UTI For surgical board

1
UTI For surgical board

• Dr. Mohamed El-Shazly
• M.D. (Urology)

2

• Urinary tract infections (UTIs) are among the
  most prevalent infectious diseases, with a
  substantial financial burden on society.

3

• In the USA, UTIs are responsible for over 7
  million physician visits annually, including more
  than 2 million visits for cystitis.
• Approximately 15 of all community-prescribed
  antibiotics in the USA are dispensed for UTI, at
  an estimated annual cost of over US 1 billion
  (Naber et al., 2010)

4

• The gold standard for the diagnosis of a urinary
  tract infection is the detection of the pathogen
  in the presence of clinical symptoms.
• The pathogen is detected and identified by urine
  culture (using midstream urine). This also allows
  an estimate of the level of the bacteriuria.

5

• The number of bacteria is considered relevant for
  the diagnosis of a UTI.
• In 1960, Kass developed the concept of
  significant bacteriuria (gt 105 cfu/mL) in the
  context of pyelonephritis in pregnancy (Kass,
  1960).

6

• gt 103 cfu/mL of uropathogens in a mid-stream
  sample of urine (MSU) in acute uncomplicated
  cystitis in women.
• gt 104 cfu/mL of uropathogens in an MSU in acute
  uncomplicated pyelonephritis in women.
• gt 105 cfu/mL of uropathogens in an MSU in women,
  or gt 104 cfu/mL uropathogens in an MSU in men,or
  in straight catheter urine in women, in a
  complicated UTI.

7

• In a suprapubic bladder puncture specimen, any
  count of bacteria is relevant

8
Evaluation

• Effective management begins by obtaining a
  careful history with attention given to current
  symptomatology, prior episodes of documented UTI,
  and risk factors that can initiate (e.g. urethral
  catheterization or sexual intercourse) or
  complicate (diabetes mellitus or pregnancy) a
  UTI.

9

• Proper collection
• A midstream voided specimen is generally
  adequate, but urethral catheterization or
  suprapubic aspiration may be necessary in an
  individual who cannot produce a clean specimen.

10

• Since UTI is a host inflammatory response to
  bacterial invasion, urinalysis will reveal pyuria
  (the presence of white blood cells in the urine)
  and bacteriuria.
• If there is bacteriuria with no pyuria in an
  asymptomatic patient, an infection is not present
  and therapy is usually not necessary.

11
PATHOGENESIS

• Complex interactions between an organism, the
  environment, and the potential host.

12

• The most common causative pathogen is
  Escherichia coli, which is responsible for 85 of
  infections in ambulatory patients and 50 of
  nosocomial infections. Proteus mirabilis,
  Klebsiella pneumonia, and Enterococcus fecalis,
  are the next most frequent isolates. (Patton,
  1991)

13
Pathogenesis

• Most infections are caused by retrograde ascent
  of bacteria from the fecal flora via the urethra
  to the bladder and kidney
• Haematogenous infection of the urinary tract is
  restricted to a few relatively uncommon microbes,
  such as Staphylococcus aureus, Candida sp.,
  Salmonella sp. and Mycobacterium tuberculosis,
  which cause primary infections elsewhere in the
  body.

14

• There are urinary pathogen virulence factors that
  promote adherence to mucosal surfaces and
  subsequent infection. The bacteria usually
  express fimbriae or pili which mediate adherence
  to the epithelial cell receptors

15

• Host factors such as the epithelial cell
  receptivity are also important in the infection
  process. For example, E. coli bound to vaginal
  epithelial cells from healthy controls less
  avidly than to vaginal epithelial cells from
  women with recurrent UTIs (Fowler et al., 1977)

16

• A single insertion of a catheter into the urinary
  bladder in ambulatory patients results in urinary
  infection in 1-2 of cases. Indwelling catheters
  with open-drainage systems result in bacteriuria
  in almost 100 of cases within 3-4 days

17
CLASSIFICATION

• Uncomplicated UTI
• Complicated UTI
• Urosepsis

18
Uncomplicated UTIs in adults

• Acute, uncomplicated UTIs in adults include
  episodes of acute cystitis and acute
  pyelonephritis in otherwise healthy individuals.

19

• The spectrum of aetiological agents is similar in
  uncomplicated upper and lower UTIs, with E. coli
  the causative pathogen in 70-95 of cases and
  Staphylococcus saprophyticus in 5-10.

20

• Acute uncomplicated cystitis in premenopausal,
  non-pregnant women
• Urine cultures are recommended for those with
  (i) suspected acute pyelonephritis
• (ii) symptoms that do not resolve or recur
  within 2-4 weeks after the completion of
  treatment

21

• A colony count of gt 103 cfu/mL of uropathogens is
  microbiologically diagnostic

22

• Cotrimoxazole 160/800 mg bid for 3 days or
  trimethoprim 200 mg for 5 days
• Alternative antibiotics are ciprofloxacin 250 mg
  bid,

23
Acute uncomplicated pyelonephritis in
pre-menopausal, non-pregnant women

• Clinical picture
• Diagnosis Colony counts gt 104 cfu
  uropathogen/mL
• ultrasound should be performed to rule out
  urinary obstruction or renal stone disease

24

• Fever gt 3 days (CT), an excretory urogram,
• or (DMSA) scan, to rule out urolithiasis, renal
• or perinephric abscesses.

25

• As first-line therapy in mild cases, an oral
  fluoroquinolone for 7 days
• severe cases should be admitted to hospital and
  treated with parenteral fluoroquinolone
  (ciprofloxacin or levofloxacin), a
  third-generation cephalosporin
• Treatment should be continued for 1-2 weeks with
  oral antibiotics

26
Recurrent (uncomplicated) UTIs in women

• Long-term, low-dose prophylactic antimicrobials
  taken at bedtime
• Prophylactic alternative methods include
  immunotherapy and probiotic therapy,
• acidification, and cranberry juice

27
UTIs in pregnancy

• Most symptomatic UTIs in pregnant women present
  as acute cystitis
• The prevalence of asymptomatic bacteriuria in
  American, European and Australian studies varies
  between 4 and 7 while 20-40 of women with
  asymptomatic bacteriuria will develop
  pyelonephritis during pregnancy.
• Treatment of asymptomatic bacteriuria lowers this
  risk

28

UTIs in pregnancy

• For a recurrent UTI, low-dose cephalexin (125-250
  mg) or nitrofurantoin (50 mg) at night
• is recommended for prophylaxis against
  re-infection

29

• For acute pyelonephritis, second- or
  third-generation cephalosporins, an
  aminoglycoside, or an
• aminopenicillin plus a BLI may be recommended
  antibiotics
• During pregnancy, quinolones, tetracyclines and
  TMP are contraindicated in the first trimester

30

• Right hydronephrosis with UTI, a ureteral stent
  may be indicated and
• Antimicrobial prophylaxis should be considered
  until delivery

31
UTIs in post-menopausal women

• In the case of a recurrent UTI, urological or
  gynaecological evaluation should be
• performed in order to eliminate a tumour,
  obstructive problems, detrusor failure or a
  genital infection

32
UTIs in post-menopausal women

• In post-menopausal women with a recurrent UTI,
  therapy with intravaginal oestriol is able to
  reduce significantly the rate of recurrences

33
URINARY TRACT INFECTIONS IN CHILDREN

• In the first year of life, mostly the first 3
• months, UTI is more common in boys (3.7) than in
  girls (2), after which the incidence changes,
  being 3 in girls and 1.1 in boys

34

• Paediatric UTI is the most common cause of fever
  of unknown origin in boys less than 3 y

35

• short courses are not advised and therefore
  treatment is continued for 5-7 days and longer.
  If the child is severely ill with vomiting and
  dehydration, hospital
• admission is required and parenteral
  antibiotics are given initially.

36

• Investigation should be undertaken after two
  episodes of a UTI in girls and one in boys ears
• Objective is to rule out the unusual occurrence
  of obstruction, vesicoureteric reflux (VUR) and
  dysfunctional voiding

37

• Voiding cystourethrography (VCU) is the most
  widely used radiological exploration for the
  study of the lower urinary tract and especially
  of VUR

38

• Even in the presence of normal
• Ultrasonography, Up to 23 of these patients may
  reveal VUR

39
Treatment

• Treatment has four main goals
• 1. Elimination of symptoms and eradication of
  bacteriuria in the acute episode
• 2. Prevention of renal scarring
• 3. Prevention of a recurrent UTI
• 4. Correction of associated urological lesions.

40

• Vesicoureteric reflux is treated with long-term
  prophylactic antibiotics.
• Endoscopic treatment
• Surgical re-implantation

41

• Recurrent UTI may be subclassified into three
  groups
• 1-Unresolved infection subtherapeutic level of
  antimicrobial, non-compliance with treatment,
  malabsorption, resistant pathogens.

42

• 2 Bacterial persistence may be due to a nidus
  for persistent infection in the urinary tract.
  Surgical correction or medical treatment for
  urinary dysfunction may be needed.
• 3 Reinfection each episode is a new
  infection acquired from periurethral,
  perineal or rectal flora

43
Factors that suggest a potential complicated UTI

• The presence of an indwelling catheter, stent
  or splint (urethral, ureteral, renal) or the use
  of intermittent bladder catheterization
• A post-void residual urine of gt 100 mL
• An obstructive uropathy of any aetiology, e.g.
  bladder outlet obstruction (including neurogenic
  urinary bladder), stones and tumour

44

• Vesicoureteric reflux or other functional
  abnormalities
• Urinary tract modifications, such as an ileal
  loop or pouch
• Renal insufficiency and transplantation,
  diabetes mellitus and immunodeficiency

45
Catheter Fever

• General aspects
• 1. Written catheter care protocols are necessary.
  
• 2. Health care workers should observe protocols
  on hand hygiene and the need to use disposable
  gloves between catheterised patients

46

• 3. An indwelling catheter should be introduced
  under antiseptic conditions.
• 4. Urethral trauma should be minimised by the use
  of adequate lubricant and the small catheter
  calibre.
• 5- The duration of catheterisation should be
  minimal.

47
SEPSIS syndrome IN UROLOGY (UROSEPSIS)

• The systemic inflammatory response syndrome,
  known as SIRS (fever or hypothermia,
  hyperleucocytosis or leucopenia, tachycardia,
  tachypnoea), is recognized as the first event in
  a cascade to multi-organ failure.

48

• Sepsis or septic shock are present, though the
  prognosis of urosepsis is globally better than
  sepsis due to other infectious sites.

49

• The treatment of urosepsis calls for the
  combination of adequate life-supporting care,
  appropriate and prompt antibiotic therapy,
  adjunctive measures (e.g. sympathomimetic amines,
  hydrocortisone, blood
• Glucose control, recombinant activated protein C)
  and the optimal management of urinary tract
  disorders

50

• Sepsis syndrome in urology remains a severe
  situation with a mortality rate as high as
  20-40.

51
URETHRITIS

• Primary urethritis has to be differentiated from
  secondary urethritis, which may be found in
  patients with indwelling catheters or urethral
  strictures

52

• The following antimicrobials can be recommended
  for the treatment of gonorrhoea
• Ceftriaxone, 125 mg intramuscularly (with local
  anaesthetic) as a single dose
• Cefixime, 400 mg orally as a single dose
• .

53

• Ciprofloxacin, 500 mg orally as single dose
• Ofloxacin, 400 mg orally as single dose
• Levofloxacin, 250 mg orally as as single dose.

54

• As gonorrhoeae is frequently accompanied by
  chlamydial infection, an antichlamydial active
  therapy
• C. trachomatis infections.
• Azithromycin, 1 g orally as single dose
• Doxycycline, 100 mg orally twice daily for 7
  days.

55
ROSTATITIS AND CHRONIC PELVIC PAINSYNDROME

• classification suggested by the National
  Institute of Diabetes and Digestive and Kidney
  Diseases (NIDDK) of the National Institutes of
  Health (NIH),

56

• I Acute bacterial prostatitis
• II Chronic bacterial prostatitis
• III Chronic abacterial prostatitis - chronic
  pelvic pain syndrome (CPPS)
• A. Inflammatory CPPS (white cells in
  semen/EPS/VB3)
• B. Non-inflammatory CPPS (no white cells in
  semen/EPS/VB3)
• IV Asymptomatic inflammatory prostatitis
  (histological prostatitis)
• CPPS chronic pelvic pain syndrome

57

• Acute Bacterial prostatitis Admission and
  parenteral antibiotics then oral for 2-4 weeks.
• Chronic prostatitis ciprofloxacin and
  levofloxacin, are considered drugs of choice
  because of their favourable pharmacokinetic
  properties (4-6 weeks)

58
EPIDIDYMITIS AND ORCHITIS

• Complications in epididymo-orchitis include
  abscess formation, testicular infarction,
  testicular atrophy, development of chronic
  epididymal induration and infertility

59

• Antimicrobials should be selected on the
  empirical basis
• Chlamidya doxycycline, 200 mg/day
• Gram negative. fluoroquinolones

60

• Thank you