uninary tract infection-尿路感染

Urinary Tract InfectionNephropathy Department, the First Affiliated Hospital of Xiamen UniversityXianghua Hou,. Definition And Incidence Rate,1.DefinitionUrinary tract infection(referred to asUTIs)urinary tract inflammationcaused by theinvasion ofa variety ofmicroorganisms(bacteria,fungi,chlamydia and mycoplasma,certain viruses).,kidneyureterbladderurethraprostatevagina,ureter bladder prostate,(1)Upper urinary tract infection Pyelonephritis Ureteritis (2)Lower urinary tract infection Cystitis Urethritis,2.Type,Female Urethra Broad Short straight,(1) Unmarried girls 2% (2) Married women 5% (3) Pregnant women bacteriuria 7% (4) Older male,female,without symptoms 10%,3.Attack Rate More common in women: femaleurethralshort,wide,straight,urethralopening near thevagina mouthand anus,. Causes,Bacteria,fungi,viruses,chlamydia,mycoplasma et al.BacteriaThe main pathogenic bacteria: Escherichiacoli 75%-90,Pathogens of Urinary tract infection,CASE 1 - A 32 year-old woman complains of dysuria and frequency; pyuria is seen in the urine sediment. Gram stain of unspun urine (x1000) shows an inflammatory cell and numerous Gram negative bacilli. Escherichia coli grew from this specimen.,CASE 2 - A 65 year-old woman complains of dysuria and frequency; pyuria is seen in the urine sediment. Gram stain of unspun urine (x1000) shows inflammatory cells and Gram positive cocci in chains. Enterococcus faecalis grew from this specimen.,CASE 3 An 18 year-old woman complains of dysuria and frequency; pyuria is seen in the urine sediment. Gram stain of unspun urine (x1000) shows inflammatory cells and Gram positive cocci in pairs and clusters. Staphylococcus saprophyticus grew from this specimen.,CASE 4 This specimen was obtained from a 42 year-old diabetic woman with a Foley catheter. Gram stain of unspun urine (x1000) shows Gram positive budding yeasts and large pseudohyphae. Candida albicans grew from this specimen.,The most common pathogenic bacteria : intestinal Gram-negative rods,1Staining：G- 2antigen：（1）O抗原（2）鞭毛抗原：H抗原（3）表面抗原：K抗原，Vi抗原3.主要致病物质：（1）菌体表面构造：菌毛、K抗原、Vi抗原（2）毒素：内毒素。 外毒素：耐热肠毒素（ETEC）、不耐热肠毒素（ETEC）、志贺样毒素（EHEC）、志贺毒素（志贺痢疾杆菌,Characteristic of intestinal G- rods,1. first Escherichia coli: more than 70%,Escherichia colipattern,Escherichia colicolonydiagram,1. normal intestinalflora,change of parasitic positioncan cause gastrointestinal purulent infection.2. specialpili adsorpt the specialreceptorson epithelial cells of urinary tract .3. can producehemolysintoxin,resistant to the immunity of membrane mucous,Characteristics of E-coli：,2.sedond:Proteus,Klebsiella pneumoniae, Gas Bacillus,Sarre Bacillus,Alcaligenesfaecalis, Pseudomonas, Staphylococcus aureusPseudomonas aeruginosa: normally appear after urinary devices inspectionProteus,Klebsiella pneumoniae: inurinary calculus Coagulasenegative staphylococci:more common insexually activewomen,. Pathogenesy,(1) Ascending infection: the most common way(2) hematogenous infection: rare(3) Lymphatic infection(4)Direct infection,1. Route of Infection,Ascending infection,(1)without obstruction of urinary tract,urinewashingand dilution(2)urea concentration,osmotic pressure,organic acid,low pH,not suitable forthe growth of bacteria(3)Bactericidalability:urinarymucosa secretion of IgG,IgA, phagocytes(4)the male prostateliquid:bactericidal effect,2.Disease resistance of organism,3. Predisposing factor,(1)urine blockage:obstruction,foreign body,renal parenchymal disease(2) malformationof urinary system andabnormal structure(3)Invasive examination(4)inflammation around urethra,urethral mouth(5)low immunity(6)genetic factors,Malformation double renal pelvis and ureter,the adsorptionability of bacteriatourinary tract epithelial cellsis an important virulencefactor,4.Pathogenicity of bacteria,Pathology,Acute cystitis Acute pyelonephritis 急性膀胱炎 急性肾盂肾炎 粘膜 充血、潮红 肾盂肾盏粘膜水肿 上皮细胞肿胀 表面脓性分泌物 粘膜下 组织充血、水肿 (单侧或双侧)细小脓肿 白细胞浸润 楔形炎症病灶 肾间质 () 白细胞浸润、小脓肿 炎症剧烈广泛性出血 肾小球 () 无形态改变,Acute cystitis,慢性肾盂肾炎,急性肾盂肾炎,Acute pyelonephritis(kidneyabscess),Acute pyelonephritis(kidneymicro abscesses),Acute inflammation,chronic inflammation, with scar,white cell cast,Acute pyelonephritis,Acute pyelonephritis,Chronicpyelonephritis,Chronicpyelonephritis,. Clinical Situation,(1)systemic symptoms:noornot obvious(2)urinary tractsymptom: frequent micturition,urgency of urination,painful urination, Suprapubicdiscomfort(3)abnormal urine:oftenwhite blood cells,30% hadhematuria,may havegross hematuria(4)the pathogenic bacteria:Escherichia coli 75%,Coagulasenegative staphylococci:more common in married women, 15%,1.Cystitis （60%),Symptoms of Cystitis,(1) Systemic symptom : Chill Headche Nausea vomiting WBC fever 38 blood culture may(+) (2) Urinary symptoms Urinary irritation symptoms: Lumbago costospinal angle tenderness (3) Pathogenic bacteria: Escherichia coliis more common,followed byProteus,Klebsiella and Enterococcus faecalisbacteria,which accounted for5%. (4) Renal concentrationfunction:can be reduced,recover to normal after treatment,2.Acute pyelonephritis,(1)urinebacteria(+),urinary tract infectionsymptoms(-)(2):incidence rateincreasedwith age,60 years old womenof 10%(3)bacteriaurinefrom thebladder or kidney(4)the pathogenic bacteria: Escherichia coli(5)pregnant women(5%),if not treatment,20%will develop into acutepyelonephritis,3.Asymptomatic bacteriuria,. Laboratory Examination,(1)urine protein：(-)() (2)WBC . Pyuria, WBC5/HP WBC8106/L .Pyuria can also happen with：LeucorrheapollutionUrinarynon-infective inflammation(interstitial nephritis),Tuberculosis,fungi,chlamydia infection,Urinalysis,.尿十项指标的英文缩写： GLU 葡萄糖 BIL 胆红素 KET 酮体 SG 比重 PH 酸碱度 PRO 蛋白质 UBG 尿胆原 NIT 亚硝酸盐 BLD(ERY) 红细胞 LEU 白细胞 Negative 阴性 Positive 阳性 Trace 微量 * 超过正常 Moderate 中等量 Large 大量,NIT (亚硝酸盐):【原理】尿液中的亚硝酸盐与试纸中的对氨基苯砷酸或磺胺发生重氮化反应，生成重氮盐，后者与试纸上的N-1-萘基乙二胺盐酸盐或四氢苯并喹啉-3-酚偶合生成红色的偶氮化合物（盖氏试剂法）。【临床意义】正常情况下，尿液亚硝酸盐的定性实验一般为阴性。当泌尿系统受到感染时，由于细菌还原硝酸盐生成亚硝酸盐，因此检测结果为阳性，常见于大肠埃希氏菌引起的泌尿系统感染。尿液亚硝酸盐检测结果为阳性时，预示着尿液中的细菌数量在10万/ml以上。,300000/h+ urine WBC counting 20-300000/hdepends 200000/h- 100000/h + urine WBC counting 3-100000/h depends 30000/h -,2. Urinary cell counting,停抗生素5天或用药前 收集标本 尿存留膀胱6-8小时 注意事项 清晨第一次尿 无菌取中段尿,3.Urinary bacteriology,(1)Urine culture,尿普通培养+计数+药敏 2次 尿高渗培养+药敏 2次,球菌 103-104/ml: 阳性 计数 标准 尿105/ml：阳性 杆菌 104-105/ml:可疑，需复查 90%,(3) Urinary sediment,(4)Chemical examination Nitrites test ： sensibility： 70.4% specificity： 99.5%,False positiveFalse negativea. 中断尿收集不规范,标本被白带污染 b. 尿标本在室温放置1小时c. 接种和检验的技术错误,（5） False positive and false negative,. Screenage examination,1.Ultrasound 2.Intravenous pyelograph IVP 3.CT、MRI,Intravenous pyelography(rightkidney stones),A.再发感染 B.疑为复杂性尿感 C.拟诊为肾盂肾炎 D.感染持续存在，对治疗反应差 （尿感急性期不宜IVP）,.女性IVP指征 :,.男性：首次尿感应作IVP, Diagnosis,Patient history Complete physical examination Urine culture Urine analysis Other examation,1How is it diagnosed?,Symptoms of urinary tractinfection + Inflammatorycomponents in urine,2. Qualitation,（1）Preliminary diagnosis,(2)Final diagnosis,A. 在排除假阳性的前提下,尿细菌定量培养 ： 球菌: 103-104/ml 阳性 尿含菌105/ml 阳性 杆菌 104-105/ml 可疑，需复查 38），明显腰痛、压痛 WBC考虑肾盂肾炎 (2)临床表现不典型，以下尿路感染症状为主诉，先给 3天抗菌治疗，能治愈为膀胱炎,如 复发为肾盂肾炎。 (3)复杂性尿感和致病菌为铜绿假单胞菌、变形杆菌者， 多为肾盂肾炎。,定 位 方 法 小 结,定 位 膀 胱 腰 痛 全身 尿WBC 膀胱冲洗 尿抗体 尿酶 IVP方 法 刺激症 肾叩痛 症状 管 型 后尿培养 包裹细菌 升高 上尿路 + + + + + + 感 染 下尿路 + 感 染,. Differential diagnosis 鉴别诊断,1.Systemic infectious disease 全身症状:明显 全身性感染疾病 尿感症状:不明显,2.Chronic Pyelonephritis 病史半年 IVP: 肾盂肾盏变形慢性肾盂肾炎 B超: 肾表面不平,一侧肾萎缩 功能改变：小管损害在先,慢性肾盂肾炎 双肾病变不对称体积变小 质地变硬 表面变形呈凹陷性疤痕,慢性肾盂肾炎,慢性肾盂肾炎切面 皮质：变薄肾乳头：萎缩肾盂肾盏：变形肾盂粘膜：粗糙， 颗粒状,3.Renal Tuberculosis 肾结核尿频、尿急、尿痛更突出一般抗菌药物无效尿沉渣：找到抗酸杆菌 尿培养：结核杆菌IVP：肾内有虫蚀样变 结核抗体及PPD皮试 （） 注意：肾结核可以和其他普通感染并存。,肾结核,肾和输尿管结核,4.Urethral syndrome 尿道综合征有尿频、尿急、尿痛，但无真性细菌尿 感染性尿道综合征 非尿感性尿道综合征 发生率 占75 占25 WBC尿 有 无病原体 支原体、衣原体 无(精神因素) 淋球菌、单纯疱疹病毒,. Treatment 治疗,(1) 尿培养：治疗前先做尿培养药敏 (2)药敏：按药敏治疗 无药敏者,首选对G杆菌有效的抗生素 (3) 祛诱因：祛除促发感染的因素 如阻塞、神经原性膀胱、结石等 (4)随诊,1. 治疗应遵循以下几条原则 ：,见效：治疗后尿菌(-) 治愈: 完成疗程后: 尿菌(-) 停药1周和1月尿菌(-) 菌尿(+),且为重新感染 治疗失败:治疗后菌尿(+),或复发,（5)疗效评定标准:,一般治疗抗感染治疗,治疗,复方新诺名、氧氟沙星、阿莫西林任选一种口服3天停药，一周后复查尿培养。一周尿培养阴性，1月后尿培养决定是否痊愈。一周后尿培养阳性（同一种细菌），根据药敏或服喹诺酮实验再服14天，再停药一周尿培养，如仍为阳性，服药6周。,急性膀胱炎的治疗,轻型：口服药物一般72小时显效（症状消失或明显减轻），否则换药，疗程14天。较重型：一般先静脉注射，症状消失后改口服，治疗14天。重症：静脉、联合。半合成青霉素、3代头孢，疗程可延长至3周。,急性肾盂肾炎的治疗,疗程结束后，停药一周复查尿培养，如尿培养阳性，且与初发时是同一细菌，根据培养药敏结果选择抗生素，治疗6周。如停药一周尿培养结果阴性，于一月时再培养一次。如培养阳性，复治6周。,急性肾盂肾炎的复诊,重新感染：感染由另一种细菌造成。复发：感染由同一种细菌造成，首次复发者，根据药敏实验服药14天，复查尿培养。二次复发者，根据药敏服药6周，三次复发者，需要小剂量抗生素长期抑菌治疗（每日剂量的一半，顿服）,再发尿感,由于尿感可引起早产、流产、低体重胎儿、也可因长期感染发生慢性肾盂肾炎，影响肾功能，所以妊娠期无症状菌尿也要治疗妊娠期尿感不可使用四环素、氯霉素、氨基甙、磺胺药。选用半合成青霉素、3代头孢,妊娠期发生尿路感染,有尿感症状者，根据药敏抗生素治疗至症状消失，后小剂量抑菌治疗至尿管拔除无症状者可暂不治疗化脓者，引流、冲洗、抗生素治疗,置留导尿管引起尿感的治疗,妇女可不予治疗孕妇必须治疗儿童需要治疗老人可不治疗肾移植、尿路梗阻及其他尿路有复杂情况 ：口服抗菌药7天至4周,无症状菌尿的治疗,肾乳头坏死 患者往往患有糖尿病、尿路梗阻，需要抗生素治疗，解除梗阻肾周围脓肿 患者常有糖尿病、尿路梗阻，需要抗生素，解除梗阻，切开引流,并发症及其治疗,. Complications 并发症,1.Re