Académique Documents
Professionnel Documents
Culture Documents
Sirilak yimcharoen
Definition
n UTI involve only the lower urinary tract or
occasionally suprapubic tenderness n acute pyelonephritis : flank pain tenderness, fever n Uncomplicated UTI : infection in structurally and neurologically normal urinary tract
Definition
n Complicated UTI : infection with functional or
structural abnormalities, indwelling catheters ,calculi, men, pregnant, children, hospitalized or in health care
Pathologic Characteristics
n Acute pyelonephritis : n enlarged, yellowish, raised abscesses n histologic :suppurative necrosis or abscess formation in renal substance. n Chronic Pyelonephritis : n parenchyma shows interstitial fibrosis with inflammatory infiltrate of lymphocytes, plasma cells n papillary atrophy and blunting n dilatated tubules contain colloid casts
Bacteriuria in adults
n prevalence of asymptomatic bacteriuria
increases in the female n prevalence of bacteriuria in young nonpregnant women is about 1% to 3%. n risk factors for urinary infection in women
n Frequent
sexual intercourse n diaphragm use especially with a spermicide n lack of urination after intercourse n history of recurrent infections
have asymptomatic bacteriuria n older than 65 years the ratio alters dramatically, with a progressive decrease in the female-to-male ratio n reasons for high frequency of UTIs in older
n n n n
obstructive uropathy from the prostate loss of bactericidal activity of prostatic secretions soiling of the perineum from fecal incontinence bladder catheter usage
Clinical Manifestations
SYMPTOMS n The lower tract symptoms
n frequent n painful
urine n suprapubic heaviness or pain n grossly bloody or bloody tinge at the end of micturition
Clinical Manifestations
SYMPTOMS n The upper tract symptoms
n fever
Diagnosis
Presumptive diagnosis of UTI n pyuria :
n at
Diagnosis
Presumptive diagnosis of UTI
n Proteinuria
n
Diagnosis
Presumptive diagnosis of UTI Dipstick n leukocyte esterase test positive n detection of pyuria n urine nitrite positive n common gram-negative organisms contain enzymes reduce nitrate in urine to nitrite n some UTIs are caused by organisms that do not convert nitrate to nitrite (e.g., staphylococcus, streptococci) n False-negative test results are common, in detection of low count bacteriuria (102 to 103/mL) n negative leukocyte esterase test plus a negative nitrite test result are strongly predictive of the absence of UTI
Diagnosis
BY CULTURE n methods for urine collection
n n n
n asymptomatic woman n 80% probability represents true bacteriuria when bacteria/mL in a clean-catch urine more than 105 n 95% of the time 104 to 105 bacteria/mL represents contamination
Diagnosis
BY CULTURE
n In men n 103 or more organisms/mL in one culture is suggestive of infection n 105/mL defines bacteriuria n patients with infection from Enterobacteriaceae.
may not reach titers of 105/mL may be in the 104 to 105/mL often contain saprophytic skin organisms
Diagnosis
UTI with Low Numbers of Organisms
Exclude vaginitis and herpes genitalis(10%)
Urine culture
105 bacteria/ml(50%)
Chlamydial (8%)
Unknown (14%)
Diagnosis
UTI with Low Numbers of Organisms n urethritis (chlamydial, gonococcal, or mycoplasmal)
n gradual
onset of milder dysuria n with or without frequency and urgency n vaginal discharge or bleeding may be present n pyuria
n herpes n usually lesions in the periurethral area
treatment no treatment - pregnancy - older patient - children - before transurethral resection of the prostate
dilution of the bacteria and removal of infected urine n increased vesicoureteral reflux n larger urine output results in dilution of antibacterial and in lower urinary concentrations of antimicrobial agents n no evidence that forcing fluids improves the results of appropriate antimicrobial therapy
Response to Therapy
n
Bacteriologic Cure
n
negative urine cultures on chemotherapy and during the follow-up period, usually 1 to 2 weeks persistence of significant bacteriuria after48 hours of treatment persistence of the infecting organism in low numbers in urine after 48 hours Sites of persistence in the urinary tract are the renal parenchyma, calculi, and prostate.
Bacteriologic Persistence
1) 2) n
Response to Therapy
n Bacteriologic Relapse n occurs within 1 to 2 weeks after the cessation of chemotherapy n often associated with renal infection, structural abnormalities, chronic bacterial prostatitis n Relapses occurring within 1 week are usually true relapses n Delayed relapses (more than 1 to 2 weeks after stopping therapy) more likely to be result of chronic bacterial prostatitis
Response to Therapy
n Reinfection n occur during the administration of chemotherapy or at any time thereafter n change in bacterial species
UTI
trimethoprim (100 mg twice daily) n trimethoprim-sulfamethoxazole (one doublestrength tablet twice daily) n fluoroquinolones (e.g., ciprofloxacin or levofloxacin)
gram-positive cocci in chains n ampicillin n amoxicillin gram-positive cocci in cluster n vancomycin for inpatients n linezolid for outpatients n because of increasing frequency of infection with community-acquired methicillin-resistant staphylococci
u/c should be obtained within 1 to 2 weeks of completion of therapy in pregnant women, recurrent symptomatic n use 7 days of therapy
n
n Short-Course Therapy n defined as 3 or fewer days of treatment n Single-dose therapy n high urinary concentrations that are prolonged for at least 12 to 24 hours and eliminates infection when presumably confined to the bladder n oral doses of 3 g of amoxicillin n one to two double-strength tablets of trimethoprimsulfamethoxazole
women who have a history of previous urinary infection caused by antibiotic-resistant organisms more than 7 days of symptoms in males (7 to 10 days of therapy)
Asymptomatic Bacteriuria
women (A-I)
n before
(A-I) n before other urologic procedures for which mucosal bleeding is anticipated (A-III)
Premenopausal, nonpregnant women (A-I) Diabetic women (A-I) Older persons living in the community (A-II) Elderly, institutionalized subjects (A-I) Persons with spinal cord injury (A-II) Catheterized patients while the catheter remains
in situ (A-I)
renal involvement a structural abnormality of the urinary tract (e.g.,calculi) chronic bacterial prostatitis
Patients who relapse after a short course or 7 to 10 days of therapy and absence of structural abnormalities should be considered for a 2-week course
(2)
those who have relatively infrequent reinfections, perhaps only once every 2 or 3 years to several times a year those who develop frequent reinfections
Women with reinfections associated with lower tract symptoms can be managed with short-course therapy
immediately after intercourse prevent reinfection n single-dose prophylactic chemotherapy taken after sexual intercourse
ciprofloxacin 125 mg n a single-strength trimethoprim-sulfamethoxazole tablet
n
n n n
considere for n asymptomatic patients who reinfect frequently and are at risk of developing renal parenchymal damage n all renal transplantation patients to prevent infection of the graft not decreased risk of UTI increased risk of resistant infections Trimethoprim-sulfamethoxazole, nitrofurantoin, or trimethoprim
amphotericin B bladder irrigation n oral fluconazole, 200 to 400 mg/day for 7 days n removing (if possible) or replacing the catheter n no benefit in treatment of asymptomatic infection, except patient undergo elective urinary tract surgery
complication of UTI
Perinephric Abscess n uncommon complication n secondary to obstruction of an infected kidney or calyx or occasionally secondary to bacteremia n symptoms
n n n n n
syndrome suggestive of acute pyelonephritis fever abdominal and flank pain palpable mass may or may not be present 50% of patients have an abnormal plain film of the abdomen
complication of UTI
Intrarenal Abscess n consequence of bacteremia n often caused by coagulase-positive staphylococci n clinical setting
n n n n
acute pyelonephritis high fever severe flank pain, and tenderness, no or very slow response to appropriate antimicrobial therapy.
complication of UTI
Intrarenal Abscess
n CT
n intense
parenchymatous inflammation and edema in a lobe of the kidney n termed acute lobar nephronia or acute focal bacterial nephritis
complication of UTI
Diagnosis complication of UTI n urinalysis
n 70%
of patients with a corticomedullary abscess urinalysis abnormal n usually normal in perinephric abscess
n Confirmation of the diagnosis requires renal
ultrasonography or CT scans
complication of UTI
Therapy n perinephric abscess
n n n
n intrarenal abscesses n diameter 3 cm antibiotic therapy alone n diameter 3 to 5 cm percutaneous or open surgical drainage n diameter>5 cm percutaneous or open surgical drainage
The end