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Introduction Bacteriuria: the presence of bacteria in the urine Significant bacteriuria: 10 5 organism or more per milliliter Pyuria: the presence of white blood cells in urine Pyuria with 5 or more cells per microscopic high-power field: reliable indicator of UTI

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  • Bacteriuria: the presence of bacteria in the urine
  • Significant bacteriuria: 105 organism or more per milliliter
  • Pyuria: the presence of white blood cells in urine
  • Pyuria with 5 or more cells per microscopic

high-power field: reliable indicator of UTI

  • The absence of such pyuria does not reliably

exclude UTI

acute pyelonephritis 1
Acute Pyelonephritis (1)
  • The most and second commonest (90%) of community-acquired UTIs in females are due to E. coli and Staphylococcus saprophyticus. Other

enterobacteria (Proteus spp., Klebsiella spp.,

Enterobacter spp.) are also encountered.

  • In male patients E. coli is also the commonest

pathogen, but other enterobacteria and

Enterococcus spp. are more commonly


acute pyelonephritis 2
Acute Pyelonephritis (2)
  • In hospital, E. coli is still common, but a high

frequency of Pseudomonas spp., Enterococcus

spp., coagulase-negative staphylococci and

Candida spp. is encountered.

  • Persistent or relapsing bacteriuria due to Proteus

mirabilis should search for staghorn calculus.

  • Patients with Staphylococcus aureus in urine

culture should be search for intravascular cannula infections, endocarditis, osteomyelitis and pneumonia.

acute pyelonephritis 3
Acute Pyelonephritis (3)
  • APN is a syndrome of fever along with evidence of renal inflammation such as costovertebral angle tenderness or flank pain.
  • Silent pyelonephritis is present in up to 30 to 50% of patients with clinical cystitis in primary care setting.
  • Deterioration of condition should prompt a search for urinary tract obstruction such as calculus or renal papillary necrosis, or for a suppurative focus in or around the kidney.
acute pyelonephritis 4
Acute Pyelonephritis (4)
  • Ultrasound is the initial investigation for patients with upper urinary tract infection and suspected obstruction. Ultrasound and KUB will detect almost all correctable lesions.
  • CT is indicated is a patient with persistent sepsis in whom ultrasound does not reveal an explanation.
  • IVU has a limited role. It is effective at excluding obstruction.
  • Retrograde urography with cystoscope will demonstrate the anatomy of the collecting system in a nonexcreting kidney.
acute pyelonephritis 5
Acute Pyelonephritis (5)
  • Aminoglycoside combined with ampicillin, cefazolin, or TMP-SMX is appropriate as empiric therapy of APN.
  • Aminoglycoside combined with ureidopenicillin such as piperacillin may be preferred for hospital-acquired infection, where P. aeruginosa and E. fecalis are more likely to be encountered.
  • E. coli isolates from community-acquired infection: 30% are resistant to ampicillin, 10% to first-generation cephalosporins and TMP-SMX, less than 2% to aminoglycoside.
acute pyelonephritis 6
Acute Pyelonephritis (6)
  • Approximately 40% of nosocomial aerobic gram-negative urinary isolates are resistant to first-generation cephalosporins.
  • In patients with a higher risk of aminoglycoside toxicity such as those with prior renal impairment, liver dysfunction,advanced age, shock, or oliguria, third-generation cephalosporins such as cefotaxime, ceftriaxone, ceftizoxime or ceftazidime; monobactam such as aztreonam; carbapenem such as imipenem; ureidopenicillin such as piperacillin, ticarcillin, or parenteral quinolone such as ciprofloxacin should be considered.
acute focal bacterial nephritis 1
Acute Focal Bacterial Nephritis (1)
  • Human kidneys consist of five to eleven lobes each of which contains a conical medullary pyramid. Each pyramid is capped by cortical tissue to from a renal lobe.
  • AFBN: infection limited to one or more renal lobes.
  • CT with contrast enhancement may reveal one or more wedge-shaped areas of decreased density.
  • IVU is usually normal. Ultrasound may be normal or reveal a solid, hypoechoic , poorly defined mass without evidence of liquefaction.
acute focal bacterial nephritis 2
Acute Focal Bacterial Nephritis (2)
  • Histopathology shows intense PMN infiltration without liquefaction, so needle aspiration or percutaneous drainage is not indicated.
  • E. coli is the most common organism isolated from patients with AFBN.
  • Antimicrobial therapy: as APN.
renal abscess 1
Renal Abscess (1)
  • Renal abscess may be due to AFBN progression to suppuration when associated with obstruction, ascending infection, or hematogenous spread.
  • The usual pathogens are enterobacteria and S. aureus (preantibiotic era, history of cutaneous staphylococcal infection such as furuncle).
  • Clinical presentations: fever and chills along with back or abdominal pain, CVA tenderness, flank mass, guarding of the upper lumbar and paraspinal muscles.
renal abscess 2
Renal Abscess (2)
  • IVU is abnormal (mass effect) but nonspecific.
  • Ultrasound shows an ovoid mass of decrease attenuation within the parenchyma.
  • CT shows a marginated low attenuation (0-20 HU) mass that fails to enhance. There may be a surrounding rim of increased enhancement (the ring sign).
  • The diagnosis can be confirmed by gallium scan, WBC scan, or needle aspiration.
renal abscess 3
Renal Abscess (3)

1. Intravenous antimicrobial therapy

2. Percutaneous drainage (ultrasound

or CT guidance)

3. Incision and drainage

4. Nephrectomy

emphysematous pyelonephritis and pyocystis 1
Emphysematous Pyelonephritis and Pyocystis (1)
  • Gas within the urinary tract has three origins:

1. Atmospheric gas introduced during

diagnostic procedures or during trauma.

2. As a result of a fistula with a hollow organ.

3. From multiplying, gas-producing organism

such as enterobacteria or anaerobes.

  • Emphysematous pyelonephritis is a disease

characteristic by gas formation in the renal

parenchyma and surrounding tissues.

emphysematous pyelonephritis and pyocystis 2
Emphysematous Pyelonephritis and Pyocystis (2)
  • Fulminant disease with high mortality.
  • The majority of patients have uncontrolled DM and obstruction of the urinary tract.
  • E. coli and other enterobacteria account for the majority of pathogens with the rest being polymicrobial anaerobes.
  • DDx: 1. Gas in renal tumor, which can occur after embolization. 2. Evolving traumatic renal infarct.
emphysematous pyelonephritis and pyocystis 3
Emphysematous Pyelonephritis and Pyocystis (3)
  • KUB: diffuse mottling of the parenchyma (early sign), extensive bubbles in the parenchyma and a gas crescent surrounding the kidney within the perinephric space (advanced cases).
  • Ultrasound: “dirty shadowing” with poorly defined margins. (“clean shadowing” with sharply defined margins in calculi).
  • CT: identify gas clearly.
emphysematous pyelonephritis and pyocystis 4
Emphysematous Pyelonephritis and Pyocystis (4)
  • Surgical intervention within 48 h combined with antimicrobial therapy has improved outcome.
  • Pyocystis (pus in the urinary bladder) can present with features of sepsis, lower urinary tract signs, and pneumaturia.
  • Antimicrobial therapy and bladder irrigation may be sufficient therapy, but necrosis of the bladder wall (gas in the muscular layers on CT) will require surgical resection.
perinephric abscess 1
Perinephric Abscess (1)
  • The perinephric space contains the kidney, the renal fat, and the adrenal gland.
  • Perinephric abscess generally arises from an intrarenal abscess.
  • The majority are due to enterobacteria and a minority to S. aureus. Polymicrobial aerobic and anaerobic bacteria are also common.
  • Documentation of anaerobic cause should search for either GI tract source or ureteric obstruction.
perinephric abscess 2
Perinephric Abscess (2)
  • Perinephric abscess is an insidious disease that has a 50% mortality due to delay in diagnosis.
  • Clinical presentations: fever and chills (most common), weight loss, nausea, vomiting, dysuria, flank or abdominal pain, pleuritic chest pain, flank mass, renal tenderness, and pain in the thigh or groin (psoas abscess).
  • Ultrasound: fluid that may contain debris or gas.
  • CT: loculated fluid collection with decrease attenuation (0-20 HU).
perinephric abscess 3
Perinephric Abscess (3)
  • The diagnosis and be confirmed by aspiration of the pus with a 20-gauge needle.
  • Most patients can be treated by a combination of intravenous antimicrobial agents and percutaneous drainage.
  • Clindamycin combined with either an aminoglycoside or a 3rd-generation cephalosporin is appropriate as initial empiric therapy if abscess due to polymicrobial aerobic and anaerobic or S. aureus organisms are suspected.
pyonephrosis 1
Pyonephrosis (1)
  • Pyonephrosis arises when infection develops proximal to an obstruction of a hydronephrotic kidney.
  • Underlying causes: calculus, stricture, neoplasm, or congenital anomaly.
  • Loss of renal function is often present. Intrarenal or perinephric abscess may also be present.
  • Clinical features: similar to perinephric abscess.
  • KUB: look for calculi.
pyonephrosis 2
Pyonephrosis (2)
  • Ultrasound: distended upper urinary tract, sedimented echoes, and internal echoes within the dilated collecting system.
  • CT: sensitive for detecting radiolucent calculi.
  • Treatment: intravenous antimicrobial agent with percutaneous drainage with nephrostomy tube, and correct the underlying disease.
uti due to candida 1
UTI due to Candida (1)
  • Candida species are normal GI tract commensals of humans whose number are usually suppressed by the bacteria flora.
  • Primary infection of the urinary tract is generally associated with prolonged placement of a urinary catheter along with antibacterial agent.
  • Disseminated candidiasis may originate in the urinary tract or secondarily seed it.
  • Candida in urine culture with 104 cfu/ml: bladder infection, and associated with renal infection.
uti due to candida 2
UTI due to Candida (2)
  • Renal infection requires systemic amphotericin B therapy in a dose of 0.6 mg/(
  • Fluconazole and 5-fluorocytosine are alternative, less reliable therapies.
  • Ketoconazole is not acceptable as it is not excreted through the kidney.
  • Hydronephrosis due to fungus ball: PCN with amphotericin B irrigation. Lack of response should prompt surgical excision.
uti due to candida 3
UTI due to Candida (3)
  • A more commonly encountered situation is that of the stable ICU patient who has persistent candiduria.
  • For such a patient amphotericin B bladder irrigation (50 mg in 1000mL of sterile water administered over 24 h by three war catheter) for 5 days should be considered.
prostatic infections 1
Prostatic Infections (1)
  • Acute bacterial prostatitis (ABP) may present with the sudden onset of high fever up to 40°C, chills and malaise which are soon followed by irritative symptoms such as urgency, frequency, dysuria.
  • Other clinical presentations: dull, aching pain in the perineum, rectum, or sacrococcygeal region; difficulty voiding or acute urinary retention.
  • Digital rectal examination reveals a very tender, swollen, and warm prostate.
prostatic infections 2
Prostatic Infections (2)
  • Gram-negative enteric organisms are now the most frequent pathogens. Enterococcus fecalis may also be responsible.
  • Treatment regimen for ABP: similar to treatment of APN.
  • If the patient responds appropriately, the parenteral antimicrobial therapy can be continued for 7 days, then oral antimicrobial agent such as TMP-SMX, norfloxacin, or ciprofloxacin for further 5 weeks.
catheter associated bacteriuria
Catheter-Associated Bacteriuria
  • One percent of patients will acquire bacteriuria from single “in-out” catheterization.
  • The per day risk of developing bacteriuria is about 5%; thus about 40% of patients catheterized for 10 days will have acquired significant bacteriuria.
  • Asymptomatic bacteriuria should be treated in all patients prior to instrumentation to avoid the development of gram-negative bacteremia and subsequent sepsis.