Urinary tract infection

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Urinary tract infection

• Dr. Mai Banakhar

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UTI

• inflammatory response of urothelium to
  bacterial invasion.

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• Bacteriuria bacteria in urine
• Asymptomatic or symptomatic
• Bacteriuria pyuria infection
• Bacteriuria NO pyuria colonization

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• Pyuria
• WBCs in urine.
• Infection
• T.B
• Bladder stone.

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Complicated VS uncomplicated

• Un complicated UTI
• UTI structurally functionally normal urinary
  tract.
• Female.
• Respond to short course of antibiotic

• Complicated UTI
• Anatomical or funtional abnormality.
• Male.
• Longer time to respond to ttt

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• Isolated UTI
• 6 months between infections.

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• Recurrent UTIgt2 infections in 6 months
• 3 UTI in 12 months.
• Reinfection by different bacteria.
• Persistence same organism from focus within
  the urinary tract.
• Struvate stone.
• Bacterial prostatitis.
• Fistula
• Urethral diverticulum.
• atrophic infected kidney.

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• Unresolved infection
• in adequate therapy , bacterial resistance to
  ttt.

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Risk factors to bacteriuria

• Female
• Age
• Low estrogen ( menopause)
• Pregnancy.
• D.M
• Previous UTI.
• FC

• Stone
• GU malignancy.
• Obstruction.
• Voiding dysfunction.
• Institutionalized elderly

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Microbiology

• Faecal-drived bacteria
• Uncomplicated UTI
• E.Coli, G-ve baccillus, (85- 50)
• Staph saprophyticus
• Enterococ faecalis
• Proteus
• Klebsiella.

• Complicated UTI
• E.coli 505
• Enterococ faecalis.
• Staph aureus
• Staph epidermidis
• Pseudomonas aeruginosa

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Route of infection

• Ascending
• Short urethra
• Reflux
• Impair urteric peristalisis.
• Pregnancy
• Obstruction
• G-ve , Edotoxins
• Organism P pili

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Route of infection

• Haematogenous
• Uncommon.
• Staph aureus.
• Candida fungemia.
• T.B

• Lymphatics
• Rarely in inflammatory bowel disease,
  reteroperitoneal abscess

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• Increase UTI risk
• Increase bacterial virulence

• Protect against UTI
• Host defences

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Factors increasing bacterial virulence

• Adhesion factors
• Toxins
• Enzyme production.
• Avoidance of host defense mechanisms

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Factors increasing bacterial virulence

• Adhesion factors
• G-ve bacteria, Pili
• Attachment to host urothelial cells.
• Single type or different types e.x E.coli
• Defined functionally be mediating
  hemagglutination (HA) of specific erythrocytes

• Mannose sensitive
• (type 1)
• Produced by all strains E.coli
• Certain pathogenic types of E.coli mannose
  resistant pili
• ( pyelonephritis)

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Factors increasing bacterial virulence

• Avoidance of host defense mechanisms
• E.coli
• Extracellular capsule
• Immunogenisity phagocytosis
• M.Tuberculosis reisit phagocytosis by preventing
  phagolysosome fusion

• Toxins
• E.coli cytokines, pathogenic effect on host
  tissues
• Enzyme production
• Proteus ureases
• Ammonia struvite stone formation

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Host defences

• Protective
• Mechanical (flushing of urine) antegrade flow of
  urine
• Tamm-Horsfall protein (mucopolysaccharide
  coating bladder prevent bacterial attachment)
• chemical Low Urine PH high osmolality
• Urinary Immunoglobulin I gA inhibit adherence

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Lower UTI

• Cystitis infection inflammation of the bladder
• Frequency, samll volumes, dysuria, urgency,
  offensive urine SP pain, haematuria, fever
  incontinence.

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Investigation

• Dipstick of MSU
• WBC ( pyuria )
• 75 -95 sensitivity infection
• False ve
• False ve
• Other causes of pyuria

• Nitrite testing
• Bacteriuria.
• Specificity gt90
• Sensitivity 35- 85
• test ------- infection
• - --------infection

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Investigation

• Microscopy
• Bacteria
• False ve low bacterial count
• False ve contamination (lactobacilli
  corynebacteria ) epithelial cells
• RBCs pyuria

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Investigation

• Indications for further investigations in LUTI.
• Symptoms of Upper UTI.
• Recurrent UTI.
• Pregnancy
• Unusal infecting organism ( proteus suggest
  infection stone)

• KUB
• Ultrasound
• IVU
• cystoscopy

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DD

• Non-infective cystitis
• radiation cystitis
• Drud cystitis ( cyclophosphamide )
• Haemorrhagic cystitis
• Urethritis

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Treatment

• Aim
• Eliminate bacterial growth from urine.
• Empirical ttt before culture sensitivity for
  the most likely organism.
• Adgusted according to the culture sensitivity.

• Resistance
• Intrinsic (proteus)
• Genetically transferred between bacteria by R
  plasmids.

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Recurrent UTI

• gt2 in 6 months or 3 within 12 months
• Reinfection Bacterial
  persistence

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Recurrent UTI

• Reinfection ( different bacteria)
• After prolonged interval with adifferent
  organism
• Reinfection in females
• No anatomical nor functional pathology
• In males BOO, urethral stricture

• Bacterial persistance ( same organism from a
  focus within tract) within short interval
• Functional or anatomical problem.
• The underlying problem should be treated

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Management Reinfection UTI

• Females
• KUB, Ultrasound, cystoscopy
• Simple Reinfection
• TTT
• Avoid spermicides
• Estrogen replacement therapy
• Low dose antibiotic prophylaxis

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Female recurrent reinfection

• Prophylactic antibiotic
• Reduce infection 90 at bed time 6-12 months
• Symptomatic reinfection
• Trimethoprim
• Nitrofurantoin
• Cephalexin
• Fluoroquinolones

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Female recurrent reinfection

• Natural youghart
• Post-intercourse antibiotic prophylactic
• Self-started therapy

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Management of bacteria persistance

• Investigations
• Kub, renal ultrasound.
• C.T, IVU
• Cystoscopy
• Treatment
• For the functional or anatomical anomaly

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Antibiotics

• Empirical therapy.
• Definitive therapy.
• Bacterial resistance to drug therapy.

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Acute pyelonephritis

• Clinical Dx
• Flank pain
• Fever.
• Elevated WBCs
• DD
• acute cholecystitis.
• Pancreatitis.

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Acute pyelonephritis

• Risk factors
• VUR
• UTO
• Spinal cord injury
• D.M
• Malformation
• pregnancy
• FC

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Acute pyelonephritis

• Pathogenisis
• Initially patchy
• Inflammatory bands from renal papilla to cortex.
• 80 E.coli, others klebsiella, proteus
  pseudomonas.

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Acute pyelonephritis

• Urine analysis culture.
• CBC , UE
• KUB ultrasoundif no response with I.V
  antibiotic for 3 days go for CTU

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Perinephric abscess

• Pathogenesis.
• Suspected??
• C.T, ultrasound
• PC drainage .
• Open surgical

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Pyonephrosis

• Infected hydronephrosis.
• Pus accumulation
• Causes
• Ultrasound. C.T
• Management PCN, I.V antibiotic, I.V fluids.

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Emphysematous pyelonephritis

• Severe form of acute pyelonephritis
• Gas forming organism
• Fever, abdominal pain with radiographic evidence
  of gas within the kidney.
• D.M
• Urinary obstruction.
• High glucose level-------fermentation,CO2
  production

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Emphysematous pyelonephritis

• Presentation sever acute pyelonephritis
• High fever systemic upset
• E.coli, commonly,
• Klebsiella proteus less frequent

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Management

• KUB
• Ultrasound, C.T
• Patients are unwell
• Mortality is high

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Management

• Conservative ?
• I.V antibiotic , IVF
• PC drainage
• Control D.M
• Sepsis is poorly controlled
• Nephrectomy

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Xanthogranulomatous pyelonephritis

• Severe renal infection
• Renal calculi obstruction.
• Result in non-functioning kidney
• E.coli proteus common.
• Macrophage full of fat deposit around the abscess
  
• Kidney, perinephric fat

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Xanthogranulomatous pyelonephritis

• Acute flank pain
• Fever tender flank mass
• C.T , Ultrasound
• Stone , mass ?? RCC

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Xanthogranulomatous pyelonephritis

• IV antibiotic ,
• Nephrectomy

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