Urinary-Tract-Infection(尿路感染全英文)课件

UrinaryTractInfection

WuYitai

DepartmentofNephrology

TongjiHospital,TongjiUniversity

UrinaryTractInfection

Wu1ContentDefinitionsEpidemiologyEtiologyPathogenesis

PathologyClinicalpresentationDiagnosisTreatmentsComplicationPreventionContentDefinitions2DefinitionofUTIUTIisdefinedasthepresenceofmicro-organismsintheurinarytract.

MostpatientswithUTIhavesignificantbacteriuria,i.e.bacterialcolonycounts

˃105

/ml,inamid-stream“cleancatch”urine.

Conversely,colonycounts＜105/mlofmidstreamurineareoccasionallyduetospecimencontamination.Acuteurethralsyndrome:dysuria,urgency,andfrequency,butwithoutbacteriuria.DefinitionofUTIUTIisdefi3AnatomicLowerUTI:urethritiscystitis(mucosalinfection)UpperUTI:pyelonephritisprostatitisintrarenalandperinephricabscesses(tissueinvasion)ClassificationofUTIs（1）AnatomicClassificationofUTIs4ClassificationofUTIs（2）ClinicalUncomplicatedUTI:LackstructuralorfunctionalabnormalitiesoftheurinarytractNormalflowofurineNOinterferencewiththenormaldefensesComplicatedUTI:Predisposinglesionoftheurinarytract,structuralorfunctionalabnormalities,e.g.congenitalabnormalityoftheurinarytract,stone,obstruction,catheter….Interferencewiththenormaldefenses,e.g.immunosuppression,renaldisease,ordiabetes.ClassificationofUTIs（2）Clini5ClassificationofUTIs（3）

EpidemiologyCatheter-associated（nosocomial）infections:SymptomaticAsymptomticNonCatheter-associated（community-acquired）infections:SymptomaticAsymptomticClassificationofUTIs（3）

Epid6EpidemiologyAlmosthalfofallwomenwillhaveatleastoneUTIintheirlives.UTIisuncommoninmenundertheageof50,butverycommonamongwomen.Asymptomaticbacteriuriaismorecommonamongelderlymenandwomen.EpidemiologyAlmosthalfofall7Etiology（1）

Community-AcquiredUTIgram-negativebacilliisthemostcommonagentE.coliEnterobacterEnterococcusProteusStaphylococcusKlebsiellaE.coliEtiology（1）Community-Acquired8Etiology（2）

Causativeorganisms:

Escherichiacoli

Klebsiella,proteusandpseudomonas

1-BacteriaS.aureus,StaphylococcusepidermidisandS.saprophyticus

Enterococci(Streptococcusfaecalis粪链球菌)

Mycobacteriumtuberculosis

Chlamydiatrachomatis,Neisseriagonorrhoeae2-VirusHerpessimplexvirus,HIV

3-FungusCandida,Histoplasmacapsulatum4-Protozoon

Trichomonasvaginalis,Schistomahaematobium

Etiology（2）Causativeorgan9CASE132year-oldwoman;Dysuriaandfrequency;Pyuriaintheurinesediment;Gramnegativebacilli.Escherichiacoli(E.coli).

CASE265year-oldwoman;Dysuriaandfrequency;Pyuria;Grampositivecocci.

EnterococcusfaecalisCASE1CASE210CASE318year-oldwomanDysuriaandfrequency;Pyuria;Grampositivecocci;Staphylococcus.CASE442year-olddiabeticwomanwithacatheter.Grampositiveyeasts.Candidagrew.CASE3CASE411RouteofInfectionAscendingroute(themostcommon)ColonizationofurethraRouteofInfectionAscendingro12PathogenesisPathogenesis13Pathogenesis（1）Theurinarytractabovetheurethraisnormallysterile.Theurethralmeatusandsurroundingperineumarecolonizedwithamixtureofskinandbowelflora.Vaginalfloraorpathogensmaycontaminatetheurethra.Pathogenesis（1）Theurinarytra14Pathogenesis（2）Hostdefensemechanisms:1.Urine:lowpH,highosmolality,highurea&organicacidconcentrationinhibitandkillmicroorganisms2.Regularurineflow:diluteandexpelpathogens3.Bladderepithelialcells:coatedwithmucus(glycosaminoglycan)preventbacteriafromadheringtobladderwallPathogenesis（2）Hostdefense15ConditionsaffectingpathogenesisGenderandsexualactivity.Pregnancy.Obstruction.（tumor,stricture,stone,BPH）Neurogenicbladderdysfunction.VesicoureteralrefluxBacterialvirulencefactorsGeneticfactors（detailsinthefollowing）Conditionsaffectingpathogene16Conditionsaffectingpathogenesis（1）GenderandsexualactivityThefemaleurethraappearstobepronetocolonizationwithcolonicgram-negativebacillibecauseofitsproximitytotheanus,itsshortlength,anditsterminationbeneaththelabia.Voidingafterintercoursereducestheriskofcystitis.Animportantfactorpredisposingtobacteriuriainmenisurethralobstructionduetoprostatichypertrophy.Conditionsaffectingpathogene17Conditionsaffectingpathogenesis（2）PregnancyUTIsaredetectedin2to8%ofpregnantwomen.Pregnantwomenwithasymptomaticbacteriuria.Bladdercatheterizationduringorafterdeliverycausesadditionalinfections.Conditionsaffectingpathogene18Conditionsaffectingpathogenesis（3）ObstructionTumorStrictureStoneBenign

prostatichypertrophy

(BPH)TheseconditionsresultinhydronephrosisandincreasefrequencyofUTI.Conditionsaffectingpathogene19Conditionsaffectingpathogenesis（4）NeurogenicBladderDysfunctionInterferencewithbladderenervation,asinspinalcordinjury,multiplesclerosis,diabetes.Theinfectionmaybeinitiatedbytheuseofcathetersforbladderdrainage.Theinfectionisfavoredbytheprolongedstasisofurineinthebladder.Conditionsaffectingpathogene20Conditionsaffectingpathogenesis（5）VesicoureteralRefluxVesicoureteralrefluxoccursduringvoidingorwithelevationofpressureinthebladder.Commonamongchildrenwithanatomicabnormalitiesoftheurinarytract.Renaldamagecorrelateswithmarkedreflux,notwithinfection.Conditionsaffectingpathogene21Conditionsaffectingpathogenesis（6）BacterialVirulencefactorsSpecificO,K,andHserogroups.Adherenceofbacteriatouroepithelialcellsisacriticalfirststepintheinitiationofinfection.Fimbriaemediatetheattachmentofbacteriatospecificreceptorsonepithelialcells.E.colistrainsusuallyproducehemolysinandaerobactin.Conditionsaffectingpathogene22Conditionsaffectingpathogenesis（7）GeneticfactorsHostgeneticfactorsinfluencesusceptibilitytoUTI.Thenumberandtypeofreceptorsonuroepithelialcellsareinpartgeneticallydetermined.Conditionsaffectingpathogene23ConditionsaffectingpathogenesisGenderandsexualactivity.Pregnancy.Obstruction.（tumor,stricture,stone,BPH）NeurogenicBladderDysfunction.VesicoureteralRefluxBacterialVirulencefactorsGeneticfactorsConditionsaffectingpathogene24PathologyCystitisMucosalhyperemiaEdemaLeukocyteinfiltrationEasybleedingGranularsurfaceSuperficialulcerPurulentexudatePathologyCystitisMucosalhype25PathologyAcutePyelonephritisAcuteinflammationHyperemia

andedemaVolumeincreaseRedcolourYellowishabscessPurulentexudatePathologyAcutePyelonephritis26PathologyChronicPyelonephritisChronicinflammationPelvisdeformedCortexscarsVolumeshrinkAsymmetricParenchymaatrophyPathologyChronicPyelonephri27PathologyInterstitialedemaNeutrophilinfiltrationWhitebloodcellcastInmicroscopyPathologyInterstitialedema28ClinicalPresentationClinicalPresentation29Clinicalpresentation（1）CystitisBurning

painFrequency,

urgencySuprapubic

painDysuriaClinicalpresentation（1）Cystit30Clinicalpresentation（2）UrethritisBurning

painFrequency,

urgencyDysuriaInfectedwithsexuallytransmittedpathogens

Clinicalpresentation（2）Urethr31Clinicalpresentation（3）AcutePyelonephritisAllcystitis

symptoms（+）or（-）Fever,

shaking

chillsNausea,

vomiting,

diarrheaTachycardia,

hypotentionMuscle

tendernessCostovertebral

angle（CVA）painGram-negative

sepsis,LeukocytosisLeukocyte

castsinthe

urineClinicalpresentation（3）Acute32Clinicalpresentation（4）Catheter-AssociatedUTIsBacteriuriadevelopsinatleast10to15%ofhospitalizedpatientswithindwelling

urethral

catheters.Theriskofinfectionis3to5%perdayof

catheterization.

Manyinfectingbacteriadisplaymarkedlygreat

antimicrobialresistance.Clinicalpresentation（4）Cathet33Howisitdiagnosed?DiagnosisPatient

historyComplete

physical

examination

Urine

cultureUrine

analysisOther

examinations

Howisitdiagnosed?DiagnosisP34MicroscopicExaminationPyuria

WBC>5/HPBacterialcolonycounts>105/mlDiagnosisMicroscopicExaminationPyuria35DiagnosisDipstickMethodsLeukocyte

esterase+Nitrite+

Urine

routine:pH,sg,protein,glucose,blood,ket,etc.DiagnosisLeukocyteesterase36Clean

urine

culture:

bacterial

counts

>105/mlSuprapubic

puncture,cathetercollectedurine>102/mlSignificant

bacteriuria

Microscopic

bacteriuriaUrineCultureTest

(very

important)DiagnosisCleanurineculture:bacter37LocalizationofUTI（No

definite

standard

method）

UltrasonographyIntravenous

pyelography（IVP）

Abdominal

CT/MRILocalizationofUTI（Nodefini38Treatments

for

differenttypes

of

UTIsTreatmentsfordifferenttyp39Acuteuncomplicatedcystitis

PathogensStaphylococcussaprophyticus(5-15%)EnterobacteriaceaeE.coli(86%)KlebsiellapneumoniaeProteusEnterococcusAcuteuncomplicatedcystitis

P40Single-dose

therapy

is

less

effectiveEspecially

with

β-lactams3-day

course

recommendedTMP-SMX,

fluoroquinolone,

nitrofurantoinNOTappropriateformalepatientsandcomplicated

UTIs7-day

course:Diabetes,age>65years,MalesIfuntreated:may

lead

to

acuteuncomplicated

pyelonephritistreatmentAcuteuncomplicatedcystitis

Treatment--AntibioticTherapySingle-dosetherapyisless41Acuteuncomplicatedpyelonephritis

PathogensEnterobacteriaceaeE.coliKlebsiellapneumoniaeProteusStaphylococcussaprophyticusAcuteuncomplicatedpyelonephr42Mildormoderatesymptoms:Outpatienttreatment(7–14days)Oraltreatment:Fluoroquinolone,

TMP/SMX,third

generation

cephalosporinSevereillpatient:HospitalizationrequiredParenteraltherapy(14days)Broad-spectrum

cephalosporinsorFluoroquinolonesAcuteuncomplicatedpyelonephritis

Treatment

(7–14days)Mildormoderatesymptoms:Acut43ComplicatedUTIs

PathogensEnterobacteriaceaeE.ColiKlebsiellapneumoniaeProteusEnterococciPseudomonasStaphylococciComplicatedUTIs

PathogensEn44Minimalormildsymptoms(10-14d).Oraltherapy:fluoroquinolone(ciprofloxacinor

ofloxacin)Severeillpatient,parenteral

therapy(10-21d).Hospitalization

required,ImipenemalonePenicillinorcephalosporinplusaminoglycosideThird

generation

cephalosporin:Ceftriaxone

or

ceftazidimeComplicatedUTIs

TreatmentMinimalormildsymptoms(145Low

urinary

tract

infection(acutecystitis):

7

days

course

antibioticsAmoxicillin,

cephalosporine,

nitrofurantoinPyelonephritis:2-4

weeks

course

antibioticsCephalosporins,

extended

spectrumpenicillinsParenteral

treatmentFollow-up

urine

culture

tests,

monthlyLow-doseprophylaxistorecurrentinfectionsAsymptimaticbacteriuriaAntibiotics

treatments

are

needed.UTI