Urinary tract infections in men:
Download
1 / 48

Urinary tract infections in men: the classical urovirulent E. coli? - PowerPoint PPT Presentation


  • 63 Views
  • Uploaded on

Urinary tract infections in men: the classical urovirulent E. coli?. Peter Ulleryd Regional Medical Officer Communicable Disease Control Västra Götaland, Sweden [email protected] Professor????. No!. Co-workers.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' Urinary tract infections in men: the classical urovirulent E. coli?' - eljah


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript

Urinary tract infections in men:the classical urovirulent E. coli?

Peter Ulleryd

Regional Medical Officer

Communicable Disease Control

Västra Götaland, Sweden

[email protected]

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


Professor
Professor????

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


No!

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


Co-workers

Torsten Sandberg Infectious Diseases, Sahlgrenska University Hospital

Jonas Hugosson, Gunnar Aus, Svante Bergdahl and Björn Zackrisson

Urology, Sahlgrenska University Hospital, Göteborg

Knut Lincoln Clinical Bacteriology, Sahlgrenska University Hospital

Flemming Scheutz

The international E. coli and Klebsiella centre (WHO), Copenhagen

James R. Johnson VA Medical Center, Minneapolis

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


Cross talk
Cross-talk

  • Not only important for bacteria

  • Also for people working with:

  • E. coli

  • UTI

  • Antibiotic resistance

  • etc

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


Menu

  • Primitive creatures

  • UTI - classification

  • Febrile UTI in men - clinic

  • Virulence factors

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


Clinicians primitive creatures
Clinicians-primitive creatures!

  • Internal medicine vs Surgeons

  • Is this of any good for my patients?

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


Giving a diagnosis
Giving a diagnosis

  • X no. of symptoms/signs=diagnosis

  • The most usual is the most abundant!

  • Ex. Fever + bacteriuria

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


Bacterial virulence factors:are they important to know for the treating physician?

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


No!

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


Just uti define
Just UTI - define!!

  • Women Men Children

  • Asymptomatic Symptomatic

  • Febrile UTI Lower UTI

  • Sporadic Recurrent

  • Complicating factors

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


Virulence

Host factors

Infection

No infection

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


UTI in men

Traditionally

- anatomic abnormalities in the newborn

- prostatic obstruction in the elderly

  • Most UTI in men are complicated

  • Less E. coli than in women

  • Often Pseudomonas, Serratia, enterococci………

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


Male UTI

  • Lower UTI = ”Cystitis”

  • Febrile UTI = ”Upper” UTI = ”Pyelo.”

  • Prostatitis – Acute, Kron bact., Kron abact., Prostatodynia

  • Urethritis

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


Febrile UTI in men-the Gothenburg prospective study

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


Inclusion criteria

  • Temperature 38.0°C

  • Clinical signs/symptoms of UTI

  • Positive urine culture

  • 104 cfu/mL MSU

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


Investigations

  • Transrectal ultrasound (TRUS)

  • Residual urine

  • Uroflowmetry

  • Urography

  • Cystoscopy

  • Prostate-specific antigen (PSA)

At entry and after3 months

During follow-up

At entry and follow-up

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


Characteristics of men with febrile UTI (n=86)

Median age 63 years (18 – 86)

Previous history of UTI 38 (44%)

Flank pain and/or

costovertebral angle 31 (36%)

tenderness

Median temperature 39.5°C (38.0 – 41.4)

Median C-reactive protein 130 mg/L (9 – 420)

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


Bacteriological findings in 86 patients with febrile UTI

Urinary isolates Blood isolates

Escherichia coli1 67 (78 %) 10

Klebsiella pneumoniae 7

Enterobacter aerogenes 1 1

Enterobacter agglomerans 1 1

Proteus mirabilis 1 1

Enterococci 4

Staphylococcus epidermidis 3 1

Group B streptococci 2

1 In one case together with Serratia marcescens

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


?

Is the prostate frequently involved in men with

febrile urinary tract

infection?

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


Fig 2. Median serum PSA after an episode of febrile UTI

15

14.0

10

PSA (µg/L)

5

3.6

2.9

2.0

1.5

0

0

1

3

6

12

n=70

n=69

n=55

n=50

n=41

months

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


Serum PSA after an episode of febrile UTI

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


Prostate volume in 55 men with febrile UTI (range)

• At entry • After 3 months

49 mL 35 mL

(14 - 104 mL) (15 - 91 mL)

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


Changes in serum PSA and prostate volumebetween the acute stage of infection and 3 months later in 49 men with febrile UTI

Reduction in prostate volume

>10% 10%

Reduction in serum PSA

>25% 40 4

25% 2 3

BJU Int 1999;84:470-4.

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


?

Is the prostate frequently involved in men with

febrile urinary tract

infection?

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


Yes!

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


Febrile UTI in men

One infection – different manifestations

Acute

pyelonephritis

Febrile

UTI

Acute

prostatitis

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


?

Is it always necessary to examine the upper and

lower urinary tract

after a febrile UTI?

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden



Lower urinary tract abnormalities in 83 men with febrile UTI Sweden

Abnormality No. (%) of findingsa

Infravesical obstruction from

BPH requiring TURP 10

Urethral stricture 5

Bladder diverticulum 5

Bladder stones 3

Bladder cancer 1

Phimosis 1

Post-void residual urine >50 mLb 13(22)

Peak urine flow rate <10 mL/sb 8(15)

a46 abnormal findings in 35 patients.

bBased on the best performance during the acute stage or at follow-up.

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden



? Sweden

Is it always necessary to examine the upper and

lower urinary tract

after a febrile UTI?

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


No! Sweden

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


Urological evaluation of male febrile UTI Sweden

  • Conclusion

  • Routine imaging of the upper urinary tract seem dispensable.

  • To reveal abnormalities of clinical importance, evaluation should primarily be focused on the lower urinary tract.

  • BJU Int 2001;88:15-20

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


Proposed urological evaluation of male febrile UTI Sweden

  • At 1 (+3 and 6) months:

  • Clinical control including urinary and obstructive symptoms

  • Dipstick for hematuria

  • Urine culture

  • Repetition of eventual abnormal laboratory tests

  • Post-void residual

  • Peak flow rate

  • DRE

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


Treatment Sweden

  • Ab concentration in the prostate

  • High pH, calcifications, reflux

  • Quinolones, (trimethoprim), ((doxycycline)) to obtain ab in prostatic secretion

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden



Virulence characteristics of E. coli in febrile UTI Sweden

MenWomen

n=74Uncomplicated Complicated FU

Hemolysin 74% 51% 41%

P-fimbriae 51% 80% 65%

Aerobactin 46% 73%

Suggesting differences in host-parasite relationships in the male and female urinary tract.

TS

JJ

CID 1994;18:579-84

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


Earlier studies of haemolysin in male uti
Earlier studies of haemolysin in male UTI Sweden

  • Barnes RC,Daifuku R, Roddy RE, Stamm WE. Lancet, 1986.

  • 10/11 isolates

  • Spach DH, Stapleton AE, Stamm WE. JAMA1992.

  • 10/14 isolates

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


Later studies of haemolysin in male uti
Later studies of haemolysin in male UTI Sweden

  • Andreu et al 22/30 73%

  • Terai et al 72/107 69%

  • Ruiz et al 30/37 81%

  • CNF1 was also very commonly found

  • concomitantly with the haemolysin gene

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


Prevalence of virulence factors jr johnson et al 2005

FUTI urine Sweden

(n=70)

Uninfected, rectal (n=70)

Prevalence of virulence factorsJR Johnson et al 2005

FUTI isolates exibited a significantly higher prevalence of virulence-associated phylogenetic groups, serotypes, and extraintestinal virulence genes.

Including haemolysin and CNF-1

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


Comparison concurrent u r isolates jr johnson et al 2005 n 65
Comparison concurrent U+R isolates Sweden JR Johnson et al 2005, n=65

  • 3 last rectal isolates+morph distinct

  • Only the urine isolate in 25 %

  • Urine clone + additional clone in 22%

  • Only nonurine clones in 54%

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


Figure 1. Distribution of virulence factor scores among concurrent urine (n = 65) and rectal (n = 67) Escherichia coli isolates from 65 men with febrile urinary tract infection. Only rectal isolates that differed clonally from the host's urine isolate are included in the rectal group. Fractional scores were rounded down to the next lowest integer value.

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


Cytotoxic necrotizing factor type 1 cnf1
Cytotoxic necrotizing factor type 1 (CNF1) concurrent urine (n = 65) and rectal (n = 67)

  • Contribute to prostatic inflammation by E. coli in a rat model.

  • Rippere-Lampere KE, Inf Imm, 2001.

  • However, another murine model, but female, demonstrated no evidence of CNF1- associated inflammation of the urinary tract.

  • Johnson DE, FEMS Imm, 2000.

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


Febrile UTI in men concurrent urine (n = 65) and rectal (n = 67)

One infection – different manifestations

Acute

pyelonephritis

Febrile

UTI

Acute

prostatitis

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


Conclusions general
Conclusions - general concurrent urine (n = 65) and rectal (n = 67)

  • Studies of very well characterized patients and bugs with specified infections (prospective)

  • Multidisciplinary in-/output of importance (cross–talk)

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


Conclusions male futi
Conclusions Male FUTI concurrent urine (n = 65) and rectal (n = 67)

  • E. coli of course.

  • Pathogenesis - Deep, Dip, Dep.

  • Do not take PSA.

  • If investigation - aim low.

  • Treatment for the prostate also.

  • Common sense allowed.

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


Thank you! concurrent urine (n = 65) and rectal (n = 67)

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden


ad