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UTI Lecture
UTI Lecture
Definition of UTI
UTIs are defined by the presence of micro
Definition
Women:
Men:
Epidemiology of UTI
1%-6% of general practitioner visits are for UTIs.
Financial Statistics
The cost of hospitalization for UTI amounts
Prevalence
Community-dwelling
Long-term
elders 25%
care elders
(chronically bacteriuric)
Marked
25-50% of women
15-40% of men
Juthani-Mehta et al., 2005
Men
Women
Palmer, 2004
Men Women
Palmer, 2004
Change
Impact
Glomeruli
number
surface area
Tubules
thickened membrane
fatty degeneration
shortening
tubule
Renal
vasculature
stiffening
narrowing
Connective
tissue
expandability &
compressibility of
bladder
filtration of blood
glomerular filtration rate by 30-40%
transport
urine-concentrating capacity
Na conservation
renal acidification
blood flow
efficiency in removal of waste
product
bladder capacity
residual urine volume after voiding
Palmer, 2004
Bacteremia40
Bacteremia
Nicolle, 2005
in females:
In males:
burning
Cloudiness in urine
Blood in urine
Micro organism counts:
100,000/ml
(traditional)
1000/ml of one type
100/ml of E.coli
Cystitis :
Inflammation of the bladder,
Pyelonephritis
Acute infection of the
kidneys caused by
progressively untreated
cystitis
Symptoms include
fever, loin pain,
increase in WBC, and
bacteraemia
Can compromise kidney
function and require IV
antibiotics
Chronic
pyelonephriti :
Caused by chronic
inflammation of renal
and tubular tissue with
scarring and shrinkage
secondary interstitial
fibrosis.
Enterococci species
Staphylococcus
saprophyticus
Staph. aureus (uncommon)
Group B strep (uncommon)
Virulence
Infection is usually an interruptive
as epithelia
Degrading enzymes for maceration of
tissue
Factors promoting endocytosis or
preventing phagocytosis
Factors to overcome or survive
mechanisms of the host defense or
combinations of factors of the five groups
Confuse ... ?
Pathogenesis of UTI
Host defences:
Urinary bladder is usually resistant to
bacterial colonisation.
Bacteria accessing the bladder are
eliminated by:
- flushing
mechanism
- urine inhibitors (PH,
osmolality, urea)
- uroepithelial
defences (cytokines,PMNs)
- TammHorsfall protien
Pathogenesis of UTI
Organism features:
Most E.coli causing UTI belong to O,K
and H serotypes.
Uropathogenic E.coli virulence factors: Have fimbria (for adherence). - Secrete
hemolysin & aerobactin. - Resist serum
bacterical action.
- Have higher K
capsular antigen.
Adherence is important in other
bacteria.
Pathogenesis of UTI
Periurethral area & urethra are colonised
by bacteria.
Bacteria enter bladder in susceptable
host.
Adherence properties enable pathogens
to colonise bladder.
Pathogens attach to uroepithelial mucosa
secretion of cytokines recruitment
of PMNs inflammation.
Pathogens may ascend through ureter to
kidney pyelonephritis.
Clinical Manifestation
Asymptomatic bacteriuria
Acute cystitis
Acute pyelonephritis
Uncomplicated /
complicated UTI
Cystitis:
Frequency, dysurea , urgency.
Suprapubic discomfort +/- tenderness.
Fever is often absent.
Acute pyelonephritis:
atypical.
Bacteremia is common.
Special situations
8%.
Of these: 25% develop acute
pyelonephritis.
Pyelonephritis in pregnancy predisposes
to:
- premature delivery.
- low birth weight
infant. - increased newborn mortality.
pts.
All chronicly cathed pts. develop
bacteriuria.
Organisms: E.coli, Proteus, Klebsiella, Serratia
Pseudomonas, Enterococci,
Candida.
Diagnosis of UTI
or instrumentation procedures
Urine dipstick:
- leukocyte esterase
- nitrite
Urine microscopy:
Complicated vs Uncomplicated
UTI
UTIs in elderly men are always considered
complicated
UTIs in women are complicated when:
Hx of recurrent UTI
Secondary to structural abnormalities
Catheters
Stones
Urinary retention
Abscess formation or urosepsis
of an earlier UTI
same pathogen
Re-infection UTI occurs >4 weeks after
earlier UTI
different pathogen
Swart, Soler & Holman, 2004
Causative Pathogens
UTI in Women
Escherichia coligram (-) etiologic agent in ~
=
80% of all UTIs
Research indicates primary source of
microbial invasion is retrograde colonization
by intestinal pathogens
Other factors influencing colonization: vaginal
pH, urethral length, capacity of bacteria to
adhere to urothelium
Osborne, 2004
Polymicromial bacteriuria
Contamination most frequent cause of
multiple microorganisms
25-33% in LTCFs may be polymicrobic due to
fistulas, urinary retention, infected stones, or
catheters
Midthun, 2004
LTCF elderly
E. coli ~ 30%
Proteus species (part of host flori in GI tract) ~ 30%
Staphylcoccus aureus, Klebsiella, Pseudomonas (gram
Symptoms vs Asymptomatic
Bacteriuria
Asymptomatic Bacteriuria (ASB)
Defined as the presence of bacteria in urine of patients
who do not have dysuria, urinary frequency, urgency,
fever, flank pain, or other symptoms related to irritation of
the urethra, bladder, or kidney
Foxman, 2003
post-menopausal women
prostatic obstruction in men, cystocele in women
CNS, i.e., P.D. & dementia
diabetics (ASB females with Type 2 diabetes
29%)
Immunological: s in inflammatory mediators (cytokines, acute
phase proteins)
Instrumental:
indwelling catheteralways bacteriuric symptoms
Wagenlehner, Naber & Weidner, 2005
Pyuria
Diagnostic Criteria
Screening/Diagnosis
Infectious Disease Society of America:
Guidelines for Dx & Rx of ASB in adults
1.
Screening/Diagnosis
Guidelines, continued
2. Pyuria accompanying ASB not an indication for
antimicrobial Rx (A-2)
3. Pregnant women should be screened in early
pregnancy, at least once & treated if positive (A1)
4. Screening of ASB & Rx if positive before these
urological procedures:
Screening/Diagnosis
Guidelines, continued
5.
6.
7.
Specific gravity
Appearance
Color
Odor
Blood or
Hemoglobin
Protein (Albumin)
Microalbuminuria
Fischbach, 2004
*Leukocyte
Esterase
__________
*U/A testing positive for nitrite & leukocyte esterase should be cultured for bacterial pathogen
Fischbach, 2004
treatment plan
Careful evaluation of WBC & differential (left shift)
Electrolytes
R/O dehydration & if IV fluids replacement needed
BUN, Creatinine
Determine renal function for nephrotoxic
medications
Blood Culture
Identify bacteremic organism in suspected
urosepsis
Urine culture:
infection
Asymptomatic: 2 +ve cultures =
infection
False negative : antibiotics, antiseptics,
urethral
Treatment of UTI
Treatment Plan
Early detection/Rx goal is to prevent systemic
infection, bacteremia
Initiation of antibiotic treatment is recommended for a
clinically-diagnosed UTI. Adjust medication when urine
C&S is final
Selection of antibiotic must be individualized and
consider:
Side effect profile
Cost
Bacterial resistance
Likelihood of compliance (convenience, fewer pills/day s
compliance)
Effect of impaired renal function on dosing
Possible adverse drug reactions in elderly (multiple drugs, comorbidities.
Osborne, 2004
Swart et al. 2004
Treatment Plan
AB Rx for at least 10 days for institutionalized
usually recommended.
Wagenlehner et al. 2005
Asymptomatic bacteriuria
cultures.
Treatment is indicated in :
- Children with VU reflux
obstruction
- Pregnancy
- Urinary
Cystitis
young females: 3 days of oral therapy
(fluoroquinolone,cotrimoxazole,cefuroxime,augmenti
n)
history of
previous
infection 7 days therapy.
In males : oral therapy for 7-10 days.
Acute pyelonephritis
Mild infections are treated orally.
(fluoroquinolones,co-trimoxazole,cefuroxime)
48hrs.
Persistant fever, +ve blood culture after 3
days of therapy..R/O obstruction, abscess.
After defervescence..change to oral therapy
to complete 2 weeks.
In males look for a predisposing cause.
FU urine cultures 2 weeks after end of
therapy.
Treatment Plan
Complicated UTI
Can be common in LTC patients
Associated with azotemia, obstruction, or indwelling foley
Can lead to bacteremia, life-threatening systemic infection
Relapse of infection:
Relapse may be due to :
- renal invovement
- structural abnormalities
- chronic bacterial prostatitis
Recurrent UTI
Infrequent symptomatic UTI : treat attacks.
In females, reinfections may be related to
prophylaxis.
Long term prophylaxis is also indicated for
frequent asymptomatic infection in:
Children with VU reflux
- Patients with obtructive uropathy
E-coli Resistance
E coli often carry multi drug resistant
Indwelling-Catheterization
Foley catheterization should be avoided if at all possible
Most effective means of UTI prevention is limitation of