2. Today’s Goals
Be able to define the various types of UTIs
Describe the classic signs of pyelonephritis
Be able to determine if a urine culture is positive
Know the types of imaging needed and who needs
imaging
Explain why we care so much about early diagnosis and
prompt treatment
Friday, October 18, 2013
3. Definitions
UTI—inflammatory response of the urothelium to
bacterial invasion.
Uncomplicated—Healthy patient with normal urinary
tract.
Complicated—compromised patient or one with a
functional or structural abnormality.
Recurrent
– Reinfection—infection from different bacteria outside the urinary
tract.
– Persistent—focus from within the urinary tract that is never
eradicated.
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4. Bacteriuria: the presence of bacteria in the urine
Significant bacteriuria: 105 organism or more per milliliter
Pyuria: the presence of white blood cells in urine
Pyuria with 5 or more cells per microscopic
high-power field: reliable indicator of UTI
The absence of such pyuria does not reliably
exclude UTI
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6. The normal urinary tract is sterile
for many reasons:
Eradication of bacteria by urinary and mucous
flow:
secretory peptides target cytoplasm of
bacteria
Urothelial bactericidal activity
Urinary secretory IgA
Blood group antigens in secretion alter
bacterial adhesion
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7. Defenses
Primary Defense
– Flow of Urine
– Voiding
Secondary Defense
–
–
–
–
–
Lactoferrin
pH
IgA
IL-6
IL-8
– Tamm-Horsfall
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8. Classification
Isolated—first infections or those isolated by 6 months(3040% of women).
Unresolved—insufficient treatment
– Resistance
– Development of resistance
– Two species one is resistant
– Rapid reinfection before completion of therapy on
initial organism
– Azotemia(poor concentration of drug)
– Papillary necrosis + azotemia
– Staghorn Calculi(mass and concentration of bacteria
Friday, October 18, 2013
too great)
11. Epidemiology
7 million office visits annually(1.2% female, 0.6% male)
Prevalence increases with hospitalization, disease, number
of infections,
Susceptible females—2 infections in 6 months = 66%
chance of developing infection in the next 6 months.
Prophylaxis changes the time to recurrence not the chance
of recurrence.
Pregnancy increases the clinical acuity of infections.
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15. Nosocomial UTI
catheter associated
Short Term
Long Term
E.coli
Enterococcus
Enterobacter
E.coli
Proteus
Candida
Proteus
Providencia
Morganella
S.aureus
Pseudomonas
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Pseudomonas
18. Escherichia coli
E. coli (serotypes: 02, O4, O6) which are
fimbrinated strains adhering to uroepithelial cells, leading to colonization and
infection is the commonest cause of urinary
tract infections.
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19. Gram negative bacilli
Pseudomonas, Proteus, and Klebsiella
infections often follow catheterization and
gynecological surgery (nosocomial
pathogen).
Infection with proteus may be complicated
by phosphate stone formation as it is urea
leads to alkaline pH.
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21. What parts of the urinary
tract can get infected?
Urethra - Urethritis
Urinary bladder – Cystitis
Ureters – Ureteritis
Kidneys - Pyelonephritis
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23. Incidence
1-3% of all GP consultations
5% of women each year with symptoms. Up
to 50% of women will suffer from a
symptomatic UTI during their lifetime.
UTI in men is much rarer
A proportion of patients may be
symptomatic in the absence of infection called 'urethral syndrome'
24. What are the signs and symptoms
of UTI?
Cystitis
Frequency
Urgency
Dysuria – painful voiding
Pain or discomfort in
suprapubic or perineal
area or lower back
Cloudy or foul-smelling
urine
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25. Causes
The most common cause is bacterial infection
– Eschericia coli is the pathogen in 70% of
uncomplicated case of lower urinary tract infections.
– Other organisms include Proteus mirabilis, Klebsiella
pneumoniae, Staphylococcus saprophyticus,
Staphylococcus aureus and Pseudomonas species.
Urethral Syndrome -not associated with any
infection
Rarely kidney or bladder stones, prostatism,
diabetes
26. Prevention
Drinking plenty of fluids helps prevent
cystitis in the first place.
If cystitis follows sexual intercourse, some
advise passing urine soon after to try and
prevent it.
There is no evidence to suggest a link
between lower urinary tract infection and
use of bath preparations
27. Beware!
Pregnant
Under age 12
Males
Systemically ill (fever, sickness, backache)
Catheterised patients
Kidney or bladder stones
28. Investigation
Urine dipstick
– can be done in the surgery and will be positive for nitrates and
leucocytes (leukocyte esterase test). This helps to differentiate
those with UTI from the 50% with urethral syndrome.
Urine microscopy and culture reveals significant bacteruria
(usually >105 /ml).
Asymptomatic bacteruria
– is present in 12-20% of women aged 65-70 years and does not
impair renal function or shorten life so no treatment
– in 4-7% of pregnant women and associated with premature
delivery and low birth weight and always requires treatment.
29. Differential Diagnosis
Urethral syndrome
Bladder lesion e.g. calculi, tumour.
Candidal infection
Chlamydia or other sexually transmitted disease.
Urethritis
Drug induced cystitis (e.g. with
cyclophosphamide, allopurinol, danazol,
tiaprofenic acid and possibly other NSAIDs)
30. Complications and Prognosis
Ascending infection can occur, leading to development of
pyelonephritis, renal failure and sepsis.
In children, the combination of vesicoureteric reflux and
urinary tract infection can lead to permanent renal
scarring, which may ultimately lead to the development of
hypertension or renal failure. 12-20% of children already
have radiological evidence of scarring on their first
investigation for UTI.
Urinary tract infection during pregnancy is associated with
prematurity, low birth weight of the baby and a high
incidence of pyelonephritis in women.
Recurrent infection occurs in up to 20% of young women
with acute cystitis.
31. Management Issues - General
50% will resolve in 3 days without
treatment
No evidence to support “drink plenty”
It is reasonable to start treatment without
culture if the dipstick is positive for nitrates
or leucocytes.
32. Management Issues - General
Culture is always indicated in
–
–
–
–
–
Men
Pregnant women
Children
Those with failure of empirical treatment
Those with complicated infection
33. Self care
Drink slightly acid drinks such as cranberry
juice, lemon squash or pure orange juice
(poor trial evidence for this)
Try a mixture of potassium citrate available
from your pharmacist (little evidence but
widely recommended)
34. Principles of Antimicrobial Therapy
Treatment of UTI should result in sterile
urine.
Antimicrobial levels in urine.
Resistant clones present 5-10% of cases
with empiric treatment.
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35. Antibiotics
Trimethoprim is an effective first line treatment.
Cephalosporins are as effective as trimethoprim
but more expensive and more likely to disrupt gut
flora.
Nitrofurantoin is as effective as trimethoprim but
more expensive and frequently causes nausea and
vomiting
The 4-quinolones (ciprofloxacin, norfloxacin,
ofloxacin) are effective in the treatment of cystitis.
To preserve their efficacy, they should not usually
be used as first line therapy
36. Antibiotics
3 days of antibiotic is as effective as 5 or 7 days
Single dose antibiotic results in lower cure rates
and more recurrences overall than longer courses.
In relapse of infection (i.e. reinfection with the
same bacteria), treatment with antibiotic for up to
6 weeks is recommended.
37. Urinary Tract Infections
T re a tm e n t o f R e c u rre n t C y s titis
R e c u r r e n t C y s t it is
R e la p s e
S e e k o c c u lt s o u r c e o f in f e c t o n
U r o lo g ic e v a lu a t io n
R e in fe
D ia p h r a g m a n
C o n s id e r c h a n g in
m e th
T r e a t lo n g e r ( 2 - 6 w e e k s )
c t io n
d s p e r m ic id e
g c o n tr a c e p t iv e
o d
U r o lo g ic e v a lu a t io n n o t
r o u t in e ly in d ic a t e d
³ 3 U T I/y r
³ 2 U T I/y r
N o r e la t io n t o c o it u s
T e m p o r a lly
r e la t e d t o c o it u s
D a ily o r t h r ic e
w e e k ly p r o p h y la x is
P o s t c o it a l
p r o p h y la x is
P a t ie n t in it ia t e d t h e r a p y
38. Antibiotics for UTI in Pregnancy
Cephalosporins and penicillins are recommended
in pregnancy because of their long term safety
record
Nitrofurantoin is also likely to be safe during
pregnancy
Quinolones, Trimethoprim and Tetracyclines are
not recommended for use during pregnancy
Seven days of treatment is required.
Urine should be tested regularly throughout
pregnancy following initial infection.
41. Clinical Manifestations
Classic signs of cystitis
–
–
–
–
–
–
–
–
–
Enuresis
Frequency
Dysuria
Hesitancy
Suprapubic discomfort
+/- UTI signs
Chills
Nausea
Flank pain
Classic signs of pyelonephritis
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In
older children and
adults
42. But… In Infants
Fever! Fever!!
Fever!!!
Lack classic signs
Irritabilty
Poor feeding
Vomiting
Diarrhea
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Present in <1/2 of infants with UTIs
43. Risk factors
Female (30%:10%)
–
–
–
Shorter urethral length
Urethral opening close to the anus
Exposure to spermicide
» Has antimicrobial activity, disrupt the periurethral
flora content
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45. Diagnosis
Urine Collection
– Suprapubic
Aspiration
– Catheterized
specimen
– Voided
specimen
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Urinalysis
– Sensitive to
colonies of
30K/ml or less
– Bacteria seen
on microscopy
with no growth
may be vaginal
flora
46. Specimen collection
Samples should be collected before the start
of antibiotics.
Transport within 2 h. if delay is suspected
then refrigeration at 4C or boric acid.
Mid stream urine.
Adhesive bags; in infants.
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47. The Positive Culture
Suprapubic
– Any number of pathogens
– Should be completely sterile
Transurethral
– 103 colony forming units
Clean catch
– 105 colony forming units
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48. Know the Adequacy of Your
Tests
“standard urinalysis”
– Urine dipstick
– Microscopy
“enhanced urinalysis”
–
–
–
Nitrites
Leukocyte esterase
Microscopy
Gram stain
84% sensitivity
Neither is sensitive enough to rule out UTI
15% of UTIs missed if culture not done
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49. UTI - Who should be studied?
Acute pyelonephritis All febrile UTIs
Males of any age with first UTI
Girls younger than 3 years with first UTI
Girls older than 3 years with second UTI
Girls older than 3 years with first UTI with:
– Family history of UTIs
– Abnormal voiding pattern
– Poor growth
– Hypertension
– Abnormalities of urinary tract
– Failure to respond promptly to therapy
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50. Urinary Tract Infections
Clinical Manifestations
Feature
Cystitis Pyelonephritis Urosepsis
Dysuria,
frequency
Suprapubic pain
+
+ or -
+ or -
+
+ or -
+ or Ğ
Fever,
tachycardia,
hypotension etc.
CVA tenderness
-
+
+
-
+
+ or -
Duration of
symptoms (days)
1Ğ7
1Ğ2
<1 - 1
51. Imaging Techniques
Indications
– Evaluation of
obstruction
– Persistence of
fever after 5-6
days of treatment
– Diabetes
Mellitus
– TB, fungus, urea
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splitting
55. A 3y/o boy has fever, shaking chills, and flank pain
consistent with a diagnosis of pyelonephritits.
Of the following, the BEST procedure to perform
immediately to define the anatomy of the genitourinary
tract is:
–
–
–
–
–
A. cystoscopy
B. intravenous pyelography
C. radioisotopic renography
D. renal ultrasonography
E. voiding cysourethrogram
56. Urinary Tract Infections
Acute Uncomplicated Pyelonephritis in Women
Mild-to-moderate illness
– Outpatient therapy
– Fluoroquinolone 7 - 14 days
Severe illness
– Hospitalization required
– Parenteral cephalosporin, fluoroquinolone or
aminoglycoside, after afebrile - oral therapy (10 - 14
day total)
Pregnancy - avoid fluoroquinolones
57. What determines a positive urine culture?
Suprapubic?
Transurethral?
Clean-Catch?
Suprapubic
13-15% of end stage renal disease
Any number of pathogens
Due to Transurethral
103 colony forming units
Undiagnosed/Untreated UTI in childhood
Clean catch
Why do we care so much about prompt diagnosis and
105 colony forming units
treatment?
27-64%
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of those with pyelonephritis develop renal scarring
59. Emphysematous Pyelonephritis
/ Pathogenesis
Acute bacterial and fungal infection:
-- E. Coli: 70~90%
-- Klebsiella, Proteus, Clostridium and
Candida
Gas in upper urinary tract:
-- iatrogenically via upper tract manipulation
-- fistula to bowel
-- ascending infection
60. Emphysematous Pyelonephritis /
pathogenesis
Gas extension: renal and hepatic vein
Diabetics predisposed to gas formation:
-- high glucose level throughout tissue
-- diabetic microangiopathic disease
-- immunodeficient-like state
66. XGP / Incidence
0.6% of all surgically proven renal infection
Women : men = 4:1
More commonly in diabetics
5th ~ 7th decades
Almost always unilateral
67. XGP / Pathogenesis
Not been elucidated
Play a role:
-- urinary tract anomalies, obstruction, chronic
infection, renal ischemia, immunodeficiency and
abnormal lipid metabolism
Diagnosis: made by histological examination of
surgically removed kidney
Characteristic: foamy macrophage
Culture: proteus mirabilus (50%), E. Coli (20%)
68. XGP / Clinical findings
Quite nonspecific:
-- anemia, malaise, leukocytosis, pyuria, flank
pain or flank mass …
Children: weight loss or failure to thrive
Associated:
-- renal calculi: 75%
-- CPN: 78%
69. XGP / Radiological findings
Renal ultrasound: hypoechoic mass
Advent CT: accurate with sensitivity (90%)
-- poor enhancing mass, thickened
Gerota’s fascia
70. XGP / Management
Absolutely no medical therapy
Open surgical nephrectomy: standard care
XGP kidney: extension to hilium and contiguous
organ
71. Treatment
Cystitis—3 Days
– 7 Days if duration of
symptoms, Diabetes, age
greater than 65, or
pregnancy
Pyelonephritis
– Women
» 7 days uncomplicated
without sepsis
» Inpatient 10-14 days
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Comlicated Pyelonephritis
– 14-21 day course
Prophylaxis
– Endocarditis—Amp/Gent
or Vanc/Gent
– Indwelling catheter—2
Doses(prior susceptibility)
– Catheter removal—preop
and 72 hours after
– TURP—Pre and Post Op
72. Urinary Tract Infections
Candidates for Prophylaxis
Women with ≥ 3 symptomatic uncomplicated
infections per 12 months
Pregnant women with asymptomatic
bacteriuria or previous symptomatic UTI is
pregnancy
Men with recurrent UTIs
79. Chronic bacterial prostatitis
History
– Bladder outflow obstruction
– Dysuria; perineal, low back, or testicular pain
– Hematuria, hematospermia, painful ejaculation
Physical examination
– Variable prostate exam
Relapsing UTI in men is the hallmark of chronic
bacterial prostatitis
– GNR most common; also Enterococcus and S. saprophyticus
80. Chronic bacterial prostatitis
Management
– Difficult to eradicate given poor penetration of
antibiotic into the non-inflamed prostate
– Bactrim and fluoroquinolones
» Doxycycline and macrolides second-line
–
–
–
–
Prolonged treatment required
Recheck prostatic fluid after treatment
Alpha-blockers to reduce symptoms
Suppressive therapy
82. Prostatodynia
History
– Persistent pelvic, suprapubic, infrapubic, scrotal,
inguinal, or perineal pain
– Lower tract obstruction and dysuria
– Absence of systemic symptoms
Physical exam usually unremarkable
No bacteria identified and no evidence of
inflammation present
Limited course of antibiotics, alpha blockade
Hinweis der Redaktion
Prostatis will affect 50% of men at some time in their life; 2 million visits a year
Fungal infections (ie Aspergillus) seen more often in immunocompromised patients
Most pts with dx of prostatitis are adults with perineal, lower back pn, lower abd pain, or ejaculatory complaints.
Most don’t have bacteriuria and thus there is little bacterial evidence of infection
Inflammatory response: in expressed prostatic secretions, semen, post massage urine, or prostate tissue
First 2 tubes should be sterile or have a colony count smaller by an order of magnitude
The diagnosis of prostatitis requires VB3 to have 10 fold increase in colonies over VB1
3 tube approach gives us sample of urethra (1), bladder (2), and prostate
2 tube approach: obtain urine before and after massage– if WBC appear, prostatitis can be inferred
NOT A SUBTLE DIAGNOSIS
Systemic symptoms include malaise, myalgias, or occasional toxic appearance
Prostate massage may cause bacteremia or vas infection.
Urine culture will generally reveal the pathogen.
These antibiotics will penetrate the prostate well under circumstances of inflammation
Bladder outflow obstruction: frequency, dribbling, diminished stream, hesitancy, and urgency
Usually seen in older men
Dysuria etc more often seen in younger men
Prostate may be enlarged, asymmetrical, boggy, or tender
Prostate fluid has high pH and makes it difficult for antibiotics to penetrate
Bactrim is the main choice as it diffuses into and concentrates into prostatic fluid
May sometimes take up to 8 –12 weeks
Alpha blockers may be of benefit in acute prostatitis as well
Suppressive therapy includes daily Bactrim, prostate reduction procedures
**** 1/3 have symptomatic and bacteriologic cure; 1/3 have symptomatic cure; 1/3 have no improvement****
Prostate abscess: immunocompromised, diabetes, indaquate initial therapy, foreign bodies, gu obstruction.
Imaging may be necessary to document the abscess (might be felt on physical examination)
1. Empiric course of abx in case of occult infection though there is no data to support this