泌尿系统感染Urinarytractinfection

泌尿系统感染Urinarytractinfection第1页/共40页UrinaryTractInfections

第2页/共40页UTIUTI-commonafflictionforwhichpatientsseekmedicalattention

UTIcanoccurfrominfancythrougholdage

morecommoninfemalesthanmales

~20%ofallfemaleswillexperienceaUTIduringtheirlifetime第3页/共40页UTI

DefinitionsTheterm“UTI”representsawiderangeofclinicalsyndromesBacteriuria:thepresenceofbacteriainurine

-doesnotnecessarilyimplyinfection

Asymptomaticbacteriuria:presenceofbacteriaintheurinarytractintheabsenceofsymptoms-clinicalsignificancecontroversialoutsidecertainpatientpopulations-pregnantwomen-patientsundergoinginvasiveproceduresoftheurinarytract第4页/共40页UTI

DefinitionsCystitis:UTIpresumedtobeconfinedtothebladder

-painful/burningurination

-urgencyorfrequency

-absenceofsymptomsorphysicalsignssuggesting

inflammationatothersiteswithintheurinarytract

Note:clinicalcriteriaarenotoriouslyinaccurateinidentifyingtheactualanatomicsiteofinfection第5页/共40页UTI

DefinitionsPyelonephritis:clinicaldiagnosiswhichimpliesamoreinvasiveinfection

-inflammationofthekidneyandrenalpelvisisassumedtobepresentwhenpatientshavepainortendernessinvolvingtheflank,togetherwithotherclinicalorlaboratoryevidenceofUTI

-fever,nausea,chills,malaise,headache,etc第6页/共40页UTI

DefinitionsProstatitis:inflammation/infectionoftheprostategland

-maypresentasacuteorchronic

Intrarenalabscess/perinephricabscess:collectionofpusinthekidneyorinthesofttissuesurroundingthekidney第7页/共40页UTI

DefinitionsComplicatedinfections-underlyingabnormalitythatpredisposespatienttoUTI

ormakesUTImoredifficulttotreateffectivelyRecurrentInfections

Relapse-recurrenceofinfectionbysameorganismafterdiscontinuationoftreatment

Reinfection-recurrenceofinfectionbyadifferentorganismafterdiscontinuationoftreatment第8页/共40页UTI

PathogenesisUTIusuallyduetopatientsownintestinalflora

-ascendingrouteofinfection

-organismsentertheurinarytractinaretrogradefashionviatheurethraComplicatingfactorssuchascatheters,nephrostomytubes,surgery,urinarystones,etc

-alloworganismstoenterandpersistinurinarytract

-alterthetypicalspectrumoforganisms

-mayhavemultipleetiologies第9页/共40页UTI

PathogenesisElderlypatients

-incontinant

-functionallyimpaired

-postmenopausalchanges

-neurologicalalterationsPregnantwomen

-alteredanatomy

Hematogenousroute

-endocarditis,bacteremias,tuberculosis

-disseminatedinfections第10页/共40页UTI

EtiologyMajorityofUTIareduetoasinglepathogen

TheEnterobacteriaceaeresponsiblefor90%ofallUTI

-gramnegativebacilli

-facultativelyanaerobic

-commonintestinalflora

Escherichiacolimostcommonlyisolatedpathogen

~80%ofallUTI第11页/共40页Community-AcquiredUTIE.coliK.pneumoniaeProteusS.saprophyticusS.epi&gm-entericsEnterococcus第12页/共40页Uro-pathogensE.coli,Klebsiellaspp.

-intrinsicgutorganisms

-highlymotile

-producefimbriae(pili)>>attachment

Proteus,Morganella,Providencia

-Ureaseproducingorganisms

-increasesurinarypH-leadstocrystalformation>>biofilms

>>colonizationofcatheter

>>protectsbacteriafromhostdefenses&antibiotics第13页/共40页NosocomialUTI

catheterassociatedShortTermLongTermE.coliE.coliPseudomonasPseudomonasProteusProteusEnterobacterCandidaProvidenciaMorganellaS.aureusEnterococcus第14页/共40页UrinalysisusuallyhaveincreasednumbersofWBC

leukocyteesterasetestisoftenpositive

nitratetestisoftenpositive第15页/共40页UrinalysisUrineculture:significantbacteriuriausuallydefinedas

>105bacteria/ml.(108/litre)

lowernumbersmaybesignificantinchildrenandincathetercollectedspecimens第16页/共40页SpecimencollectionShouldallpatientswithasuspectedUTIbecultured?

Communityacquiredvsnosocomial?

Shouldallisolatesbeidentified?

Susceptibilitytesting?第17页/共40页SpecimencollectionCleancatchmidstreamspecimens

-mostfrequentlyusedmethod

-urethracleanedpriortocollection

-firstvoidurineallowedtopasstoclearurethra

-mid-streamcollectedinsterilecontainer

Collectionbags(children)

-usedinyoungchildrenlackingbladdercontrol

-oftencontaminated

-mostmeaningfulresultisanegativeculture第18页/共40页SpecimencollectionSuprapubicaspiration/straightcatheters

-invasive

-specimenobtaineddirectlyfrombladder

Indwellingcatheters

-urineobtainedbyinsertingneedleintocatheterorthroughdiaphram

-preferabletoobtainspecimenfromnewcatheter,ratherthanoldcatheter第19页/共40页SpecimentransportSenttoandprocessedbylabasquicklyaspossible

-Require:methodofcollection

timeofcollection

patient’santibiotics

Specimensnotreceivedbylabin1-2hoursMUSTberefridgerated

Urinesnotreceivedwithin24hoursornotrefridgeratedwillberejectedbylaboratory第20页/共40页AntimicrobialTherapyEmpiricTherapy

-basedonmostprobablepathogens

-localratesofresistance

-acuteinfectionvschronic

-reinfectionorrelapse

-indwellingcatheteretc第21页/共40页ManagementofUTIAnatomical/FunctionalPredispositiontoUTIImpairedbladderemptyingDysfunctionNeuropathyVURBOODiverticulum第22页/共40页ManagementofUTIAnatomical/FunctionalPredispositiontoUTIObstructionAnylevelVURCalculiverydifficulttoeradicateifUTIandstones第23页/共40页ManagementofUTIAnatomical/FunctionalPredispositiontoUTIIntrarenalRenalscarsInterstitialnephritisPapillarynecrosisMedullaryspongekidneyAPKDCongenitalcalycealobstruction第24页/共40页ManagementofUTIAnatomical/FunctionalPredispositiontoUTIAssociatedconditionsDiabetesmellitusPregnancyImmunosuppressionElderly第25页/共40页ManagementofFemaleUTIBacterialFactorsAdherenceAdhesinsFimbriaeNon-fimbrialAdhesinsBiofilmsImportantincatheterUTISolubleVirulenceFactorProductionDisruptbladderprotectivemucuslayer第26页/共40页ManagementofFemaleUTIBacterialFactorsIronAcquisitionMechanismsSiderophoresandHaemolysinsAllowgrowthSerogroupandSerumROagLPSouterG-vePreventcomplementdestructionCapsulesKagcoversbacteriacapsuleProtectsvphagocytosisandcomplementattack第27页/共40页ManagementofFemaleUTIBacterialFactorsIgProteasesCleavegutIgAUretericParalysisP.FimbriaeandendotoxinMotilityAscentofLUTUreaseProductionHydrolyseureaandincreasesammoniawhichincreasesbacterialadherence第28页/共40页ManagementofFemaleUTIHostFactorsColonisationofvagina,introitus,urethraBiologicalpredispositionHormonedeficiencyvaginalatrophySpermicidaljellyincreasesvaginalpHAntibioticsreducevaginallactobacilliandincreasepHAscenttobladderSexualmilkbackCatheterisation第29页/共40页ManagementofFemaleUTIHostFactorsEstablishmentofbacteriainbladderUrinecomposition(extremesinhibitbacterialgrowth)ReducedIgAandIgGReducedGAGlayerinthebladderLowurineflowIncompleteemptying第30页/共40页ManagementofFemaleUTIMSSUwhensymptomaticUSSrenaltractwithpostvoidresidualKUBTargetedflexiblecystoscopy(8%yield)macroscopichaematuriamicroscopichaematuriabetweenUTIspersistentUTI第31页/共40页ManagementofFemaleUTI3daysoralantibioticsorx1highdoseifcompliancepoor14daysantibioticsifpyelonephritisAddressanyunderlyingcause(rare)Generaladviceincreasefluidintakecranberryjuicevoidbeforeandaftersi第32页/共40页ManagementofFemaleUTIHygienewashwithoutsoappatorairdrycottonpants6monthslowdoseprophylacticantibioticsaltergutfloramayaffectCOCPSelf-startantibiotictherapy第33页/共40页ManagementofMaleUTIMSSUwhensymptomaticUSSrenaltractwithflowrateandpostvoidresidualKUBFlexiblecystoscopymacroscopichaematuriamicroscopichaematuriapersistentUTI第34页/共40页ManagementofMaleUTIUTI-7daysoralantibioticsAddressunderlyingcause第35页/共40页ManagementofChildhoodUTIHist