Urinary tract infection

1. Urinary tract infection Dr. Mai Banakhar

2. UTI • inflammatory response of urothelium to bacterial invasion.

3. Bacteriuria: bacteria in urine • Asymptomatic or symptomatic • Bacteriuria + pyuria= infection • Bacteriuria NO pyuria = colonization

4. Pyuria : • WBCs in urine. • Infection • T.B • Bladder stone.

5. Un complicated UTI: UTI structurally & functionally normal urinary tract. Female. Respond to short course of antibiotic Complicated UTI: Anatomical or funtional abnormality. Male. Longer time to respond to ttt Complicated VS uncomplicated

6. Isolated UTI: • 6 months between infections.

7. Recurrent UTI:>2 infections in 6 months • 3 UTI in 12 months. • Reinfection by different bacteria. • Persistence : same organism from focus within the urinary tract. • Struvate stone. • Bacterial prostatitis. • Fistula • Urethral diverticulum. • atrophic infected kidney.

8. Unresolved infection: • in adequate therapy , bacterial resistance to ttt.

9. Female Age Low estrogen ( menopause) Pregnancy. D.M Previous UTI. FC Stone GU malignancy. Obstruction. Voiding dysfunction. Institutionalized elderly Risk factors to bacteriuria

10. Faecal-drived bacteria Uncomplicated UTI E.Coli, G-ve baccillus, (85%- 50%) Staph saprophyticus Enterococ faecalis Proteus Klebsiella. Complicated UTI E.coli 505 Enterococ faecalis. Staph aureus Staph epidermidis Pseudomonas aeruginosa Microbiology

11. Route of infection • Ascending • Short urethra • Reflux • Impair urteric peristalisis. • Pregnancy • Obstruction • G-ve , Edotoxins • Organism P pili

12. Haematogenous: Uncommon. Staph aureus. Candida fungemia. T.B Lymphatics: Rarely in inflammatory bowel disease, reteroperitoneal abscess Route of infection

13. Increase UTI risk Increase bacterial virulence Protect against UTI Host defences

14. Factors increasing bacterial virulence • Adhesion factors • Toxins • Enzyme production. • Avoidance of host defense mechanisms

15. Adhesion factors G-ve bacteria, Pili Attachment to host urothelial cells. Single type or different types e.x E.coli Defined functionally be mediating hemagglutination (HA) of specific erythrocytes Mannose –sensitive (type 1) Produced by all strains E.coli Certain pathogenic types of E.coli mannose resistant pili ( pyelonephritis) Factors increasing bacterial virulence

16. Avoidance of host defense mechanisms E.coli Extracellular capsule Immunogenisity phagocytosis M.Tuberculosis reisit phagocytosis by preventing phagolysosome fusion Toxins: E.coli cytokines, pathogenic effect on host tissues Enzyme production: Proteus ureases Ammonia struvite stone formation Factors increasing bacterial virulence

17. Host defences • Protective • Mechanical (flushing of urine) antegrade flow of urine • Tamm-Horsfall protein (mucopolysaccharide coating bladder prevent bacterial attachment) • chemical : Low Urine PH & high osmolality • Urinary Immunoglobulin I gA inhibit adherence

18. Lower UTI • Cystitis: infection& inflammation of the bladder • Frequency, samll volumes, dysuria, urgency, offensive urine SP pain, haematuria, fever & incontinence.

19. Dipstick of MSU WBC ( pyuria ) 75 -95% sensitivity infection False –ve False +ve Other causes of pyuria Nitrite testing: Bacteriuria. Specificity >90% Sensitivity 35- 85% + test ------- infection - --------infection Investigation

20. Investigation • Microscopy : • Bacteria : • False –ve low bacterial count • False +ve contamination (lactobacilli & corynebacteria ) epithelial cells • RBCs & pyuria

21. Indications for further investigations in LUTI. Symptoms of Upper UTI. Recurrent UTI. Pregnancy Unusal infecting organism ( proteus suggest infection stone) KUB Ultrasound IVU cystoscopy Investigation

22. DD • Non-infective cystitis: • radiation cystitis • Drud cystitis ( cyclophosphamide ) • Haemorrhagic cystitis • Urethritis

23. Aim : Eliminate bacterial growth from urine. Empirical ttt before culture & sensitivity for the most likely organism. Adgusted according to the culture & sensitivity. Resistance : Intrinsic (proteus) Genetically transferred between bacteria by R plasmids. Treatment

24. Recurrent UTI • >2 in 6 months or 3 within 12 months Reinfection Bacterial persistence

25. Reinfection ( different bacteria) After prolonged interval with adifferent organism Reinfection in females No anatomical nor functional pathology In males BOO, urethral stricture Bacterial persistance ( same organism from a focus within tract) within short interval Functional or anatomical problem. The underlying problem should be treated Recurrent UTI

26. Management Reinfection UTI • Females • KUB, Ultrasound, cystoscopy • Simple Reinfection TTT Avoid spermicides Estrogen replacement therapy Low dose antibiotic prophylaxis

27. Female recurrent reinfection • Prophylactic antibiotic: • Reduce infection 90% at bed time 6-12 months • Symptomatic reinfection • Trimethoprim • Nitrofurantoin • Cephalexin • Fluoroquinolones

28. Female recurrent reinfection • Natural youghart • Post-intercourse antibiotic prophylactic • Self-started therapy

29. Management of bacteria persistance • Investigations: • Kub, renal ultrasound. • C.T, IVU • Cystoscopy • Treatment : • For the functional or anatomical anomaly

30. Antibiotics • Empirical therapy. • Definitive therapy. • Bacterial resistance to drug therapy.

31. Acute pyelonephritis • Clinical Dx: • Flank pain • Fever. • Elevated WBCs • DD: • acute cholecystitis. • Pancreatitis.

32. Acute pyelonephritis • Risk factors: • VUR • UTO • Spinal cord injury • D.M • Malformation • pregnancy • FC

33. Acute pyelonephritis • Pathogenisis : • Initially patchy • Inflammatory bands from renal papilla to cortex. • 80% E.coli, others klebsiella, proteus& pseudomonas.

34. Acute pyelonephritis • Urine analysis & culture. • CBC , U&E • KUB & ultrasoundif no response with I.V antibiotic for 3 days go for CTU

35. Perinephric abscess • Pathogenesis. • Suspected?? • C.T, ultrasound • PC drainage . • Open surgical

36. Pyonephrosis • Infected hydronephrosis. • Pus accumulation • Causes • Ultrasound. C.T • Management: PCN, I.V antibiotic, I.V fluids.

37. Emphysematous pyelonephritis • Severe form of acute pyelonephritis • Gas forming organism • Fever, abdominal pain with radiographic evidence of gas within the kidney. • D.M • Urinary obstruction. • High glucose level-------fermentation,CO2 production

38. Emphysematous pyelonephritis • Presentation: sever acute pyelonephritis • High fever & systemic upset • E.coli, commonly, • Klebsiella & proteus less frequent

39. Management • KUB • Ultrasound, C.T • Patients are unwell • Mortality is high

40. Management • Conservative ? • I.V antibiotic , IVF • PC drainage • Control D.M • Sepsis is poorly controlled • Nephrectomy

41. Xanthogranulomatous pyelonephritis • Severe renal infection • Renal calculi & obstruction. • Result in non-functioning kidney • E.coli & proteus common. • Macrophage full of fat deposit around the abscess • Kidney, perinephric fat

42. Xanthogranulomatous pyelonephritis • Acute flank pain • Fever & tender flank mass • C.T , Ultrasound • Stone , mass ?? RCC

43. Xanthogranulomatous pyelonephritis • IV antibiotic , • Nephrectomy