Urinary tract infection ????

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Urinary tract infection????

• ? ?
• Renal Division, Renji Hospital
• Shanghai Second Medical University

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Introduction

• Urinary tract infection (UTI) is the most common
  of all bacterial infections, affecting humans
  throughout their life span.
• Not only is UTI common, but the range of clinical
  effects it can produce is exceptionally broad,
  from acute pyelonephritis with gram-negtive
  sepsis to asymtomatic bacteriuria.

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Introduction

• UTI
• upper pelvic ?? calyx ?? ureter ???
• lower bladder ?? urethra ??
• pyelonephritis cystitis urethritis
• Femalemale
• 101

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Definition

• UTI a broad term that encompasses both
  asymptomatic microbial colonization of the urine
  and symptomatic infection with microbial invasion
  and inflammation of urinary tract structures.
• Acute pyelonephritis (??????) a pyogenic, focal
  infection of the renal parenchyma accompanied by
  local and systemic symptoms of infection.
• Chronic pyelonephritis(??????) the pathologic
  and radiologic findings of chronic cortical
  scarrings, tubulointerstitial damage, and
  deformity of the underlying calyx.

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Pathogen

• Gram-negtive enterobacteria is most common 95
• E.coli???? 60-80
• Proteus mirabilis ????
• Klebsiella sp?????
• Pseudomonas sp ???? (urinary tract
  instrumentation)
• Serratia sp ????
• Gram-positive organisms 5-10
• Streptococcus faecalis ????
• Staphylococcus aureus ???????
• Staphylococcus albus ??????
• Fungi ??
• Yeasts ??
• Viruses ??

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Possible routes of infection

• Ascending infection
• Most UTI are believed to occur by the
  ascending route.
• urethra?bladder?ureter?pelvis?calyx
  ?parenchyma
• Hematogenous infection Relatively rare
• Staphylococcal bacteremia ?????
• Intestine to kidney by way of lymphatics
• ?????? ??? ???
• Direct infection
• ?? ??????

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Ascending infection urethra?bladder?ureter?pelvis
?calyx ?parenchyma Hematogenous
infection circulation ? parenchyma ?calyx ?pelvis
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The defence mechanism of urinary tract

• Valve at the junction of ureter and bladder.
• The dilution and removal of bacteria in urine
  which occurs with micturition.
• The high concentration of urea and low pH in
  urine restrict the growth of bacteria.
• Antibacterial ability of mucosa secret IgA, IgG.
• Prostatic fluid

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Factors predisposing to infection

• Obstruction to the flow of urine anywhere from
  the kidney to urethra is well recognized as the
  most important predisposing cause.
• Congenital abnormalities such as polycystic
  kidney disease ???, vesicoureteral reflux
  ???????.
• urinary tract instrumentation
• Female urethra
• Disturbence of immune capacity such as diabetes,
  anemia, chronic hepatic disease, chronic kidney
  disease, tumor and so on.
• Inflammation of near area
• Other factors

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Pathology - Acute Phase

• Macroscopic examination
• Mucosa is edematous and congestive, and contain a
  variable number of abscesses on the capsular
  surface and on cut sections of the cortex and
  medulla.
• Occasionally, areas of inflammation extend from
  the cortex into the medulla in the shape of
  wedge.

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Pathology - Acute Phase

• Histologic changes
• Tubular epithelial cells are edematous, necrosis
  and detach from basement membrane.
• Some tubules are damaged and others are
  destroyed, many tubules contain leukocytes.
• Acute inflammation with polymorphonuclear
  leukocyte infiltraton may be found.
• The glomeruli and blood vessels are relatively
  free of inflammatory changes.

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Pathology - Chronic Phase

• Macroscopic examination
• Parenchymal scarring and underlying caliceal
  deformity.
• The kidneys are frequently irregular, and
  reduction in size is often unilateral or
  asymmetrical.
• The kidney usually has flat-based or U-shaped
  scars.

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Chronic pyenephritis. Note the irregularly scared
kidney, dilated and blunted calices.
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Chronic pyenephritis broad scars in a patient
with chronic VUR.
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Pathology - Chronic Phase

• Histologic changes
• increase in interstitial fibrous tissue
• tubule atrophy and necrosis
• periglomerular fibrosis

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Clinical presentations

• Acute pyelonephritis
• Systemic symptoms rigors and high fever, often
  with fatigue, nausea and vomiting, abdominal pain
  or diarrhea.
• Local manifestations Dysuria frequancy, and
  nocturia. Back and loin pain (with exquisite
  tenderness on percussion of the costovertebral
  angle).
• Urine Cloudy urine, pyuria.

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Clinical presentations

• Chronic pyelonephritis
• Asymptomatic bacteriuria, dysuria and frequency,
  vague complaints of flank or abdominal
  discomfort, and intermittent low-grade fevers.
• May be divided into the following five types
  Recurrent type Low-grade fever type Hematuria
  type Insidious type Hypertension type

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Recurrence

• clinical characteristic of pyelonephritis
• Relapse
• If bacteriuria recurs with the same
  pathogen within a short time following cessation
  of therapy, the recurrence is defined as a
  relapse.
• Reinfection
• infection with new organism.

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Complications

• Papillary necrosis
• Perinephric abscess
• Septicemia
• Renal stone and obstruction

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Complications- Papillary necrosis

• An uncommon complication in pyenephritis.
• Occurs more often in diabetic patients.
• Patients sometimes have renal colic with
  hematuria due to passage of papillae down the
  ureter.
• The IVP may show loss of papillae.

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Complications- Perinephric abscess

• rare complication of pyelonephritis, often
  associated with obstruction to urine flow or DM .
• Symptoms and signs loin pain accentuated by
  movement, chills and fever, urinary frequency and
  dysuria.
• Ultra-sound, radiation examination help to
  diagnosis.

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Laboratory examinations

• Urinary routine
• White cells are frequently observed.
• Detection of leukocyte casts is also an
  indication of involvement of the kidney.
• hematuira
• Proteinuria, lt 2g/d, low molecular protein.
• Low gravity, high pH, when the tubular
  dysfunction occurs.

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Laboratory examinations

• Grams stain
• The simplest method for detecting significant
  bacteriuria is to examine the urine under the
  microscope, using Grams stain.
• If bacteria are found using the oil immersion
  objective, there are likely to be more than 105
  bacteria/ml of urine.

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Laboratory examinations

• clean mid-stream urine culture
• The most widely used method of collecting urine
  for culture and is the method of choice.
• If the bacterial counts gt 100000/ml, can be
  defined significant result.
• When bacterial count lt 10000/ml, can be regard as
  contaminated.
• Coccus count reaches 100010000/ml also can be
  defined significant result.

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• Clean mid-stream urine culture, notice
• the procedure should be done before antibiotic
  therapy or 5 days after cessation antibiotic
  therapy.
• the first uriation is preferred for the bacteria
  can grow more.
• strict attention to asepsis is necessary.

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Other examinations

• Blood routine test WBC?,ESR ? ,CRP ?
• Antibody-coated bacteria help to distinguish
  pyelonephritis from the lower UTI
• Renal function tests defect in urinary
  concentrating, acidification capacity as well as
  glomerular filtration function.
• Radiologic evaluations

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Radiologic evaluations

• objective delineate abnormalities that would
  lead to changes in the medical or surgical
  mangement of the patient.
• Indication recurrence complicated UTI clinical
  presentation of pyelonephritis rare pathogen
  infection persistent infection male
• Notice should be avoided during acute phase

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Diagnosis

• Acute pyelonephritis
• The diagnosis can be established
  according to the systemic, local symptoms and
  signs as well as the urine test.

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Diagnosis

• History exceed half year, companied with
• IVP show the deformity and stricture of pelvis
  and calices
• The kidneys are irregular, often asymmetrical
• Decreased tubular ability.

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Differential diagnosis

• Lower UTI Antibody-coated bacteria(-)
• urine culture after
  bladder sterilized
• absence of systemic
  symptom
• Urethral syndrome urine culture(-)
• Renal TB dysuria, frequency and nocturia
  persistent
• and obvious
• urine TB culture()
• serous anti-TB antibody()
• X-ray

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distinguished from chronic glomerulonephritis
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Treatment

• Acute pyelonephritis
• General treatment rest in bed, increase fruid
  intake and so on.
• Antibiotic treatment should start antibiotic
  therapy immediately after urine collection.
  Serious patient should be given combined 2
  antibiotic drugs and the drug should be given
  through intravenous route. The antibiotic course
  usually is 1014 days.

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Treatment

• Chronic pyelonephritis
• General treatment
• the most important effort should be made to
  correct the underlying complicating factors such
  as urinary tract obstruction, congenital
  abnormality and so on.
• Rest, fruid intake to increase urine volume is
  also needed.

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Treatment

• Chronic pyelonephritis
• Principles of antibiotic treatment including
• combined antibiotic therapy is usually need.
• treatment course 24 weeks.
• correct the underlying complicating factors.
• the treatment of acute phase is similar to acute
  pyelonephritis

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Thank you