Urinary Tract Infection(尿路感染全英文)图文.ppt

urinarytractinfectionwuyitaidepartmentofnephrologytongjihospital,tongjiuniversity,content,definitionsepidemiologyetiologypathogenesispathologyclinicalpresentationdiagnosistreatmentscomplicationprevention,definitionofuti,utiisdefinedasthepresenceofmicro-organismsintheurinarytract.mostpatientswithutihavesignificantbacteriuria,i.e.bacterialcolonycounts105/ml,inamid-stream“cleancatch”urine.conversely,colonycounts105/mlofmidstreamurineareoccasionallyduetospecimencontamination.acuteurethralsyndrome:dysuria,urgency,andfrequency,butwithoutbacteriuria.,anatomicloweruti:urethritiscystitis(mucosalinfection)upperuti:pyelonephritisprostatitisintrarenalandperinephricabscesses(tissueinvasion),classificationofutis（1）,classificationofutis（2）,clinicaluncomplicateduti:lackstructuralorfunctionalabnormalitiesoftheurinarytractnormalflowofurinenointerferencewiththenormaldefensescomplicateduti:predisposinglesionoftheurinarytract,structuralorfunctionalabnormalities,e.g.congenitalabnormalityoftheurinarytract,stone,obstruction,catheter.interferencewiththenormaldefenses,e.g.immunosuppression,renaldisease,ordiabetes.,classificationofutis（3）,epidemiologycatheter-associated（nosocomial）infections:symptomaticasymptomticnoncatheter-associated（community-acquired）infections:symptomaticasymptomtic,epidemiology,almosthalfofallwomenwillhaveatleastoneutiintheirlives.utiisuncommoninmenundertheageof50,butverycommonamongwomen.asymptomaticbacteriuriaismorecommonamongelderlymenandwomen.,etiology（1）,community-acquiredutigram-negativebacilliisthemostcommonagent,e.coli,enterobacter,enterococcus,proteus,staphylococcus,klebsiella,e.coli,etiology（2）,causativeorganisms:escherichiacoliklebsiella,proteusandpseudomonas1-bacterias.aureus,staphylococcusepidermidisands.saprophyticusenterococci(streptococcusfaecalis粪链球菌)mycobacteriumtuberculosischlamydiatrachomatis,neisseriagonorrhoeae2-virusherpessimplexvirus,hiv3-funguscandida,histoplasmacapsulatum4-protozoontrichomonasvaginalis,schistomahaematobium,case132year-oldwoman;dysuriaandfrequency;pyuriaintheurinesediment;gramnegativebacilli.escherichiacoli(e.coli).,case265year-oldwoman;dysuriaandfrequency;pyuria;grampositivecocci.enterococcusfaecalis,case318year-oldwomandysuriaandfrequency;pyuria;grampositivecocci;staphylococcus.,case442year-olddiabeticwomanwithacatheter.grampositiveyeasts.candidagrew.,routeofinfection,ascendingroute(themostcommon),colonizationofurethra,pathogenesis,pathogenesis（1）,theurinarytractabovetheurethraisnormallysterile.theurethralmeatusandsurroundingperineumarecolonizedwithamixtureofskinandbowelflora.vaginalfloraorpathogensmaycontaminatetheurethra.,pathogenesis（2）,hostdefensemechanisms:1.urine:lowph,highosmolality,highurea&organicacidconcentrationinhibitandkillmicroorganisms2.regularurineflow:diluteandexpelpathogens3.bladderepithelialcells:coatedwithmucus(glycosaminoglycan)preventbacteriafromadheringtobladderwall,conditionsaffectingpathogenesis,genderandsexualactivity.pregnancy.obstruction.（tumor,stricture,stone,bph）neurogenicbladderdysfunction.vesicoureteralrefluxbacterialvirulencefactorsgeneticfactors（detailsinthefollowing）,conditionsaffectingpathogenesis（1）,genderandsexualactivitythefemaleurethraappearstobepronetocolonizationwithcolonicgram-negativebacillibecauseofitsproximitytotheanus,itsshortlength,anditsterminationbeneaththelabia.voidingafterintercoursereducestheriskofcystitis.animportantfactorpredisposingtobacteriuriainmenisurethralobstructionduetoprostatichypertrophy.,conditionsaffectingpathogenesis（2）,pregnancyutisaredetectedin2to8%ofpregnantwomen.pregnantwomenwithasymptomaticbacteriuria.bladdercatheterizationduringorafterdeliverycausesadditionalinfections.,conditionsaffectingpathogenesis（3）,obstructiontumorstricturestonebenignprostatichypertrophy(bph)theseconditionsresultinhydronephrosisandincreasefrequencyofuti.,conditionsaffectingpathogenesis（4）,neurogenicbladderdysfunctioninterferencewithbladderenervation,asinspinalcordinjury,multiplesclerosis,diabetes.theinfectionmaybeinitiatedbytheuseofcathetersforbladderdrainage.theinfectionisfavoredbytheprolongedstasisofurineinthebladder.,conditionsaffectingpathogenesis（5）,vesicoureteralrefluxvesicoureteralrefluxoccursduringvoidingorwithelevationofpressureinthebladder.commonamongchildrenwithanatomicabnormalitiesoftheurinarytract.renaldamagecorrelateswithmarkedreflux,notwithinfection.,conditionsaffectingpathogenesis（6）,bacterialvirulencefactorsspecifico,k,andhserogroups.adherenceofbacteriatouroepithelialcellsisacriticalfirststepintheinitiationofinfection.fimbriaemediatetheattachmentofbacteriatospecificreceptorsonepithelialcells.e.colistrainsusuallyproducehemolysinandaerobactin.,conditionsaffectingpathogenesis（7）,geneticfactorshostgeneticfactorsinfluencesusceptibilitytouti.thenumberandtypeofreceptorsonuroepithelialcellsareinpartgeneticallydetermined.,conditionsaffectingpathogenesis,genderandsexualactivity.pregnancy.obstruction.（tumor,stricture,stone,bph）neurogenicbladderdysfunction.vesicoureteralrefluxbacterialvirulencefactorsgeneticfactors,pathology,cystitis,mucosalhyperemiaedemaleukocyteinfiltrationeasybleedinggranularsurfacesuperficialulcerpurulentexudate,pathology,acutepyelonephritis,acuteinflammationhyperemiaandedemavolumeincreaseredcolouryellowishabscesspurulentexudate,pathology,chronicpyelonephritis,chronicinflammationpelvisdeformedcortexscarsvolumeshrinkasymmetricparenchymaatrophy,pathology,interstitialedemaneutrophilinfiltrationwhitebloodcellcast,inmicroscopy,clinicalpresentation,clinicalpresentation（1）,cystitisburningpainfrequency,urgencysuprapubicpaindysuria,clinicalpresentation（2）,urethritisburningpainfrequency,urgencydysuriainfectedwithsexuallytransmittedpathogens,clinicalpresentation（3）,acutepyelonephritisallcystitissymptoms（+）or（-）fever,shakingchillsnausea,vomiting,diarrheatachycardia,hypotentionmuscletendernesscostovertebralangle（cva）paingram-negativesepsis,leukocytosisleukocytecastsintheurine,clinicalpresentation（4）,catheter-associatedutisbacteriuriadevelopsinatleast10to15%ofhospitalizedpatientswithindwellingurethralcatheters.theriskofinfectionis3to5%perdayofcatheterization.manyinfectingbacteriadisplaymarkedlygreatantimicrobialresistance.,howisitdiagnosed?,diagnosis,patienthistorycompletephysicalexaminationurinecultureurineanalysisotherexaminations,microscopicexamination,pyuriawbc5/hp,bacterialcolonycounts105/ml,diagnosis,diagnosisdipstickmethods,leukocyteesterase+nitrite+,urineroutine:ph,sg,protein,glucose,blood,ket,etc.,cleanurineculture:bacterialcounts105/mlsuprapubicpuncture,cathetercollectedurine102/mlsignificantbacteriuriamicroscopicbacteriuria,urineculturetest(veryimportant),diagnosis,localizationofuti,（nodefinitestandardmethod）,ultrasonographyintravenouspyelography（ivp）abdominalct/mri,treatmentsfordifferenttypesofutis,acuteuncomplicatedcystitispathogens,staphylococcussaprophyticus(5-15%)enterobacteriaceaee.coli(86%)klebsiellapneumoniaeproteusenterococcus,single-dosetherapyislesseffectiveespeciallywith-lactams3-daycourserecommendedtmp-smx,fluoroquinolone,nitrofurantoinnotappropriateformalepatientsandcomplicatedutis7-daycourse:diabetes,age65years,malesifuntreated:mayleadtoacuteuncomplicatedpyelonephritistreatment,acuteuncomplicatedcystitistreatment-antibiotictherapy,acuteuncomplicatedpyelonephritispathogens,enterobacteriaceaee.coliklebsiellapneumoniaeproteusstaphylococcussaprophyticus,mildormoderatesymptoms:outpatienttreatment(714days)oraltreatment:fluoroquinolone,tmp/smx,thirdgenerationcephalosporinsevereillpatient:hospitalizationrequiredparenteraltherapy(14days)broad-spectrumcephalosporinsorfluoroquinolones,acuteuncomplicatedpyelonephritistreatment(714days),complicatedutispathogens,enterobacteriaceaee.coliklebsiellapneumoniaeproteusenterococcipseudomonasstaphylococci,minimalormildsymptoms(10-14d).oraltherapy:fluoroquinolone(ciprofloxacinorofloxacin)severeillpatient,parenteraltherapy(10-21d).hospitalizationrequired,imipenemalonepenicillinorcephalosporinplusaminoglycosidethirdgenerationcephalosporin:ceftriaxoneorceftazidime,complicatedutistreatment,lowurinarytractinfection(acutecystitis):7dayscourseantibioticsamoxicillin,cephalosporine,nitrofurantoinpyelonephritis:2-4weekscourseantibioticscephalosporins,extendedspectrumpenicillinsparenteraltreatmentfollow-upurineculturetests,monthlylow-doseprophylaxistorecurrentinfectionsasymptimaticbacteriuriaantibioticstreatmentsareneeded.,utiinpregnantwomentreat