肾内科uti的课件资料

肾内科uti的课件资料第1页/共48页Generalremarks

Inthischapter,UTIresultingfrombacterialinvasionisdiscussed.Anatomically.

Itisdividedintouppertracturinaryinfection(pyelonephritis)andlowertracturinaryinfection(cystitis)incidence：UTIisacommondisease(2%inpopulation),particularlyinfemaleadults(10%).第2页/共48页第3页/共48页Etiologyandpathogenesis

Pathogen：

gram-negativebacteria（Specificallycoliformbacteria,proteusbacteria）Pyocyanicinfectionisfrequentlyseeninpatientswithinstrumentation.Proteusbacteriaisoftenseeninpatientswithcalculus.第4页/共48页BacterialvirulencefactorsAhighdegreeofbacterialadherence,whichismediatedbythebacterialfimbriae.Somebacteriacanproducehemolysinwhichcanresistthebody’sdefensesystem.Drugresistancestrains第5页/共48页第6页/共48页HostdefensemechanismsEfficientemptyingofthebladderwithvoiding.Aprotectiveglycosaminoglycanlayer.ThehighosmolalityandextremesofpH.IgG,IgAandorganicacidsecretedbyurinarytractmucosa.第7页/共48页HostsusceptibilityfactorsurinarytractObstructionsuchascalculus,vesicoureteralrefluxorintrarenalreflux.

(thepresenceofUTIwithstructurallyorfunctionallyabnormalurinarytractiscalledcomplicatedUTI)ThedeformityofurinarysystemInstrumentationoftheurinarytractHostdefensesystemgetweak,forinstance,diabetesmellitusPregnancy,genderneurogenic

bladderGenetic

factor第8页/共48页InfectionrouteTheascendingroute:periurethraltissues→urethra→bladder→ureter→renalpelvis→renalmedullaThehematogenousrouteLymphogenousspreadDirectextensionfromotherorgansmayoccur第9页/共48页第10页/共48页第11页/共48页ClinicalmanifestationcystitisIrritativevoidingsymptomsfrequency,urgency,dysuria(burningordiscomfortonurination),suprapubicdiscomfortUrinalysispyuria,bacteriuria,hematuriaBloodtest:generallynormal

第12页/共48页Acutepyelonephritis

Irritativevoidingsymptoms,flankpain.Systemictoxicityfever,shakingchills,nausea,vomitingSigntendernessofureterspotonpalpation,exquisitetendernessonpercussionofthecostovertebralangle.LaboratoryfindingsBloodtest:leukocytosisandaleftshit.Urinalysis:pyuria,bacteriuria,hematuria.Bloodculture:maybepositive.第13页/共48页

Asymptomaticbacteriuria

nosymptomispresent,yetbacteriuriaexists.第14页/共48页Laboratoryfindings

Urinalysisafindingof≥5WBC/Hpor≥8000WBC/ml↓UTIwhitecellcasts→pyelonephritis.hematuria,proteinuria第15页/共48页LaboratoryfindingsDetectionofbacteriuriaCollectionofurinesample:Theurineiscollectedinmidstreambeforedrugisusedoratleast7daysafterdrugadministration.Avoidingcontamination,beingsenttothelaboratorywithin1h.第16页/共48页

UrinecultureCFUs≥105/ml→significantbacteriuria.CFUsbetween104~105/ml→suspectedUTI→reexaminationCFUs＜104/ml→maybecontamination

(Qualitative

urineculture:iftheurineforcultureisfromcystpuncture,thenwhenpositive,itindicateatrueUTI)第17页/共48页第18页/共48页

Urinesmearexaminedbymicroscopy

when≥1bacteriuria/oil-immersedHP

Chemicaltestforbacteriuria

Nitratereductiontest

thetestisdependentonthebacterialreductionofnitrateintheurinetonitrite.itiseffectiveinidentifyinginfectionduetogram-negativebacteria.第19页/共48页Imaging

IndicationAllmalepatientsFemalepatientrecurrentUTIcomplicatedUTIdisappointingresponsetoantimicrobialtherapy4.everinfectedduringpregnancy第20页/共48页ImagingstudiesincludeUltrasonographyIntravenouspyelogram(IVP)Computedtomography

Notice

IVPshouldnotbedoneintheacutephaseofUTI.第21页/共48页DiagnosisOFUTIsignificantbacteriuriaApositiveresultofurinecultureinwhichurinespecimenisfromcystpuncture.Quantitativeurineculture:apatientbeingsymptomatic,CFUs≥105/mlforonce.apatientbeingasymptomatic,CFUs≥105/mlfortwice(itshouldbethesamespecies)

第22页/共48页DiagnosisOFUTIwhenafemalepatientwithirritativevoidingsymptomandCFUs≥102/ml,UTIshouldbeconsideredandtreatmentforUTIshouldbegiven.

第23页/共48页Infection-localizingdiagnosisurinecultureafterbladderwashouttheassayforantibody-coatedbacteria（ACB)urinaryconcentratingability,urineβ2-MG，urinewhitecellcast.第24页/共48页

bilateralureteralcatheterrization.

itistooinvasiveforgeneraluse.clinicalpractice1.acutepyelonephritisfever(T＞38℃),shakingchills,backpain,WBC↑tendernessonpercussionofthecostovertebralangle2.3daysofantibioticstreatment,ifbeingcured→cystitis,ifnot→pyelonephritis.第25页/共48页Chronicpyelonephritis：

thecorticalscarringacorrespondingcalicealdeformitytubuledamageandinterstitial

inflammationandscarring

第26页/共48页Differentialdiagnosis

1.renaltuberculosis

aprominentirritativevoidingsymptomnullitytocommonantibioticsmycobacteriuminurinePPD（+）stricture,cavities,calcificationinIVP第27页/共48页第28页/共48页第29页/共48页第30页/共48页第31页/共48页2.urethralsyndrome:

exhibitirritativevoidingsymptomnosignificantbacteriuriaInfectiveurethralsyndrome:

causedbyotherpathogenssuchasvirus,mycoplasms,chlamydia.Urinalysisshowpyuria.

Non-Infectiveurethralsyndrome:noWBCisseenwithurinalysis.Probablyitisbecauseofpsychologicalproblems.第32页/共48页treatmentAntibiotics

G—Bacillus（sulfonamide,quinolones,β-lactamdrugsemisytheticpenicillins,cephalosporins）Afterthedrugsensitivitytestforoffendingorganismsisavailable,thenantibioticsaregivenaccordingtothetest.

第33页/共48页Acutecystitis:singledosetherapyanda3-daycourseoftherapy

↓followeduptoseewhethertheinfectioniscontrolledornotitshouldnotbeusedinpatientswithpregnancy,complicatedinfection,suspectedpyelonephritisormalepatients第34页/共48页

Acutepyelonephritis

intensiveantimicrobialtherapyshouldbeadministrated.antibioticsfor14daysorally.noeffectwithin72h→adjustthetreatment.

Moderateacutepyelonephritis:intravenoustherapyofantibiotics↓defervescesfor72horalagentatleast14days

第35页/共48页

Acutepyelonephritis

Severeacutepyelonephritis:

acombinationofantibioticsaregivenintravenously,oftenanaminoglycosidecombinedwithaβ-lactamdrugorcephalosporins.第36页/共48页

TherapyforrecurrentUTI：Relapsinginfection：

infectionoccurwithin6wofthecessationofantimicrobialtherapyandiscausedbythesameorganism.Reinfection：

causedbyanorganismwhichisdifferentfromtheoriginalone.第37页/共48页

TherapyforrecurrentUTI：

receiveshortcoursetherapyof7days→followedup7daysaftercessationoftherapy.Ifnosymptom，bacteriuriaandpyuria→curereinfection；Stillwithsymptoms,bacteriuriaandpyuria→treataccordingtodrugsensitivitytest.IfsucceededReinfection,iffailed→abigdoseantimicrobialsfor6weeks.patientswithmorethan3UTIs/years→longtermprophylaxistherapy.第38页/共48页treatmenturinarytractinfectioninpregnancychoosedrugsthataresafetofetus(ampicillincephalexin)asymptomaticbacteriuriaWomeninpregnancy,childrenbeforeschool-age,previoussymptomaticUTI,withcomplicatedfactors---shouldreceivetreatment.第39页/共48页Complication

Acuterenalpapillarynecrosis：accompaniedbydiabetesorurinarytractobstruction.leadtosepsisorARF.presentwithhighfever,severebackpain,hematuria,andureterobstructiontreatment:strengthenantimicrobialtherapy,andobstr