problem.
• The underlying problem should be treated
Management Reinfection UTI
• Females
• KUB, Ultrasound, cystoscopy
• Simple ReinfectionTTTAvoid spermicidesEstrogen replacement therapyLow dose antibiotic prophylaxisdose antibiotic prophylaxis
Female recurrent reinfection
• Prophylactic antibiotic:• Reduce infection 90% at bed time 6-12
months• Symptomatic reinfection• Trimethoprim• Nitrofurantoin• Cephalexin• Fluoroquinolones
Female recurrent reinfection
• Natural youghart
• Post-intercourse antibiotic prophylactic
• Self-started therapy
Management of bacteria persistance
• Investigations:
• Kub, renal ultrasound.
• C.T, IVU
• Cystoscopy
• Treatment :
• For the functional or anatomical anomaly
Acute pyelonephritis
• Clinical Dx:• Flank pain• Fever.• Elevated WBCs
• DD: • acute cholecystitis.• Pancreatitis.
Acute pyelonephritis
• Risk factors: • VUR• UTO• Spinal cord injury• D.M• Malformation• pregnancy• FC
Acute pyelonephritis
• Pathogenisis :
• Initially patchy
• Inflammatory bands from renal papilla to cortex.
• 80% E.coli, others klebsiella, proteus& pseudomonas.
Acute pyelonephritis
• Urine analysis & culture.
• CBC , U&E
• KUB & ultrasoundif no response with I.V antibiotic for 3 days go for CTU
Pyonephrosis
• Infected hydronephrosis.
• Pus accumulation
• Causes
• Ultrasound. C.T
• Management: PCN, I.V antibiotic, I.V fluids.
Emphysematous pyelonephritis
• Severe form of acute pyelonephritis
• Gas forming organism
• Fever, abdominal pain with radiographic evidence of gas within the kidney.
• D.M
• Urinary obstruction.
• High glucose level-------fermentation,CO2 production
Emphysematous pyelonephritis
• Presentation: sever acute pyelonephritis
• High fever & systemic upset
• E.coli, commonly,
• Klebsiella & proteus less frequent
Management
• Conservative ?
• I.V antibiotic , IVF
• PC drainage
• Control D.M
• Sepsis is poorly controlled
• Nephrectomy
Xanthogranulomatous pyelonephritis
• Severe renal infection
• Renal calculi & obstruction.
• Result in non-functioning kidney
• E.coli & proteus common.
• Macrophage full of fat deposit around the abscess
• Kidney, perinephric fat
Xanthogranulomatous pyelonephritis
• Acute flank pain
• Fever & tender flank mass
• C.T , Ultrasound
• Stone , mass ?? RCC