Urinary tract infection.ppt

urinarytractinfections overviewofuti 7millionofficevisitsyearly1millionhospitalizationsabout2 3rdsofpatientsarewomen 40 to50 ofwomenhaveutiatsomepointduringtheirlivesimportantcomplicationsofpregnancy diabetesmellitus polycysticdisease renaltransplantation conditionsthatimpedeurineflow structuralandneurologic overviewofutibyageandsex terms urinarytractinfectionsignificantbacteriuriaasymptomaticbacteriuriaacutepyelonephritischronicpyelonephritis upper versus lower utiurethralsyndrome terms 2 uti thefindingofmicroorganismsinbladderurinewithorwithoutclinicalsymptomsandwithorwithoutrenaldiseasesignificantbacteriuria thefindingof 105cfu mlofurine butlowercountscanbesignificant terms 3 asymptomaticbacteriuria significantbacteriuriawithoutclinicalsymptomsorotherabnormalfindings acutebacterialpyelonephritis aclinicalsyndromeoffever flankpain andtenderness oftenwithconstitutionalsymptoms leukocytecastsintheurine andbacteriuria orhistologicfindingsthereof terms 4 chronicbacterialpyelonephritis long standinginfectionassociatedwithactivebacterialgrowthinthekidney ortheresiduumoflesionscausedbysuchinfectioninthepastchronicinterstitialnephritis renaldiseasewithhistologicfindingsresemblingchronicbacterialpyelonephritisbutwithoutevidenceofinfection terms 5 upperuti infectionabovethelevelofthebladder loweruti infectionatorbelowthelevelofthebladder urethralsyndrome clinicalmanifestationsofloweruti dysuria frequency urgency withoutsignificantbacteriuria terms 6 pyuria thepresenceofpus wbc s leukocytes inurine whichmayormaynotbecausedbyuti thepreferredmethodforquantitationisenumerationinunspunurineusingacountingchamber theleukocyteesterasenitritetesthasasensitivityofbetween70 and90 forsymptomaticuti asymptomaticbacteriuria inpatientswithasymptomaticbacteriuriawithoutinfection acolonycountof 105cfu mldefinesinfectionscreeninghaslittleapparentvalueinadultsexceptduringpregnancyandpriortourologicsurgeryupto40 ofelderlymenandwomenhaveasymptomaticbacteriuria frequencyofsignificantbacteriuria afteronebladdercatheterization 2 medicaloutpatients 5 pregnancyatterm 10 hypertensivepatients 14 diabetesmellitus 20 womenwithcystocoele 23 frequencyofsignificantbacteriuria 2 congenitalurologicdisease 57 hydronephrosis nephrolithiasis 85 indwellingcatheter opendrainage 48hours 98 reference jacksonetal archinternmed1962 110 663 screeningforsignificantbacteriuria screeningforasymptomaticbacteriuriainadultshaslittlevalueexceptfortwosituations pregnancy becauseofthehighriskofacutepyelonephritiswithitsaccompanyingriskoffetalcomplications andpriortourologicsurgery becauseoftheriskofpostoperativesepsis urinarytractbacteriology atroomtemperature thedoublingtimeofcommonaerobicbacteriaisabout20minutessomecontaminantsinvoidedurine lactobacilli cornyebacteriumspecies gardnerella alpha hemolyticstreptococci anaerobesanybacterialgrowthissignificantifthespecimeniscollectedfromanormally sterilesite e g directbladderpuncture urinarytractbacteriology 2 inpyelonephritis the 105cfu ml rulebreaksdown fewercoloniescanbesignificant upto20 ofyoungwomenwithacuteuncomplicatedpyelonephritishavebetween103and104cfu ml incatheterizedpatientsinwhomspecimensareobtaineddirectlyfromthecatheter between102and104cfu mlshouldmaybesignificant urinarytractbacteriology 3 patientswithuncomplicatedinfectionalmostinvariablyhaveasingleorganism thisisnotnecessarilythecasewithcomplicatedinfectionsunspunmidstreamurine onebacterium high poweredfield hpf correlateswith 105 ml thus highpositivepredictivevalue urinarytractbacteriology 4 gram sstainofspunurine absenceofvisiblebacteriamakes 105cfu mlhighlyunlikely thatis highnegativepredictivevalue 20 ofpatientswithurinarytractinfectiondonothavepyuria etiologyofcommunity acquireduti aerobicgram negativerodsmostoftene coliaccountsforabout90 staphylococcussaprophyticushasbeenincreasinglyappreciatedinrecentyears withseasonality tendingtooccurinthesummer rare anaerobes pyogeniccocci viruses etiologyofnosocomialuti e coliisthemostcommonpathogenhowever alsocommonareotherenterobacteriacae proteus klebsiella enterobacter serratia providenciaspecies andpseudomonadaceae notably pseudomonasaeruginosa enterococci ofteninobstructiveuropathyyeasts candidaalbicans others urease producingmicroorganisms ureasesplitsureaintoammonia whichhasadirecttoxiceffectonthekidney inactivatesc4 andalkalinizestheurinewithproductionofstruvitecrystals mgnh4p04 6h20 crystalsproteusmirabilismostoften alsoprovidencia morganella s saprophyticus klebsiella corynebacteriumd2 mycoplasmaeradicateifatallpossible utiinchildren newborns overallrateisabout1 higherinmalesthaninfemales preschoolchildren utiis10to20timesmorecommoningirlsschool agedchildren about1 2 ofschoolgirlshavebacteriuriaonanygivenday utiinadults women bacteriuriaincreaseswithageandsexualactivitymen bacteriuriaisrarebeforeage50 andasacorollary callsformoreaggressiveevaluationthaninwomen subsequently bacteriuriaincreaseswithonsetofprostatism roleofbacterialvirulenceinuti bacterialadherencetouroepithelialcellsinvolvesspecificbindingofbacterialsurfacereceptors adhesins tocomplementarycomponentsontheepithelialcells receptors theabilityofe colitoadheretouroepithelialcellsisassociatedwiththepresenceofpiliorfimbriae theroleofbacterialvirulence 2 specificityhasbeenassociatedwiththegal alpha 4 galspecificadhesionlocalizedatthefimbrialpolymer however virulenceofe colistrainsdoesnotseemtodependuponasinglevirulencefactor theremaywellbeanadditiveeffectamongmultiplevirulencefactors includingadhesins hemolysin capsularpolysaccharide aerobactin hostdefenses antibacterialpropertiesofurine osmolality extremesofhighorlowosmolalitiesinhibitbacterialgrowth highureaconcentrationhighorganicacidconcentrationph hostdefenses anti adherencemechanisms bacterialinterference naturallyendogenousbacteriaintheurethra vagina andperiurethralregion urinaryoligosaccharides havethepotentialtodetachepithelial bounde colitamm horsfallprotein uromucoid coatingofe colibythisproteinmightpreventattachment hostdefenses miscellaneous mucopolysaccharideliningofthebladderurinaryimmunoglobulinsspontaneousexfoliationofuroepithelialcellswithbacterialdetachmentmechanicalflushingofmicturition routesofurinarytractinfection ascendinginfectionisthoughttobethecommonrouteofnearlyallformsofurinarytractinfection bacteriainitiallycolonizeperiurethraltissues descending hematogenous infectioncanbeimportantforafeworganismssuchass aureusandcandidaalbicans butingeneralthekidneyresists metastaticinfection mechanismsofloweruti experimentally 99 9 ofabladderinoculumofbacteriaispromptlyexcretedbyvoiding possiblebiologicexplanationsforthefrequencyofutiinsomewomeninclude deficientantibodiesinvaginalsecretions andbiochemicaldifferencesinreceptorsonuroepithelialcells mechanismsofupperuti ascentofbacteriafromthebladdertothekidneysispromotedbyobstructionandbyreflux inaddition motilebacteriacanascendagainsttheflowofacolumnofurine gram negativebacteria orendotoxinderivedfromthem caninhibitureteralperistalsis mechanismsofupperuti 2 therenalmedullaisan immunologicdesert itslowph 5 5 andhighosmolality whichmayreach1300mosm lkwithasodiumof425mmandureaof850mm drasticallyinterferenotonlywithallaspectsofleukocytefunctionbutalsowithantibodyandcomplementfunction localizationofupperversusloweruti indirect patternofrecurrence i e sameorganism maximumurinaryconcentration waterloadingtest serumantibodies cellularexcretion urinaryproteinsdirect renalbiopsy ureteralcatheterization fairley sbladderwashouttest antibody coatedbacteriatest localizationofupperversusloweruti 2 inpractice frequency dysuria andurgency lowerutisymptoms canoccurwithupperutiaswell feverandflankpainindicateacuteupperurinarytractinfection scarringofthekidneybyimagingproceduressuggestschronicuti thedistinctionissometimesdifficult acuteuncomplicatedcystitisinyoungwomen acutedysuriainyoungwomenusuallyindicates acutebacterialcystitis theurethralsyndrome orvaginitisacutebacterialcystitisisusuallycharacterizedbysuddenonset multipleurinarysymptoms pyuria andsometimeshematuria acuteuncomplicatedcystitisinyoungwomen 2 althoughmostpatientshavelowerurinarysymptomsonly 30 to50 mayhavesubclinicalrenalinvolvementcauses e coli 80 s saprophyticus 10 to15 andoccasionallyklebsiella proteusmirabilis andothermicroorganisms acuteuncomplicatedcystitisinyoungwomen 3 ashortcourseofantibiotics e g threedays usuallysufficesabbreviatedwork ups e g leukocyte esterasenitritetest withoutcultureorroutinefollow upisnowacceptablefortypicalencounters acuteuncomplicatedpyelonephritisinyoungwomen largelyaclinicaldiagnosispyuriaisusuallypresent about20 havepositivebloodcultures causativeorganismsthesameaswithcystitispredisposingfactors structuralabnormalities strainsofe coliwithuniquemarkers genetically determinedcarbohydratereceptorsonuroepithelialcells whitebloodcellcasts highlysignificant presencesuggestspyelonephritis recurrentutisinwomen between20 and25 ofyoungwomenwithacuteuncomplicatedcystitishave2ormoreinfectionsperyear usuallyduetoreinfectionwithadifferente colistrainpredisposingfactors genetically determinedreceptorsonuroepit