版权说明:本文档由用户提供并上传,收益归属内容提供方,若内容存在侵权,请进行举报或认领
文档简介
1Urinarytractinfection
尿路感染2IntroductionUrinarytractinfection(UTI)ofthebladder,kidney,or(inman)theprostateisoneofthemostcommonhumaninfections.3DefinitionsUTIisthepresenceofbacteriaorothermicroorganismsintheurineorgenitourinarytissues.Symptomatic:maymanifestasbladderinfection
Asymptomatic:bacteriuriawithoutsignsorsymptomsUncomplicatedUTI:occursinwomenusually
ComplicatedUTI:occursinindividualswithfunctionalorstructuralabnormalities4upperpelvic肾盂
calyx肾盏
ureter输尿管pyelonephritis肾盂肾炎prostatitis前列腺炎intrarenal&perinephricabscesseslowerbladder膀胱
urethra尿道
cystitis膀胱炎urethritis尿道炎AnatomicCategorieskidney5PathogenHostObstructionGenderandSexualactivityPregnancyNeurogenicBladderDysfunctionVesicoureteralRefluxHowtohappen6PathogenGram-negativeorganismsismostcommon95%
E.coli大肠杆菌60-80%Proteus变形杆菌Klebsiella克雷伯杆菌Pseudomonas绿脓杆菌Serratia沙雷杆菌Gram-positiveorganisms5-10%
Staphylococcussaprophyticus腐生葡萄球菌Streptococcusfaecalis粪链球菌Staphylococcusaureus金黄色葡萄球菌Staphylococcusalbus白色葡萄球菌Chlamydiatrachomatis沙眼衣原体Neisseriagonorrhoeae淋球菌Viruses病毒HerpessimplexvirusFungi真菌Yeasts原虫7BacterialVirulenceFactorsInfectingorganismshaveavariablecapacitytostimulateorevadeactivationoftheimmuneresponse.Uropathogenicproducehemolysin
(溶血素)andaerobactin(菌素)Fimbriae(菌毛):I,P,SSpecificO,KandHserogroups.Escherichiacoli大肠杆菌8HostdefensesofthenormalurinarytractValveatthejunctionofureterandbladder.Thedilutionandremovalofbacteriainurinewhichoccurswithmicturition.Hostdefensesotherthanvoidingthatcontributetomaintainingsterilityofurine.DefenseExampleUrinecharacteristicsPH↓,osmolality↑,concentrationoforganicacidsUrineproteinsTamm-Horsfallprotein;secretoryIgA,IgG;lactoferrin(乳铁蛋白),lipocalin(载脂蛋白),ectInflammatorycellsPolymorphonuclearleukocytesUroepitheliumMucopolysaccharidelayer,CytokineproductionProstatesecretionsChemokines,immunoglobulinsHostgeneticfactorsHostgeneticfactorsinfluencesusceptibilitytoUTIwomenwhohaveexperiencedrecurrentUTIsthenumberandtypeofreceptorsonuroepithelialcells910Obstructionstone
obstructionhydronephrosisAnyimpedimenttothefreeflowofstone,urine-tumor,stricture,orprostatichypertrophyresultinhydronephrosisandagreatlyincreasedfreguencyofUTI.11GenderandSexualactivity(♀:♂=8:1)12PregnancyUTIsaredetectedin2-8%ofthepregnantwomenSymptomaticuppertractinfectionsareuncommonUppertractinfectionresultfromdecreasedureteraltoneandperistalsis,temporaryincompetenceofvesicoureteralvalvespregnancy13NeurogenicBladderDysfunctionThesepatientusuallyaccompanywithspinalcordinjury,tabesdorsalis,multiplesclerosis,diabetes,andotherdiseasesInterferencewithbladderenervationTheinfectionmaybeinitiatedbytheuseofcatheterforbladderdrainagecatheter14
VesicoureteralReflux
UrinerefluxfromthebladdercavityupintotheuretersandsometimesintorenalpelvisItoccursduringvoidingorwithelevationofpressureinthebladderDisturbenceofimmunecapacity
suchasdiabetes,anemia,chronichepaticdisease,chronickidneydisease,tumorandsoonInflammationofnearareaProstatitisVaginitismanOthers15Possibleroutesofinfection
Ascendingroute
MostUTIarebelievedtooccurbytheascendingroute.urethra→bladder→ureter→pelvis→calyx→parenchymal
Hematogenousroute
RelativelyrareStaphylococcalbacteremia金葡菌血症Directinfection
trauma
organsinfectionaroundthekidneyLymphaticrouteIntestinetokidneybywayoflymphatics
appendicitis
colitisAscending16Pathology-AcutePhase
Macroscopicexamination:Mucosaisedematousandcongestive,andcontainavariablenumberofabscessesonthecapsularsurfaceandoncutsectionsofthecortexandmedulla.Occasionally,areasofinflammationextendfromthecortexintothemedullaintheshapeofwedge.AcuteCystitis17Pathology-AcutePhase
Histologicchanges:Tubularepithelialcellsareedematous,necrosisanddetachfrombasementmembrane.Sometubulesaredamagedandothersaredestroyed,manytubulescontainleukocytes.Acuteinflammationwithpolymorphonuclearleukocyteinfiltrationmaybefound.Theglomeruliandbloodvesselsarerelativelyfreeofinflammatorychanges.18Pathology-ChronicPhase
Macroscopicexamination:Parenchymalscarringandunderlyingcaliceal
deformity.Thekidneysarefrequentlyirregular,andreductioninsizeisoftenunilateral.Thekidneyusuallyhasflat-basedorU-shapedscars.19Pathology-ChronicPhase
Histologicchanges:increaseininterstitialfibroustissuetubuleatrophyandnecrosisperiglomerularfibrosisCystitisCystitisisacommonsyndromethataffectsotherwisehealthywomen10%ofyoung,sexuallyactive,premenopausalwomenexperienceaUTIeachyear60%ofallwomenhaveoneormoresuchinfectionsintheirlifetimeFrom2-5%ofwomenexperiencefrequentrecurrentinfectionViaascendingrouteE.coliisthemostcommonagent2021Cystitis-ClinicalpresentationLocalmanifestations:urgency,frequency,
dysuria,
stranguria,orhesitancy.
andsuprapubicpainSystemicsymptoms:absenceUrine:grosslycloudyandmalodorous,bloodyinabout30%ofcases;whitecellsandbacteriacanbedetectedAcutepyelonephritisLesscommon
thancystitisThehighestincidenceisamongyoungwomenaged20-30yearsHospitalizationisrequiredforasmanyas20%ofaffectednonpregnantwomenE.coliisisolatedin85%to90%ofwomenRiskfactors:recentsexualintercourse,diabetes2223Acutepyelonephritis-ClinicalpresentationLocalmanifestations:Backandloinpain(withexquisitetendernessonpercussionofthecostovertebralangle).Dysuriafrequancy,andnocturia.Prominentsystemicsymptoms:rigorsandhighfever,oftenwithfatigue,nauseaandvomiting,abdominalpainordiarrhea.Urine:Cloudyurine,pyuria,hematuria,leukocytecastsBlood:leukocytecount↑,C-reactiveproteinandprocalcitonin(降钙素原)↑
ChronicpyelonephritisAsymptomaticbacteriuria,dysuriaandfrequency,vaguecomplaintsofflankorabdominaldiscomfort,andintermittentlow-gradefevers.Maybedividedintothefollowingfivetypes:Recurrenttype;Low-gradefevertype;Hematuriatype;Insidioustype;Hypertensiontype2425UrethritisApproximately30%ofwomenwithacutedysuria,freguency,andpyuriahavemidstreamurineculturesshoweithernogrowthorinsignificantbacterialgrowth.Adistinctionshouldbemadebetweenwomeninfectedwithsexuallytransmittedpathogens.26Catheter-associatedUTIsBacteriuriadevelopsinatleast10%to15%ofhospitalizedpatientswithindwellingurethralcathetersGram-negativeorganisms:E.coliorProteus,Pseudomonas,Klebsiella,SerratiaGram-positiveorganisms:Staphylococci,enterococciandCandidausuallycausetheseinfectionsFactorsassociatedwithanincreasedrisk:female,prolongedcatheterization,severeunderlyingillness,etc.MostCatheter-associatedUTIscauseminimalsymptoms27ComplicationsPapillarynecrosisPerinephricabscessPapillarynecrosisAnuncommoncomplicationinpyelonephritisOccursmoreoftenindiabeticpatientsSymptomsandsigns:Hematuria,painintheflank,
chillsandfeverTheIVPmayshowlossofpapillae-"ringshadow"28PerinephricabscessRarecomplicationofpyelonephritisOftenassociatedwithobstructionorDMSymptomsandsigns:loinpainaccentuatedbymovement,chillsandfever,urinaryfrequencyanddysuria.Ultra-sound,radiationexamhelptodiagnosis.2930DiagnosisUrinaryroutineWhitecellsarefrequentlyobserved.HematuiraDetectionofleukocytecastsisalsoanindicationofinvolvementofthekidney.Proteinuria,<2g/d,lowmolecularprotein.Lowgravity,highpH,whenthetubulardysfunctionoccurs.31DiagnosisGram’sstainThesimplestmethodfordetectingsignificantbacteriuriaistoexaminetheurineunderthemicroscope,usingGram’sstain.Ifbacteriaarefoundusingtheoilimmersionobjective,therearelikelytobemorethan105bacteria/ml.32Diagnosiscleanmid-streamurinecultureThemostwidelyusedmethodofcollectingurineforcultureandisthemethodofchoice.Ifthebacterialcount>105/ml,canbedefinedsignificantresult.Whenbacterialcount<104/ml,canberegardedascontaminated.Coccuscountreaches103~104/mlalsocanbedefinedsignificantresult.33Cleanmid-streamurineculture,notice:theprocedureshouldbedonebeforeantibiotictherapyor5days
aftercessationantibiotictherapy.thefirstmorningurinationispreferredforthebacteriacangrowmore.strictattentiontoasepsisisnecessary.34DiagnosisBloodroutinetest:WBC,ESR,CRPAntibody-coatedbacteria:helptodistinguishpyelonephritisfromthelowerUTIsRenalfunctiontest:defectinurinaryconcentrating,acidificationcapacityaswellasglomerularfiltrationfunction.Bloodcultures:inpatientwithsuspectedpyelonephritisorurosepsis35UrologicevaluationImaging:Ultrasound,X-ray,CTscan,MRI
KUB+IVP(intravenouspyelography)(Notice:
shouldbeavoidedduringacutephase)Cystoscopy:obstructionstone
hydronephrosis36Decisionprocessforupper&lowerUTIupperUTI(Pyelonephritis)lowerUTI(Cystitis)Signs&SymptomsFeverYesNoDysuriaMaybepresentYesFrequencyMaybepresentYesFlankpainYesNoDiagnosisPyuriaYesYesLeukocytecastsMaybepresentNoAntibody-coatedbacteriaMaybepresentNoC-reactionprotionIncreasedNormalBloodculturesPositivein~30%Negative37TreatmentAquantitativeurinecultureoracomparablealternativediagnostictestshouldbeperformedbeforeempiricaltreatmentFactorspredisposingtoinfection,suchasobstructionandcalculiReliefofclinicalsymptomsdoesnotalwaysindicatedbacteriologiccureEachcourseoftreatmentshouldbeclassifiedafteritscompletionasafailureoracureUncomplicatedinfectionsinlowerurinarytractrespondtoshortcourseoftherapy,whileuppertractinfectionsrequirelongertreatmentCommunity-acquiredinfections,especiallyinitialinfections,areusuallyduetomoreantibiotic-sensitivestrainsInpatientswithrepeatedinfections,orrecenthospitalization,thepresenceofantibiotic-resistantstrainsshouldbesuspectedTreatmentAcuteuncomplicatedcystitisGeneraltreatment:rest,increasefluidintakeAntibiotictreatment:3-dayregimens:oralTMP-SMX(复方新诺明),TMP(三甲氧苄胺嘧啶),quinolone(喹诺酮)7-dayregimens:Diabetes,males,Pregnancy:7-daytreatmentwithamoxicillin(阿莫西林)orcephalosporin(头孢菌素).
3839TreatmentAcuteuncomplicatedpyelonephritisGeneraltreatment:restinbed,increasefruidintakeandsoonAntibiotictreatment:Startantibiotictherapyimmediatelyafterurinecollection.Mildtomoderateillness,oralquinolonefor7-14days,orsingle-dosecephalosporinintravenousfollowedbyoralTMP-SMXfor14days.Seriousorpregnantpatientshouldbegivenantibioticdrugsthroughintravenousroute.Theantibioticcourseusuallyis14days.TreatmentComplicatedUTIsManyoftheinfectingstrainsareantibiotic-resistantEmpiricalantibiotictherapyideallyprovidesbroad-specturmcoverageWithminimalormildsymptoms,oraltherapywithquinolonefor10-14d.Untilcultureresultsandantibioticsensitivitiesareknown.Insevereillness,hospitalizationandparenteraltherapyEmpiricalregimens:Imipenemalong,
apenicillinorcephalosporinplusanaminoglycosideThetherapyshouldbeadministeredbytheinformationofantimicrobialsensitivityfor10-21days
40TreatmentAsymptomaticbacteriuriaInnoncatheterizedpatientsiscommon,especiallyamongelderlypatients.TheantimicrobialtherapyisunnecessaryHigh-riskpatientsmayrequiretreatment.Thetherapywithanoralagentfor7dBacteriuriainpatientswithcathetershouldnotbetreatedunlessthepatientisfebrileorhasotherevidenceofsystemicinfectionRemovalofthecatheterassoonaspossibleisbeneficialfortherapy41PreventionUrinateshortlyaftersexualintercourseinwomenDoubleortriplevoidingIncreasedfluidintakeWomenwhoexperiencefrequentsymptomaticUTIs,arecandidatesfortreatmentwithlong-termandlow-doseantibiotics.42PrognosisTheprognosisofuncomplicatedcystitisandpyelonephritisaregenerallygood.Thepatientswithcomplicationsmayleadtofurtherreductionofrenalfunction.Patientswithurosepsishaveapoorprognosis,withfatalityratesofabout30%orhigher.43CaseMissChen,34yearsoldSymptoms:
urgency,frequency,
bloodyurine
for2days
44whatwillyoudofirst?45historycollection
UTIhistory,underlyingdisease,sexualhistory,
Medicationhistoryphysicalexamination
takeatemperature,
costovertebralanglepain
38.4°C
温馨提示
- 1. 本站所有资源如无特殊说明,都需要本地电脑安装OFFICE2007和PDF阅读器。图纸软件为CAD,CAXA,PROE,UG,SolidWorks等.压缩文件请下载最新的WinRAR软件解压。
- 2. 本站的文档不包含任何第三方提供的附件图纸等,如果需要附件,请联系上传者。文件的所有权益归上传用户所有。
- 3. 本站RAR压缩包中若带图纸,网页内容里面会有图纸预览,若没有图纸预览就没有图纸。
- 4. 未经权益所有人同意不得将文件中的内容挪作商业或盈利用途。
- 5. 人人文库网仅提供信息存储空间,仅对用户上传内容的表现方式做保护处理,对用户上传分享的文档内容本身不做任何修改或编辑,并不能对任何下载内容负责。
- 6. 下载文件中如有侵权或不适当内容,请与我们联系,我们立即纠正。
- 7. 本站不保证下载资源的准确性、安全性和完整性, 同时也不承担用户因使用这些下载资源对自己和他人造成任何形式的伤害或损失。
最新文档
- 分级护理的护理沟通与协作
- 自体干细胞移植护理中的沟通技巧
- 冠心病患者心理护理技巧培训
- 经验与启示类试题及答案
- 2026年中考考前模拟-语文(安徽卷)(考试版A4)
- 《ISO9000-2026 质量管理- 基础和术语》之术语“3.8有关数据、信息和文件的术语”专业深度解读与应用指导材料(雷泽佳编制-2026A0)
- 特殊群体性病筛查服务
- 陶瓷成型施釉工岗位安全意识考核试卷含答案
- 物业管理师操作技能能力考核试卷含答案
- 煤层气排采工岗前基础能力考核试卷含答案
- 信托法教学课件
- CBT3790-97船舶管子加工技术条件
- JB-T 14314-2022 活塞式调流阀
- 景区游客最大承载量应急预案
- SJ-T 11798-2022 锂离子电池和电池组生产安全要求
- 新质生产力解读课件
- 功能色母粒企业标准
- 高中记叙文写作指导名师优质课获奖市赛课一等奖课件
- 药食同源健康养生演示文稿
- CA1340自动车床杠杆机械制造课程设计
- 2018杭州西湖区小升初新生素质测试卷-英语
评论
0/150
提交评论