4 urinary tract infection

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URINARY TRACT INFECTION

Transcript of 4 urinary tract infection

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URINARY TRACT

INFECTION

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DefinitionsUTI : Inflammatory response of urothelium to

bacterial invasion associated with bacteriuria &

Pyuria.Bacteriuria: Presence of bacteria in urine

which is normally free of bacteria.It may be due to contamination.Pyuria: Presence of WBCs in urine.Bacteriuria without pyuria: Colonization with no infection.Pyuria without bacteriuria: T.B, stones, cancer.

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Uncomplicated UTI: Inf. in normal U.T both structurally & functionally.

Complicated UTI: U.T is functionally or structurallyabnormal, host is compromised, increased virule-nce of bacteria (pregnancy, elderly, DM, instrume-ntation).First or isolated: Never had inf. before or since along time.Unresolved inf.: not responded to antimicrobials.Recurrent inf.: occur after successful resolution of

inf.

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Incidence & Epidemiology-UTIs are the most common bacterial inf.-1.2% of office visits by females & 0.6%

by males.-50% of females will experience UTI

during life.-Once a pt. has inf., is likely to develop

subseque- nt infections.

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Pathogenesis:Routes of infection:1-Ascending route:-Bowel reservoir----urethra----bladder e.g: perineum soiled with faeces. indwelling catheter-Cystitis may ascend to kidney by VUR.2-Haematogenous route:-Renal infection with staph. From a septic focus.3-Lymphatic route:-Not common.-From adjacent organs (severe bowel inf. – RP

abscess).

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Urinary Pathogens:E. Coli : 85% of community acquired 50% of hospital acquiredProteus, klebsiella, gm +ve (E. faecalis):

remain.Bacterial adherence:Bacterial adhesins:-UP expresses a number of adhesins that

allow it to attach to U.T tissues.

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Natural defenses of U.T:1- Periurethral & urethral region: Normal flora of introitus & urethra contain orga- nisms as lactobacilli & streptococci forming a barrier against UP. - Flow of urine.2- Urine: - Organisms normally colonizing the urethra do not multiply in urine. - Bacterial growth is inh. by dilute urine or high or

high osmolality assoc. with low Ph. - Tamm-Horsfall ptn. (1000ng/ml) block bacterial binding to urothelial receptors.3- bladder emptying.4- General immunity.

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Diagnosis -Urine & U.T are normally free of bacteria

& infl. Urine collection:-Mid stream.-How to collect ? voided or catheterized Suprapubic aspiration: highly accurate, useful in newborn pts who can not void-Non circumcised: prepuce retracted, glans

washed-In females: spread labia, wash introitus, mid str.

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Urine analysis:5-10 ml centrifuged for 5 min. at 2000 rpm.Bacteriuria found in 90% of infs. with counts >100000 CFU/ml.2 WBCs/HPF in centrifuged specimen= 10 in anunspined specimen & both correlates with bacte-ruria.Imaging techniques:-Not required in most cases.-Indications: fever- failure to respond to treatment recurrent infs.- D.M- history of stones or surgery.-Plain, IVU, VCUG, U/S, CT.

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Principles of antimicrobial treatment:

-Efficacy is dependent on drug level in urine &

duration this level remains above MIC of inf. organism.

-Concentration in blood is not important as in urine, except in septicemia or bacterimia.

-Patients with renal failure:Dose modification are necessary for drug

cleared only by kidneys.Conc. power is impaired ---difficult

eradication of infection.

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Bladder infectionsUncomplicated cystitis:-Most caes in females.-25% between 20-40 yrs.Risk factors:-Weak urine flow.-Promote colonization: sexual activity.-Facilitate ascent: catheter, fecal incontinence.Clinical presentation:-Dysuria, frequency, urgency, S.P pain.-Haematuria, foul smelling urine.-Fever & chills usually absent (superficial mucosal

infection).Causative organism: E. coli 80-90%

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Lab diagnosis:-urine analysis: pyuria, bacteriuria, hematuria.-urine culture: often not necessary.Treatment:-TMP-SMX, quinolones, floroquinolones-Duration: 3 days.Complicated cystitis:-Occur in compromised U.T or by resistant

org.-mild cystitis----life threatening renal inf. &

urosepsis.-Urine culture is mandatory.-treatment of cause.

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Kidney InfectionsAcute Pyelonephritis:-Inflammation of both renal parenchyma &

pelvis.Causative organism:-E. coli (80%), proteus, klebsiella, pseudomonas-Rarely, gm +ve.Pathology:-Renal enlargement, capsule strips easily, small yellowish white cortical abscesses with parench- ymal hyperemia.-Glomeruli usually spared, neutrophil infiltrate.

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Clinical picture:-Chills, fever (100F or >), flank pain.-LUTS (dysuria, urgency, frequency).-GIT symptoms.Lab diagnosis:-CBC: leucocytosis with predominance of

neutrophils, inc.ESR & C- reactive ptn.U.A: WBCs in clumps, bacterial rods. WBC casts Specific casts (bacteria in ptn matrix).U.C:Blood culture:

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Radiology:IVU: renal enlargement (1.5 cm greater in

length). focal “ (focal bacterial nephritis) disappear with treatment. calyceal & ureteral dilatation (endotoxins)U/S & CT: to diagnose complicated PN to reevaluate pts not responding

after 72 hours treatment.Treatment: Antibiotics for 7 days. Bed rest – antipyretics. Hospitalize or not ?

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Emphysematous PN:-Acute necrotising parenchymal & perirenal infn. caused by gas forming UP.-Organism cause fermentation of glucose ----CO2.-However, not common in diabetics. Should be considered compl. of severe PN.-Mortality rate 20-40%Causative organism:-E. coli (commonest), klebsiella, proteus.Clinical picture:-Triad of fever, vomiting, flank pain.-Pneumaturia, when infn. involves collecting

system.

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Imaging:-Plain KUB: crescentic gas shaddow (in

renal space) & loculated “ “ (in parench.)

-IVU: rare of value (NF or poorly functioning K.)

U/S: gas.CT: procedure of choice.Treatment: surgical emergency-Fluid resuscitation & broad spectrum

antibiotics.-Nephrectomy if no improvement after

few days. Can be deferred if condition improved.

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Renal Abscess:-Collection of purulent material confined to renal parenchyma.-Usually due to VUR in an obstructed kidney.-Causative organism: g +Ve or –Ve.Clinical picture:-Triad------cystitis-History of g +Ve source of inf.(1-8 weeks) before onset of symptoms. e.g: skin carbuncle.Lab diagnosis:-Leucocytosis, pyuria, bacteriuria (if communicat).-Urine culture: no or different organism (bld

borne).

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Radiology:-Renal enlargement & distortion of renal contour.-Renal fixation on insp. & exp. films.-Obliteration of psoas shadow & scoliosis.-CT is the procedure of choice Renal enlargement & area of low attenuation. Thickening of perinephric fascia.Treatment:-PC or open drainage (DD. Renal tumor).-I.V antibiotics & observation, if <3cm.-----good

response.-Follow up with U/S or CT till complete resolution.

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Infected Hydronephrosis & Pyonephrosis:Infected HN: bacterial inf. in a hydronephrotic k.Pyonephrosis:inf. HN associated with suppuration of renal parenchyma----partial or total loss of

renal function.Differentiation not always easy.Clinical picture:-Triad.-Bacteria may not be present if ureter completely obstructed.Radiology: internal ecchoes in dilated P.C

system.Treatment: drainage &antibiotics.

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Perinephric abscess:Etiology:-Rupture of a cortical abscess into perinephric sp.-Infected perirenal hematoma or urinoma.-Spread of osteomyelitis from T.B lumbar spine.When it rupture through renal fascia ---paraneph.abscess.Clinical picture: insidious onset, 1/3 afebrile. Local signs of infl. (hotness, redness, oedema, loin mass may be pointing) No response to antibiotics.

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Radiology:-Absent psoas shaddow, elevated or

immobile diaphram.-U/S & CT: ecchogenic collection.Treatment:-Surgical drainage (if large)-PC “ (if small)

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PROSTATITISEtiology:1- G –Ve: E. coli (80%), kleb.,

pseudomonas,….2- G +Ve: staph aureus (5-10%)3- Chlamydia & U. urealyticum: minor

role.Risk factors:1- Intra-prostatic ductal reflux.2- Immunologic alteration inside

prostate.3- Acute epididymitis, indwelling

catheter, TURP especially with infected urine.

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Pathology:-Increase no. of infl. cells within parenchyma.-Lymphocytic infil. in stroma adjacent to acini (most common pattern).-Corpora amylacea (deposition of pr. secretion around a sloughed epithelial cell) may obstruct pr. gland.Classification: “Traditional classification system”Type s. of UTI bacteria infl. cells

1-ABP: severe + +2-CBP: mild + + 3-NBP: ----- - +4-Prostatodynia: ----- - -

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Clinical picture:1- ABP: fever, severe irritative &

obstructive C/O. 5%------- CBP2- CBP: asymptomatic irritative & obstructive C/O3- NBP: pain (predominant C/O) in

perineum,S.P, penis, testis, low back.4- Prostatodynia: painful ejaculation

(50%) symptoms tend to wane & wax

over time 1/3 improve over one year.

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Diagnosis:1- Physical examination: -Important but not helpful for diagnosis or

classificat ABP: prostate is hot, boggy, very tender Other types: prostate is normal.2- Cytology & culture: - Stamey 4 glass urine collectionTreatment:1- Antibiotics: for ABP & CBP.2- Alpha adr. blockers: for NBP & prostatodynia with poor relaxation of B.N -----increase ur. flow & decrease IPR.

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3- Anti-inflammatory: NSAIDs- cortisone.4- Ms. relaxants: NBP & prostatodynia may be due to smooth

& skeletal ms dysregulation of pelvis & perineum.5- Phytotherapy: Some plant extracts show 5 alpha-

reductase activity, alpha blocker, anti- inflammatory.6- Allopurinol: IPR---inc. metabolites containing purine &

pyrimidine in pr. ducts-----inflammation.

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Orchitis:Definition:-Inflammation of testis, & also describe testicular pain without evidence of infl.Etiology:-Isolated orchitis is relatively rare & usually viral due to blood spread.-Orchitis of bacterial origin usually occur due tolocal spread from ipsi. epididymis (E. coli, pseud.,Staph, strept.,N. gonorrhea).Presentation:-Pain- fever- nausea & vomiting- tenderness-

secondary hydrocele.

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Diagnosis:Urine analysis- urethral swabU/S: to rule out malignancy & torsionTreatment: Rest- scrotal support- hydration-

antipyretics- AI Antibiotics.Chronic orchitis:-Inflammation & pain in testis, without

swelling for >6 weeks.-Self limited & may take years to resolve.

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Epididymitis:-Acute : sudden pain, infl., swelling.-Chronic: pain & infl. with no swelling >6 weeks. may be due to inadequate treatment.-Spread from bladder, urethra & prostate.-Starts in tail-----body-----head.-Testis is involved in most cases-----epididymo-

orchitis.Treatment:-antibiotics for 4-6 weeks.-Chronic: self-limiting taking long duration.-Epididymectomy: with treatment failure & to curepain.

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Tuberculosis (T.B)-Always considered in a pt. with vague

long standing urinary C/O with no obvious

cause.-Age: 20-40 yrs, uncommon in children.When to suspect? -Following presentation without obvious

etiology. Frequency—recurrent cystitis not

responding to treatment---gross or microscopic

hematuria--- sterile pyuria.

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T.B of kidney:-Organism settle in blood v. close to glomeruli.-Caseating granulomas develop & consist of giant cells (Langhans) surrounded by lymphocytes & fibroblasts.-Caseous material open through calyces---cavities of moth-eaten appearance.-Course depends on virulence & resistance.-If pathology progress + obst.---autonephrectomy.-If healing occur---fibrosis & calcification---stricture in calyces or PUJ.-Mycobacterium may remain viable in calcific

lesions.

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T.B of ureter:-T.B ureteritis---fibrosis---str. usually at

UVJ-Whole ureter may be affected---multiple

levels ureteric str.T.B of bladder:-Starts around U.O---infl. & edema---T.B

granuloma-T.B ulcers is rare, occasionally whole

bladder is covered by infl. velvety granulation---

bladder fibr- osis & contraction---golf-hole U.O---VUR.

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T.B of epididymis & testis:-Painful & infl. scrotal swelling. D.D:

ep.orchitis.-Globus minor affected alone in 40%.-Testicular affection without ep. is very

rare.-Scrotal sinus.T.B of penis----superficial glanular ulcer.

D.D:Tr.T.B of urethra ---urethral stricture.

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Diagnosis:1-Tuberculin test: -M.T.B complex (M.T.B—M. bovis—M.

microti—M. africanum).-Intradermal inj. of a PPD of tuberculin.-Infl. condition reaching max.between

48-72 hrs.-Central indurated zone surrounded by

erythema.-+Ve reaction =inf., but not indication of

active T.B or C/O due to T.B.2-Urine examination:-Sterile pyuria-2ry inf.(20%)-

microhematuria(50%)

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3-Urine culture:-Lowenstein-Jensen.-Takes 6-8 weeks (slowly growing).-3-5 consequetive early morning samples (org. is intermittently excreted).4-Imaging:-Plain KUB:-Calcification in kidney, ureter, bladder, seminal vesicle.-Plain chest & spine.-IVU:-Fibrosed & occluded calyx (lost calyx).-Moth-eaten cavities, HUN, contracted bladder.

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TreatmentFirst line drugs:1-Isoniazid (INH): hepatotoxicity,

peripheral neuritis. 5 mg/kg maximum 300 mg2-Rifampicin: hepatotoxicity 10 mg/kg max. 600 mg3-Pyrazinamide: hepatotoxicity 20-25 mg/kg4-Streptomycin: ototoxicity5-Ethambutol: retrobulbar neuritis 15-25 mg/kg

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Cornerstone is multidrug treatment to decreaseduration of treatment & drug resistant developm-ent.Second line drugs: -kanamycin—amikacin—ciprofloxacin……Guidelines:-Short course 6 months regimen.-All drugs given in a single dose.-Followup with urine culture at 3, 6, 12 months after treatment finished.Surgery: delayed until medical treatment

adminis- tered for 4-6 weeks.

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Parasitic diseasesUrinary schistosomiasis:Caused by S. haematobium.Pathology & pathogenesis:-Worms in pelvic v. plexus----eggs in lower UT.-Granulomas formed in response to egg Ag------ large,bulky, hyperemic polypoid masses. As egg laying ceases, eggs are destroyed or calcified & infl. wanes & replaced by f.t. (inactive form). Acute& chronic bladder ulcers-Obstructive uropathy occur due to chronic dis. Usually bilateral asymmetrical (JV & lower ureter)-Bladder cancer is a sequalae:early, sq.c.c (60-

90%).

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Presentation:Acute:” Katayama fever” -fever, lymphadenopathy, splenomegaly, urticaria -occur 3-9 weeks after inf. -terminal hematuria & dysuria.Chronic:-HUN—contracted bladderDiagnosis:1-Presence of eggs with terminal spikes is diagn- ostic of & only possible during active inf.2-Serologic tests: do not diff. between acute & ch inf.3-Plain & IVU.

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Treatment:Medical:Praziquentel: drug of choicecure rate 80-100%dose:2 oral doses of 40mg/kg in 24 hrsNo serious side effects.Surgical: nephrectomy—ureteric

implantation

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FilariasisLymphatic filariasis:-Causative organism: W. bancrofti-Cycle proceeds from human---mosquito---human.-Acute lymphatic infiltration----fever, lymphangitis

& lymphadenitis---chronic lymphatic obstruction & dilation----hydrocele, elephantiasis of limbs & chyluria.-Diagnosis: C.p & Giemsa stain for blood.-Treatment: Diethylcarbamazine (DEC), ivermectin,

albendazole.

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Nonlymphatic Filariasis:-Transmitted by black flies (Simulum species).-Adult worms inhibit S.C tissues----f. nodules in

which it is encapsulated.-Microfilaria travel through dermis & eye

----------blindness.-Diagnosis: Microscopic exam. of skin snips under normal

saline or Giemsa stain.Treatment:-Ivermectin. DEC not used due to severe

allergicimmune response to microfilaria dying in skin.