内科学教学课件：尿路感染1

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