泌尿系统感染

Urinarytractinfections(UTI)尿路感染2EpidemiologyThe

incidence

is

secondafterrespiratoryinfections50%-60%ofallfemaleshaveatleastoneepisodeofaUTIatsometimeintheirlives.AnatomyoftheurinarysystemKidneysfilterbloodUreterscarryurinetobladderBladderstoresurineuntilitisexpelled(throughurethra)OnlylowerpartofurethrahasaresidentbacterialfloraRestoftheurinarytractisnormallysterileUrinaryTractTermsUTI:thefindingofmicroorganismsinbladderurinewithorwithoutclinicalsymptomsandwithorwithoutrenaldiseaseSignificantbacteriuria（有意义细菌尿）:thefindingof>105cfu/mlofurine(butlowercountscanbesignificant)EtiologyofUTIE.coli(大肠杆菌）isthemostcommonpathogenHowever,alsocommonareotherEnterobacteriaceae(肠杆菌）Enterococci（肠球菌）:ofteninobstructiveuropathyYeasts（酵母菌）:dysbacteriosis(菌群失调)UrinaryTractInfections:

RoutesofInfection（1）Ascendinginfection–mostcommonE.coli(~70%)大肠杆菌

–uropathogenicstrains肾盂肾炎菌株

Proteus变形杆菌属,Pseudomonas假单胞菌属,Klebsiella克雷伯菌属,etc.(recurrent,hospitalacquired)（反复发作，医院获得性）上行感染ascendingroute：又称逆行感染。最多见。（尿道→膀胱→输尿管→肾脏）女性易尿感。致病菌：大多为大肠杆菌HematogenousDebilitatedpatients（衰弱病人）KidneyinjuryS.aureus金黄色葡萄球菌,groupAStrepA组链球菌,opportunistic(immunocompromised)免疫功能低下Clinicalsetting:septicemia败血症，endocarditis心内膜炎血行感染hematogenousroute：少见。发生在原存在严重尿路梗阻或免疫力差患者常见为肾皮质感染，致病菌多为金黄色葡萄球菌。肾结核。淋巴道途径lymphaticroute

：更少直接感染extendinvaderoute

：最少见UrinaryTractInfections:

RoutesofInfection（2）Mechanical(Hydrokinetic)Chemical(Urine)ImmunologicalCellularVirulenceFactors致病因素HostDefenses宿主防御UrinaryTractInfections:

PathogenesisObstructionpredisposestoinfectionObstructioninterfereswitheradicationObstructionpredisposestorecurrenceObstruction+Infection

↑pressureinflammationischemiadirectinjuryChronicpyelonephritisUrinaryTractObstruction尿路梗阻:

RelationshipwithinfectionHydronephrosisInfectionAcuteRecurrent/persistentChronicobstructivepyelonephritisRenalfailureHypertensionUrinaryTractObstruction:

ConsequencesWeakenedbodyresistancetodisease机体抗病能力减弱DiabetesmellitusPregnancyRenalfailureImmunosuppressedpatientsIatrogenicfactors医源性因素CatheterisationSurgery,e.g.prostatectomy导尿与尿路感染泌尿外科及术后病人中40%的医院内感染(Nosocomialinfection)发生在泌尿系统，而其中的80%与留置尿管有关一次导尿的感染机会为1%-2%留置导尿3-4天并行开放引流尿液，50%-70%的患者将有感染长期留置导尿管者（＞30天），细菌尿的发生为100%。ImpactofCAUTI(Catheter-associatedUrinaryTract

Infection)Mostcommontypeofhealthcare-associatedinfection>30%ofHAIsreportedtoNHSNEstimated>560,000nosocomialUTIsannuallyIncreasedmorbidity&mortalityEstimated13,000attributabledeathsannuallyLeadingcauseofsecondaryBSIwith~10%mortalityExcesslengthofstay–2-4daysIncreasedcost–

$0.4-0.5billionperyearnationallyUnnecessaryantimicrobialuse50%-60%ofallfemaleshaveatleastoneepisodeofaUTIatsometimeintheirlives.Whyfemales?ShorturethraProximityofurethratotheanusItsterminationwithinthelabiaUseofspermicidecontraceptivesPregnancyMenalsohaveanantibacterialsubstanceintheirprostateglandthatreducestheirrisk.诊断方法：症状+体征+实验室化验+辅助检查Thesymptomsofurinarytractinfectionsmayvarywithageandthepartoftheurinarysystemthatwasaffected.Inyoungchildren,urinarytractinfectionsymptomsmayincludediarrhea,lossofappetite,nauseaandvomiting,feverandexcessivecryingthatcannotberesolvedbytypicalmeasures.Olderchildrenontheotherhandmayexperienceabdominalpain,orincontinence.Lowerurinarytractinfectionsinadultsmaymanifestwithsymptomsincludinghematuria(bloodintheurine)diagnosis:symptoms(1)LocalizationofupperversuslowerUTI:inpracticeFrequency,dysuria,andurgency(lowerUTIsymptoms)canoccurwithupperUTIaswell.Feverandflankpainindicateacuteupperurinarytractinfection.ScarringofthekidneybyimagingproceduressuggestschronicUTI.Thedistinctionissometimesdifficult.cystitisDysuriaUrgencyFrequencySuprapubicpainCloudy,foulsmellingurineHaematuria30%TendersuprapubisAcutepyelonephritisRapidlydevelopingsymptomsoverafewhoursoradayFever,chills,rigor,myalgiaNausea,vomiting,diarrhoeaRATortendernessondeeppalpationFeaturesofGramnegsepsisHaematuriaintheacutephaselaboratorydata:CollectionofSpecimensCleanmid-streamspecimenofurineEarlymorningsamplepreferredCatheterspecimenSuprapubicaspirationDifferentialspecimenfromtwouretersInstructionstothepatientsEarlytransporttothelabessential尿标本的采集Urinecollection

：中段尿、导尿、穿刺-最可靠。

laboratoryUrinalysis:WBCs(>5perhigh-powerfield),RBCs,bacteria,castsUrinecultureDifferencebetweeninfectedandcontaminatedurine

InfectionContamination

Morethan105Organisms/mllessthan104

Organisms/ml

Asinglebacterialspp.MorethanoneorganismWhitebloodcellcastsHighlysignificant!Presencesuggestspyelonephritis白细胞管型提示肾盂肾炎Investigations(1)

RadiologyIndicatedin:RecurrenceMaleaffectationChildrenSeveresymptomsInvestigations(2)ToolsincludeIVU,USS,CTscanDetectscalculi,obstruction,incompleteemptyingMRIincontrastallergies

CLASSIFICATIONOFUTIs

Traditionally,UTIsareclassifiedbasedonclinicalsymptoms,laboratorydata,andmicrobiologicalfindings.Practically,UTIshavebeendividedinuncomplicatedandcomplicatedUTIs,andsepsis.CLASSIFICATIONOFUTIsEAUGUIDELINE：ANATOMICALLEVELOFINFECTIONsGRADEOFSEVERITYOFINFECTIONsUNDERLYINGRISKFACTORSsMICROBIOLOGICALFINDINGSThesymptoms,signsandlaboratoryfindingfocusontheanatomicallevelandthedegreeofseverityoftheinfection.Theriskfactoranalysiscontributestodefineanyadditionaltherapeuticmeasurerequired(i.e.drainage).

Anatomicallevelofinfection

URETHRAURETHRITISBLADDER

CYSTITISKIDNEYPYELONEPHRITISBLOODSTREAMSEPSIS

Gradeofseverity

complicatedUTIAcomplicatedUTIisaninfectionassociatedwithacondition,suchasstructuralorfunctionalabnormalitiesofthegenitourinarytractorthepresenceofanunderlyingdisease,whichincreasestherisksofacquiringaninfectionoroffailingtherapy.TwocriteriaaremandatorytodefineacomplicatedUTI:apositiveurinecultureandoneormoreofthefactorslistedinTableFactorsthatsuggestapotentialcomplicatedUTI

留置导尿或留有尿路支架、残余尿超过100ml梗阻返流尿流改道放化疗损伤尿路上皮围手术期的尿路感染肾功能不全或肾移植、糖尿病TreatmentprinciplesUrineculturemustbedonebeforecommencingempiricaltherapyIdentifyandcorrectpredisposingfactorsIdentifytypeofUTIandtreataccordinglyPreventrecurrenceHowisaUrinaryTractInfectionTreated?restfluidsantibiotics:Thechoiceofdrugandlengthoftreatmentdependonthepatient'shistoryandtheurinetestresults.Thesensitivitytestisespeciallyusefulinhelpingthedoctorselectthemosteffectivedrug.Also:DrinkplentyofwaterQuitSmokingAvoidspicyfoods,coffee,andalcoholUsepainkillertoeasepainProphylaxisofUTI(1)NursingCare:HealthpromotiontopreventUTIFluidintake2–2.5Ldaily,moreifhotweatherorstrenuousactivityisinvolvedb. Emptybladderevery3–4hoursProphylaxisofUTI(2)c. Females1. Cleanseperinealareafromfronttoback2. Voidbeforeandaftersexualintercourse3. Maintainintegrityofperinealtissuesa.Avoiduseofcommercialfemininehygieneproductsordouchesb.Wearcottonunderweard.Maintainacidityofurine(useofcranberryjuice,takeVitaminC,avoidexcessmilkandmilkproducts,sodiumbicarbonate)女性注意事项：1清洁会阴：从前向后2性生活前后排尿3避免会阴受损Uncomplicated(simple)CystitisDefinitionHealthyadultwoman(overage12)Non-pregnantNofever,nausea,vomiting,flankpainDiagnosisDipstickurinalysis(nocultureorlabtestsneeded)TreatmentTrimethroprim/Sulfamethoxazolefor3daysMayusefluoroquinolone(ciprofoxacinorlevofloxacin)inpatientwithsulfaallergy,areaswithhighratesofbactrim-resistanceRiskfactors:SexualintercourseMayrecommendpost-coitalvoidingorprophylacticantibioticuse.ComplicatedCystitisDefinitionFemaleswithcomorbidmedicalconditionsAllmalepatientsIndwellingfoleycathetersUrosepsis/hospitalizationDiagnosisUrinalysis,UrinecultureFurtherlabs,ifappropriate.TreatmentFluoroquinolone(orotherbroadspectrumantibiotic)7-14daysoftreatment(dependingonseverity)Maytreatevenlonger(2-4weeks)inmaleswithUTIPyelonephritisInfectionofthekidneyAssociatedwithconstitutionalsymptoms–fever,nausea,vomiting,headacheDiagnosis:Urinalysis,urineculture,CBC,ChemistryTreatment:2-weeksofTrimethroprim/sulfamethoxazoleorfluoroquinoloneHospitalizationandIVantibioticsifpatientunabletotakepo.Complications:Perinephric/Renalabscess:Suspectinpatientwhoisnotimprovingonantibiotictherapy.Diagnosis:CTwithcontrast,renalultrasoundMayneedsurgicaldrainage.NephrolithiasiswithUTISuspectinpatientwithsevereflankpainNeedurologyconsultfortreatmentofkidneystoneProstatitisSymptoms:Painintheperineum,lowerabdomen,testicles,penis,andwithejaculation,bladderirritation,bladderoutletobstruction,andsometimesbloodinthesemenDiagnosis:Typicalclinicalhistory(fevers,chills,dysuria,malaise,myalgias,pelvic/perinealpain,cloudyurine)ThefindingofanedematousandtenderprostateonphysicalexaminationWillhaveanincreasedPSAUrinalysis,urinecultureTreatment:Trimethoprim/sulfamethoxazole,fluroquinoloneorotherbroadspectrumantibiotic4-6weeksoftreatmentRiskFactors:TraumaSexualabstinenceDehydrationUrethritisChlamydiatrachomatisFrequentlyasymptomaticinfemales,butcanpresentwithdysuria,dischargeorpelvicinflammatorydisease.SendUA,Urineculture(ifpyuriaseen,butnobacteria,suspectChlamydia)Pelvicexam–senddischargefromcervicalorurethralosforchlamydiaPCRChlamydiascreeningisnowrecommendedforallfemales≤25yearsTreatment:Azithromycin–1gpox1Doxycycline–100mgpoBIDx7daysNeisseriagonorrhoeaeMaypresentwithdysuria,discharge,PIDSendUA,urineculturePelvicexam–senddischargesamplesforgramstain,culture,PCRTreatment:Ceftriaxone–125mgIMx1Cipro–500mgpox1Levofloxacin–250mgpox1Ofloxacin–400mgpox1Spectinomycin–2gIMx1Youshouldalwaysalsotreatforchlamydiawhentreatingforgonnorhea!Question#1An18-yearoldwomanpresentswithurinaryfrequency,dysuria,andlow-gradefever.Urinalysisshowspyuriaandbacilli.Shehasneverhadsimilarsymptomsortreatmentforurinarytractinfection.Question#1WhatcategoryofUTIdoesthispatienthave?Doesthispatientrequirefurthertesting?Wouldyoutreatthispatient,andifso,withwhatandhowlong?Question#2An18-yearoldwomanpresentwithherthirdepisodeofurinaryfrequency,dysuria,andpyuriainthepast4months.Question#2Whatfurtherquestionsdoyouhaveforthispatient?WhattypeofUTIdoesthispatienthave?Whattestingmightyouperforminthispatient?Howwouldyoutreather,andforhowlong?Question#3 A24-yearoldwomanpresentswithfever,chills,nausea,vomiting,flankpainandtenderness.Hertemperatureis40°C,pulserateis120/min.,andbloodpressureis100/60mmHg.Question#3Whatfurtherstudiesdoyouwantinthispatient?Howwouldyoutreatthispatient?Whatmightyoudoifshedoesnotimproveafter3-4days?Question#4 A78-yearoldfemalepresentswithanindwellingfoleycatheterandpyuria.Question#4Whatwouldyoudoforthispatientatthistime?Howmightyourwork-up/managementchangeifshewashavingfeversandconfusion?Question#5 58-yearoldmanpresentswithhisfirstepisodeofurinaryfrequencyanddysuria.Urinalysisshowspyuriaandbacilli.Question#5WhattypeofUTIdoesthispatientlikelyhave?Howwouldyoutreatthisman,andforhowlong?WhatactivitieswouldputthispatientatriskforUTI?Question#6A28-yearoldmalehadasexualencounterwithaprostitutewhileonabusinesstripinSeattle1weekago.Afterreturninghome,henotedaburningsensationonurinationandayellowdischargeinhisunderwear.Microsc