urinary tract infection

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1 : 1 Urinary Tract Infection Presented by: Dr Rajiv Gupta
2 : 2 Urinary Tract Infection Urinary tract infection (UTI) is an infection that affects any part of the urinary tract. Mostly Bacterial UTIs can involve urethra prostate bladder kidneys
3 : 3 Overview of UTI by age and sex
4 : 4 Risk factor Abnormality of normal flow of urine Kidney stone Enlarged prostate Vesicoureteral reflex Neurogenic bladder Indwelling urinary catheter Compromised immune function Diabetes Immunosupressive drug
5 : 5 Etiology The most common causes of UTI infections are Escherichia coli Community acquired Nosocomial
6 : 6 Mohammed Akram, Mohammed Shahid and Asad U Khan. Etiology and antibiotic resistance patterns of community-acquired urinary tract infections in J N M C Hospital Aligarh, India. Annals of Clinical Microbiology and antimicrobials 2007, 6:4 doi:10.1186/1476-0711-6-4 E. coli (61%), K. pneumoniae (22%), S. aureus (07%), P. aeruginosa (04%), A. Baumannii (03%)
7 : 7 Hooton TM, stamm WE: diagnosis and treatment of uncomplicated urinary tract infection. Infect Dis Clin North Am 11:551, 1997
8 : 8 Etiology Gram –ve bacillus Staphylococcus saprophyticus accounts for 5 - 15% of UTIs, mostly in younger women E. faecalis- elderly men
9 : 9 Etiology Fungal pathogens Candida Cryptococcus neoformans – commonly seed prostate Viruses Adenovirus 11 and 21 Parasites Trichomonas Schistosoma
10 : 10 Ascending infection Bacteria in perineal area ascends through the urethra, enters the urinary bladder and multiplies This is the most common route of infection e.g. E.coli to the bladder Haematogenous infection <2% In a patient with bacteremia, bacteria may be “seeded” into the kidneys from the blood e.g. staph. aureus Route of infection
11 : 11 Host defenses: antibacterial properties of urine Osmolality (extremes of high or low osmolalities inhibit bacterial growth) High urea concentration High organic acid concentration pH
12 : 12 Host defenses: anti-adherence mechanisms Bacterial interference (naturally endogenous bacteria in the urethra, vagina, and periurethral region) Urinary oligosaccharides (have the potential to detach epithelial-bound E. coli Tamm-Horsfall protein (uromucoid): coating of E. coli by this protein might prevent attachment
13 : 13 Host defenses: anti-adherence mechanisms Normal vaginal flora Maintain acidic environment Interference with adherence Production of H2O2 Urinary oligosaccharides (potential to detach epithelial-bound E. coli Tamm-Horsfall protein (uromucoid): coating of E.coli by this protein might prevent attachment
14 : 14 Local host defense factors that govern host susceptibility in urinary tract infection
15 : 15 Host defenses: miscellaneous Prostatic secretion
16 : 16 Pathogenesis
17 : 17 Pathogenesis of UTI Host defences: Urinary bladder is usually resistant to bacterial colonisation. Bacteria accessing the bladder are eliminated by: - flushing mechanism - urine inhibitors (PH, osmolality, urea) - uroepithelial defences (cytokines,PMNs) - Tamm- Horsfall protien
18 : 18 Pathogenesis of UTI Organism features: Most E.coli causing UTI belong to O, K and H serotypes Uropathogenic E.coli virulence factors: P fimbriae Secrete hemolysin & aerobactin Resist serum bactericidal action Important in pathogenesis of Pyelonephritis Structurally normal
19 : 19 Type I Pilus
20 : 20 Type 1 pilus-mediated bacterial attachment to the bladder epithelium. Mulvey M A et al. PNAS 2000;97:8829-8835 ©2000 by National Academy of Sciences
21 : 21 Clinical Classification Lower UTI Asymptomatic Bacteriuria Cystitis Urethritis Prostatitis Upper UTI Pyelonephritis Uncomplicated / Complicated
22 : 22 Symptoms Symptoms suggesting lower UTI Dysuria Frequency Urgency Suprapubic pain Symptoms suggesting upper UTI Loin pain Fever & rigor Nausea & vomiting Mirco & Macroscopic hematuria
23 : 23 Asymptomatic bacteriuria > than 105 organisms /ml in the urine of apparently healthy asymptomatic patient Common in females & elderly E coli 25% develop symptomatic UTI 25% clear spontaneously Person on increased risk Clinical presentation .
24 : 24 Cystitis Inflammation of the bladder Most common UTI Causes may be : Bacterial Viral Fungal Parasitic Frequency, dysuria, urgency Suprapubic discomfort +/- tenderness Fever is often absent
25 : 25 Urethritis Inflammation of the urethra. Highly associated with sexual activity
26 : 26 In men purulent discharge clear discharge In women up to 80% of infections are with few symptoms or are asymptomatic Clinical feature: Dysuria, frequency, urgency and Suprapubic discomfort
27 : 27 Prostatitis Infection of prostate gland Any bacteria that can cause a urinary tract infection can cause acute bacterial prostatitis, including: Escherichia coli Enterococci Klebsiella pneumonia Proteus mirabilis Pseudomonas aeruginosa Staphylococcus aureus
28 : 28 Prostatitis Almost always bacterial in nature Clinical feature Dysuria Frequency Pain in prostatic, pelvic or perineal area Fever Recurrent cystitis
29 : 29 Pyelonephritis Symptomatic infection of the kidney Two major route ascending route E. coli P. mirabilis K. pneumoniae the hematogenous route S. aureus, Salmonella species, P. aeruginosa Candida
30 : 30 Clinical feature Loin pain Fever with rigors Tenderness over kidneys Nausea Vomiting
31 : 31
32 : 32 Emphysematous Pyelonephritis Production of gas in renal and perinephric tissue
33 : 33 Xanthogranulomatous Pyelonephritis Chronic urinary obstruction together with chronic infection Destruction of renal parenchyma Abscesses E coli & proteus Women (2;1) Usually unilateral
34 : 34
35 : 35 Contd Predisposing factor Calculous, obstructive uropathy & DM (70%) Urology procedure (38%) Presentation Renal pain Recurrent UTI Fever Malaise, anorexia and weight loss
36 : 36 Complicated UTIs Symptomatic episode of cystitis or pyelonephritis in patients with Structurally abnormal Urethral or blader neck obstruction PKD & Foreign body – stone & catheter Functionally abnormal Neurogenic bladder DM Multiple sclerosis
37 : 37 Catheter associated UTI Most common source of nosocomial infection Bacteriuria 10-15% pt with short term Organism E coli Klebsella Staph.aureus, enterococcus & candida Individuals on increase risk
38 : 38 Cont Route – intraluminal & periurethral Formation of Bio-film Clinically – minimal symptoms with or without fever Short term catheter If pt on long term catheterization 7-14 days course of a/b recommended
39 : 39 Prevention of CAUTI Avoid insertion of unnecessary catheters Sterile insertion Maintain downhill, unobstructed flow Use of closed drainage system Care of catheter Prompt removal
40 : 40 Recurrent infections Recurrent UTI’s—culture-confirmed UTI’s * >3 in 1 year or * > 2 in 6 months Relapse is occurrence of bacteruria with same organism < 2 wk of completed therapy Incomplete antibiotic course Antibiotic resistant Failure to eradicate due to renal stones, scars, cystic disease, Uncontrolled DM, Prostatitis Cystocele Re-infection is infection with different bacteria > 2 week of treatment Mostly occurs in Hospitalized patients ,DM
41 : 41 Diagnostic tool History Urine dipstick test, urinalysis and urine cultute
42 : 42 Physical Examination Urine collection 1st morning specimen is best Most concentrated and has acidic pH, in which cell & cast are well preserved Specific gravity Measure of concentrating ability of urine 1.003-1.030 & its depends upon the state of hydration Appearance Freshly voided urine is clear Pus cell & bacteria Alkaline urine ? phosphates ? cloudy Acid urine ? urates ? cloudy
43 : 43 Cont Color Pale yellow to amber (urochrome) Yellow – concentrated urine Deep yellow- bilirubin Red – hematuria, Hemoglobinuria, myoglob Orange- Urobilinogen Red – Porphyria Odor Faint odor Foul smell - bacteria Fishy – UTI with proteus Fruity – ketoacidosis & starvation
44 : 44 Cont pH 4.6 – 8.0 is normal (avg 6.0) Requires fresh sample Acidic urine- ketosis, E coli, high protein diet Alkaline – proteus/pseudomonas, severe vomiting & CRF, citrus fruit
45 : 45 Chemical examination Protein Glucose Ketone Bilirubin & bile salt Urobilinogen Blood Hemoglobin Myoglobin
46 : 46 Chemical Test For Presence of Bacteriuria Nitrite dipstick Rapid indirect test to detect bacteria Common gram –ve organism contain enzymes ? reduces nitrate to nitrites Gram positive and pseudomanas Leukocyte esterase Detect pyuria Esterase is released by leukocytes (WBC’s) in urine 87% specificity & 67% sensitivity Negative dipstick in symptomatic pt ?think other explanation to pt symptom ?consider urine culture
47 : 47 Microscopic Examination ‘‘Liquid Biopsy Of The Urinary Tract’’ Cells RBC Normally 0-1 cells/hpf WBC Pyuria In men >3 In women >5 Eosinophil acute interstitial nephritis sec to drug hypersensitivity
48 : 48 Cont Epithelial cell Squamous epithelial cell Transitional epithelial cell Renal tubular cells- acute tubular necrosis Organism Bacteria Candida Trichomonas vaginalis Egg of schistosoma haematobium Microflaria
49 : 49 Cont Cast Result of damage to the renal tubule Distal tubules and collecting duct Composed of precipitate of Tamm Horsfall protein Non cellular cast Hyaline cast Granular cast- Pyelonephritis Waxy cast Broad cast


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