Urinary Tract Infections &Tubulointertitial Diseases Dr Y-Ataipour IUMS Hashemi-Nejad Hospital
Epidemiology • More commom in female than male • In infants & elderly more common in males • ABU in 5% of women ( 20-40 years old ) • 50 – 80% of women acquire at least one episode of UTI during their life. • 20 – 30% of UTI in women become recurrent • Early recurrent ( in 2 wks ) = relapse
Etiology ( uropathogen ) UTI is caused usually by enteric g neg rods In cystitis E coli in 75 – 90% Staph saprophyticus in 5 – 15% Klebsiella , proteus , enterococcus, citrobacter in 5 – 10% In pyelonephritis also E coli is common microorganism .
UTI • Symptomatic ( ABU ) • Asymptomatic
UTI • Upper UTI • Acute pyelonephritis • Acute prostatitis • Perinephricabcesse • Intrarenalabcess • Lower UTI • Cyctitis • Urethritis
UTI • Community aquired (non-catheter ) • Nosocomial ( catheter associated )
UTI Complicated Uncomplicated
Uncomplicated UTI • Normal urinary tract • Normal renal function • Nonvirulent pathogens ( E.coli )
Complicated UTI • Urinary tract abnormalities • Impaired host defence ( DM ) • Virulent pathogens • Proteus , Pseudomonas ,Staph • Renal failure
UTIexistes when more than 100000 bacteria per ml of urine is detected. In symptomatic patients bacterial count of 100-10000 may signifays infection. Multiple bacteria in culture= contamination.Acute urethralsyndrome:dysuria,frequency without significant bacteriuria.
Sterile Pyuria • Recently treated UTI (<2 wk ) & Partially treated UTI • Prostatitis • Calculi • Interstitial nephritis • Lupus Nephritis • Polycystic kidney • Appendisitis • Chemical cystitis • Bladder tumor • Papillary Necrosis • Acute Rejection
Risk Factors For UTI • Urinary Tract Obstructions • Female gender • Pregnancy • DM • Sexual intercours • Immunosuppression • Stone • Catheter • Urinary tract malformation • Decreased host defence
Pathogenesis of UTI • Ascending of bacteria from periurethral • area to the bladder is most common • mechanism of UTI ( g- bacilli ). • Hemategenous access of bacteria to the • kidneys is seen in staph aureuspyelonephritis
Host Defences in UTI • Flushing & diluting effect of urine • Antibacterial effect of urine & bladder • mucosa • High urea concentration & high osmolarity • of urine • Prostatic secretions have antibacterial properties • Bladder epithelial cells secrete cytokines & chemokines • as IL6 , IL8 which interact with bacteria causing PMN • to enter to the bladder epithelia to clear bacteria
Conditions affecting pathogenesis • Pregnancy;UTI seen in 2-8% of pregnants • 20-30% of asymptomatic bacteriuria will • end to acute pyelonephritis. • Obstruction • NeurogenicBladder • VUR • Sexual activity • Bacterial virulence • Genetic Factors
Bacterial Virulence • E.coli strains causing symptomatic UTI • belong to O , K , H serogroups having • virulence genes. • Bacterial adherence to uroepithelial cells is • critical step . • Bacterial fimbria mediate this attachement • to specific receptors on epithelial cell, • causing IL6 & IL8 production. • UropathogenicE.coli also produces the cytokines • like Hemolysin & aerobactin resistant to bactericidal • action of serum.
Genetic Factors • Positive maternal Hxexistes in some pts • P fimbriae mediate attachement of E.coli • to P-positive RBC can cause • Pyelonephritis • P-negative groups have lower risk of • Pyelonephritis
Bacterial clonization • Lactobacilli as a normal vaginal flora could • protect against the initiation of UTI by : • maitenance of an acidic vaginal enviroment • which diminishes E.coliclonization , • interfering with the adherance of uropathogens , • producing the H2O2 . • production of antibacterial agents .
Bacterial clonization • In post menopausal women , because the lack • of estrogen , they have higher PH in the • vagina, fewer Lactobacilli ,and higher risk • of clonization of uropathgens ( E.coli) • Estrogen replacement can reduce incidence • of UTI in post menopausal women .
Acute Pyelonephritis • Complicated UTI • Emergency state needing hospitalization • High fever , chills(shaking) , flank pain , toxic appearance • CVA tenderness, dysuria , frequency • Superimposing on pregnancy, Obstruction • Complications : Septicemia, Renal failure • Fetal growth retardation • Abortion
Acute Pyelonephritis (Diagnosis) • Clinical (signs & symptoms ) • Leukocytosis , Leukocyturia, • Bacteriuria • Urine culture , blood culture • Ultasonography
Acute pylonephritis(therapy) • Parenteral Antibiotics • cephalosporines (3rd generation ) • Quinolones
Other types of pyelonephritis Emphysematous pyelonephritis (in DM) Xantogranulomatouspyelonephritis in Stag horn stone with UTI
Acute Cystitis • More common in young females • Symptoms more than signs • Low grade fever, dysuria, frequency • suprapubic pain • Can presente as gross Hematuria • Hony moon cystitis • Treatment(ciprofloxacin,co-tri moxasol) • Nitrofurantoin, Nalidixicacide
Acute Urethritis • Gonococcus • Chlamydia • E.coli • Staph. Sarophyticus • HSV
Acute Urethritis • Dysuria • Frequency • Urethral Discharge • Fever & Chills ( gonococcal)
Acute Urethritis(Treatment ) • Chlamydial : Azithromycin: 1 gr in a single dose • Doxycycline: 100 mg BID for 7day • Gonococcal :Ciprofloxacin • Cefixime
Acute Prostatitis • Usually in young males ( E.coli , Klebsiella ) • Fever , Chills, dysuria • Perinial discomfort • Tense ,boggy and tender prostate on RE . • Treatment : Ciprofloxacin • 3rd generation cephalosporin • Imipenem , Aminoglycoside
Perinephric Abcess • Complication of pyelonephritis • Septicemia • Resistant UTI to medical treatment • Persistant Fever • Diagnosed by ultrasound study • Treatment : Surgical drainage + Antibiotics
Catheter associated UTI • Treatment of symptomatic patients . • Sterile closed system . • Attention to aseptic technique. • Topical periurethral antimicrobial ointment • If Candida is detected in urine : Remove catheter
Prevevtion of Recurrent UTI(prophylaxy) Low dose& long term antibiotics Single dose antibiotic for females ( post coital ) Co trimoxsasol , fluquinolon , nitrofurantoin
TIN )) Tubulointerstitial Nephritis Allergic ( mostly drug induced ) Sjogren syndrome TIN with Uveitis TIN in SLE Granulomatous Interstitial Nephritis Infection associated AIN Crystal deposition Light chain cast nephropathy Lymphomatous infiltration Idiopathic AIN
Allergic AIN ( acute ) Antibiotics : beta-lactam, sulfonamides , quinolones, rifampicin ethambutal, vancomycin erythromycin, acyclovir NSAID Diuretics Anticonvulsants : phenytoin , valporate carbamazepine,phenobarbital Miscellaneous : proton pump inhibitors,H2 bloc allopurinol , captopril
Infection associated AIN Bacterial : strep , staph , legionella, salmonella Brucella , E coli Viral : EBV , CMV , HIV, polyoma Hantavirus Miscellaneous : leptospira , mycoplasma Rickettsia
Crystal associated AIN Uric acide Calcium Calcium oxalate Phosphate Indinavir Acyclovir Sulfonamides
Clinical presentation of AIN ARF Fever Skin rashes Positive drug history(antibiotics or other drugs) Eosinophilia Eosinophiluria ?
Treatment of AIN Stopping the drugs responsible for AIN Corticosteroides in : Drug induced AIN Sarcoidosis SLE Sjogren Idiopathic AIN
Chronic Tubulointertitial Nephritis Phenacetin containing analgesic was the most common cause of CTIN in USA until 1983 . Now CIN is mostly due to renal ischemia or secondary to a primary glomerular diseases . VUR Sickle cell Nephropathy Analgesic Nephropathy & Papillary Necrosis Lithium associated Nephropathy Calcineurin inhibitors(cyclosporine , Tacrolimus) )
Chronic TIN (cont.. ) Metabolic Disorders : Chronic uric acid Nephropathy Hypercalcemic Nephropathy Hypokalemic Nephropathy Hperoxaluria Cystinuria
Cystic & Hereditary disorders Polycystic kidney disease Medullary sponge kidney Medullry cystic disease
Miscellaneous Chronic GN Chronic obstruction Radiation Nephritis Aging
Papillary Necrosis One of the clinical presentation of CIN Presenting with renal colic due to passage of necrotic papilla Papillary Necrosis can occure in Analgesic nephropathy Sickle cell nephropathy DM with UTI
Clinical picture of CTIN Progressive decline in renal function Urinary concentrating defect ( DI ) Fanconisynd , RTA , Proteinuria Prominent anemia History of analgesic use or exposure to heavy metals ( lead , cadmium ) , other agents