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Presentation 2 Revised Uti Final

Urinary tract infections (UTIs) affect any part of the urinary system and are more common in females, with various risk factors including anatomical, physiological, and genetic predispositions. UTIs can be classified as uncomplicated or complicated, with different treatment protocols based on severity and patient demographics, including special considerations for pregnant women and men. Diagnosis typically involves history, urine tests, and cultures, while treatment may include antibiotics and preventive measures such as increased fluid intake.

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0% found this document useful (0 votes)
34 views35 pages

Presentation 2 Revised Uti Final

Urinary tract infections (UTIs) affect any part of the urinary system and are more common in females, with various risk factors including anatomical, physiological, and genetic predispositions. UTIs can be classified as uncomplicated or complicated, with different treatment protocols based on severity and patient demographics, including special considerations for pregnant women and men. Diagnosis typically involves history, urine tests, and cultures, while treatment may include antibiotics and preventive measures such as increased fluid intake.

Uploaded by

arjun sankar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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URINARY TRACT

INFECTION
(UTI)

Dr Sushmitha M O
House surgeon
:INTRODUCTIO
N
A Urinary tract infection (UTI) is an infection in any part of the urinary
system-kidneys, ureters, bladder and urethra.

The term urinary tract infection encompasses clinical entities, including asymptomatic bacteriuria,
cycstitis, prostatits, and pyelonephritis.

Generally UTI is more commom in females than males.The prevalance of UTI in women is about 3%
at the age of 20, increasing by about 1% in each subsequent decade.

In males, UTI is uncommon except in the first year of life and in men over 60 year.

*Bacterial colonization is confined to the lower end of the urethra and the remaing urinary tract is
sterile.
:ANATOMY
:RISK
FACTORS
1)IATROGENIC/DRUGS:

-Indwelling catherter

-Antibiotic use

-Spermicides usage

2) BEHAVIOURAL:

-Voiding dysfuction/incomplete voiding

-Frequent or recent sexual intercourse


3) ANATOMIC/PHYSIOLOGIC:

- Vesicourethral reflex

Feamles (females have shorter urethra -4cm)

Preganancy (progesterone mediated)

4) GENETIC:

- Familial tendency

- Susceptible uroepithilial cells (secreats less IgA)

- Vaginal mucus properties may allow EColi binding more ready

* Maternal history of UTI, diabetes, and urinary incontinence are also important risk factors.

* Women who diabetic, on insulin are at higher risk than who non diabetic or on oral hypoglycemic
drugs.
:TYPES
UNCOMPLICATED UTI: It is usually considered to be cystitis or pyelonephritis that occurs in
premenopuasal adult women with no structural abnormality of the urinary tract and who are not pregnent
and have no significant co morbidity that could lead to more serious outcomes.

Complicated UTI can involve either sex at any age A UTI is considered complicated if:

1. the patient is a child, or is pregnant,

2. the patient has any of the following:

A structural or functional urinary tract abnormality and obstruction of urine flow

A comorbidity that increases risk of acquiring infection or resistance to treatment, such poorly controlled
diabetes, chronic kidney disease, or immunocompromise.

Recent instrumentation or surgery of the urinary tract


:ETIOLOGY
The uropathogens causing UTI vary by clinical syndrome but are usually enteric gram negetive rods
that are migrated to urinary tract
Data on etiology and resistance are generally obtained from laboratory surverys and
organisms are identified only in cases in which urine is sent for culture-typically when
complicated UTI or pyelonehritis isn suspected.

In community-acquired infections, the increased


prevalence of multidrug-resistant uropathogens
has left few oral options for therapy in some
case.
:PATHOGENESI
S
* In the majority of UTIs, bacteria establish infection by ascending fromthe urethra to the
bladder. Continuing ascent up the ureter to the kidney is the pathway for most renal
parenchymal infections.
* However, introduction of bacteria into the bladder does not inevitably lead to
sustained and symptomatic infection. The interplay of host, pathogen,and environmental
factors determines whether tissue invasion and symptomatic infection will occur
Haematogenous spread accounts for <2% of documented
UTIs and caused by relatively virulent organisms such as
1. Salmonella
2. S.aureus
* Hematogenous infections may produce focal abscesses
or areas of pyelonephritis within a kidney and
result in positive urine cultures.
ENVIRONMENTAL FACTORS
1) VAGINAL ECOLOGY - is the important factor affecting the risk of uti in women.
— colonisation of vagina intro it’s and peri urethral area by intestinal flora
— sexual intercourse
— Nanoxynol-9 in spermicide is toxic to normal vaginal lactobacilli and thus increase the risk of
uti.
— In postmenopausal women, the previously predominant vaginal lactobacilli are replaced by
colonizing gram negative organisms.

2)ANATOMIC AND FUNCTIONAL ABNORMALITIES


Any condition that permits urinary stasis or obstruction predisposes the individual to UTI.
— Foriegn bodies- stones or urinary catheters (These provide an inert surface for bacterial
colonization and formation of a persistent biofillm )
—Vesicourethral reflux
— urethral obstruction secondary to prostatic hypertrophy
— short distance from urethra to anus
3) HOST FACTORS
A familial disposition to UTI and to pyelonephritis is well documented
— Women with recurrent UTI are more likely to have had their first UTI before the age of 15
years and to have a maternal history of UTI.
— Vaginal and periuretral mucosal cells from women with recurrent UTI bind threefold more
uropathogenic bacteria than do mucosal cells from women without recurrent infection.
—Mutations in host innate immune response genes also have been linked to recurrent UTI and
pyelonephritis.
4)MICROBIAL FACTORS
*An anatomically normal urinary tract presents a stronger barrier to infection than a compromised
urinary tract.
*Thus, strains of E. coli that cause invasive symptomatic infection of the urinary tract in otherwise
normal hosts often possess and express genetic virulence factors, including surface adhesins that
mediate binding to specific receptors on the surface of uroepithelial cells.

Best studied adhesions are - P fimbriar


- Hair like protein
- Type 1 pilus
:CLINICAL
SYNDROMES
1) CYSTITIS
Presents with - Dysuria
Increased urinary freaquency
Urgency
Nocturia
Hesitancy
Suprapubic discomfort
Gross haematuria
( Fever and unilateral back or flank pain is generally an
Indication that the upper urinary tract is involved)
2) PYELONEPHRITIS
— Mild pyelonephritis presents with low grade fever with or without lower back or
costovertebral angle pain
— Severe pyelonephritis manifest with low grade- High grade fever( picket -fence)
Rigors
Nausea and vomiting
Flank and/or loin pain
Patients with diabetes may present with obstructive uropathy associated with acute papillary
necrosis when the sloughed papillae obstruct the ureter.

* Emphysematous pyelonephritis is a particularly severe form of the disease that is


associated with the production of gas in renal and perinephric tissues and occurs almost
exclusively in diabetic patients
* Xanthogranulomatous pyelonephritis occurs when chronic urinary obstruction (often by
staghorn calculi), together with chronic infection, leads to suppurative destruction of renal
tissue

* If there is continued fever and/or bacteremia despite antibacterial therapy o e should


suspect intraparenchymal abscess formation.
3)PROSTATITIS
Acute bacterial prostatitis preset as - Dysyria
Increased frequency
Pain in the prostatic pelvic or perineal area
Fever and chills are usually present
Along with bladder outlet obstruction syndrome

Chronic bacterial prostatitis preset more insidiously - with recurrent episodes of


cystitis sometimes associated with pelvic or perineal pain.

4)ASYMPTOMATIC BACTERIURIA
A diagnosis of ASB can be considered only when the patient does not have local or
systemic symptoms referable to the urinary tract .
Usually bacteriuria is usually detected incidentally when screening for a reason
unrelated to genitourinary tract.
:DIAGNOSTIC
TOOLS
• History

• Urine dipstick test

• Urine analysis

• Urine culture
• History- The history given by the patient has a high predictive value in
uncomplicated cystitis.
*A meta-analysis evaluating the probability of acute UTI on the basis of
history and physical findings concluded that, in women presenting with at least
one symptom of UTI (dysuria, frequency, hematuria, or back pain) and without
complicating factors, the probability of acute cystitis or pyelonephritis is 50%.
*If vaginal discharge and complicating
factors are absent and risk factors for UTI are present, then the probability of UTI
is close to 90%, and no laboratory evaluation is needed.
The differential diagnosis to be considered when women present with dysuria includes
1) Cervicitis (C. trachomatis, Neisseria gonorrhoeae),
2) Vaginitis (Candida albicans, Trichomonas vaginalis),
3) Herpetic urethritis,
4) Interstitial cystitis,
5) Noninfectious vaginal or vulvar irritation.

**Women with more than one sexual partner and inconsistent use of condoms are at
high risk for both UTI and sexually transmitted disease, and symptoms alone do not
always distinguish between these conditions.
Urine Dipstick Test. -tested rapidly

Nitrate positive: is highly specific for UTI, but the test is not very sensitive.
The leukocyte esterase test is very specific for the presence of > 10 WBCs/µl and is fairly sensitive.

:A dipstick test negative for both nitrite and leukocyte


esterase in this type of patient should prompt consideration
of other explanations for the patient’s symptoms and
collection of urine for culture

:A negative dipstick test is not sufficiently sensitive to rule


out bacteriuria in pregnant women, in whom it is important to
detect all episodes of bacteriuria.
Urine analysis - Urine microscopy reveals pyuria in nearly all cases of cystitis and
hematuria in ~30% of cases

Microscopic examinations:
-Pyuria: Most truly infected patients have > 10 WBCS/μL.
-The presence of bacteria in the absence of pyuria:due to contamination during sampling.
-Microscopic hematuria occurs in up to 50% of patients, but gross hematuria is
uncommon.
-WBC casts: pyelonephritis, glomerulonephritis, and noninfective tubulointerstitial
nephritis.
-Pyuria in the absence of bacteriuria and of UTI is possible, for example, if patients have
nephrolithiasis, a uroepithelial tumor, appendicitis, or inflammatory bowel disease or if the
sample is contaminated by vaginal WBCS.

Urine culture - The detection of bacteria in a urine culture is the diagnostic gold standard
for UTI
Major drawback is time consuming
Cultures are recommended in complicated UTI or an indication for treatment of
bacteriuria. Common examples include the following:

1)Pregnant women
2)Postmenopausal women
3)Men
4)Prepubertal children
5)Patients with urinary tract abnormalities or recent instrumentation
6)Patients with immunosuppression or significant comorbidities
7)Patients whose symptoms suggest pyelonephritis or sepsis
8)Patients with recurrent UTIs (≥ 3/yr)
:DIAGNOST
IC
APPROACH
:TREATMENT
• URETHRITIS : Sexually active patients with symptoms are
usually treated presumptively for STDs pending test results.
A typical regimen is ceftriaxone 250 mg IM
plus either azithromycin 1 g po once or doxycycline 100 mg po
bid for 7 days.

• CYSTITIS : First-line treatment of uncomplicated cystitis is


nitrofurantoin 100 mg po bid for 3 days (it is contraindicated if
creatinine clearance is < 60 mL/min),
trimethoprim/sulfamethoxazole
(TMP/SMX) 160/800 mg po bid for 3 days
• PYELONEPHRITIS : High rates of TMP-SMX-resistant E. coli in
patients with pyelonephritis have made fluoroquinolones the first-
line therapy for acute uncomplicated pyelonephritis.
According to randamized clinical trial
—7-day course of therapy with oral ciprofloxacin (500 mg twice
daily, with or without an initial IV 400-mg dose) was highly
effective. If
susceptibility is known oral TMP-SMX (one double-strength tablet
twice daily for 14 days) also is effective.
If susceptibility is not known and TMP-SMX is
used, an initial IV 1-g dose of ceftriaxone is recommended.
Combinations of a β-lactam and a β-lactamase inhibitor (e.g., ampicillin-
sulbactam, piperacillin-tazobactam) or a carbapenem ertapenem, meropenem)
can be used in patients with more complicated histories, previous episodes of
pyelonephritis, anticipated antimicrobial resistance, or recent urinary tract
manipulations

**In general, the treatment of such patients should be guided


by urine culture results.

Once the patient has responded clinically, oral therapy should be substituted for
parenteral therapy

*Alternative management
cranberry concentrates (PAC s proanthocyanidins)
Increase fluid intake
Ural: urine alkiniser
:UTI IN PREGNANT WOMEN
— Ampicillin and the cephalosporins have been used extensively
in pregnancy and are the drugs of choice for the treatment of
asymptomatic or symptomatic UTI in this group of patients.
— Generally, pregnant women with ASB are treated for 4–7 days in the absence of
evidence to support single-dose therapy.
— For pregnant women with overt pyelonephritis, parenteral β-lactam therapy with or
without aminoglycosides is the standard of care.

*Association between nitrofurantoin and birth defects has not been confirmed yet.
*Sulfonamides should clearly be avoided both in the first trimester (because of possible teratogenic
effects) and near term (because of a possible role in the development of kernicterus).
*Fluoroquinolones are avoided because of possible adverse effects on fetal cartilage development.
:UTI IN MEN - Since the prostate is involved in the majority of cases of febrile UTI
in men, the goal in these patients is to eradicate the prostatic infection as well as the
bladder infection
If uropathogen is susceptible- 7-14 day course of flouroquinolones or TMP-SMX is
recommended.
For acute bacterial prostatitis - 2-4 weeks of treatment necessary
For chronic bacterial prostatitis- 4-6 weeks of treatment necessary
For recurrences which are not uncommon in chronic prostatitis, often warrant a 12-
week course of treatment.
:COMPLICATED UTI- Should always start empirical treatment without waiting for culture
reports.then use antibiotics according to culture reports.

For Xanthogranulomatous pyelonephritis- Nephrectomy


For emphyematous pyelonephritis- initially per cutaneous drainage fallowed by
nephrectomy if needed

:ASYMPTOMATIC BACTERIURIA - should be treated mainly in pregnant


women,persons undergoing urologic surgery,renal transplant recipients in all others
treatment is discouraged as treatment doesn’t decrease frequency of symptomatic
infection.
• PATIENTS ON CATHETER - One should not rely on classical
clinical symptoms or signs for predicting the likelihood of
symptomatic UTI in catheterised patients.
Signs and symptoms compatible with catheter-
associated UTI include:
1)New onset or worsening of fever, rigors
2)Altered mental status, malaise, or lethargy
3)Flank pain or costovertebral angle tenderness
4)Acute haematuria
Antibiotics course is usually 7-14 days
:CANDIDURIA- The appearance of Candida in the urine is an increasingly common
complication of indwelling catheterization, particularly for patients in the intensive care unit,
those taking broad-spectrum antimicrobial drugs, and those with underlying diabetes
mellitus. In many studies, >50% of urinary Candida isolates have been found to be non-
albicans species

Treatment— Removal of the urethral catheter


(Therapy is recommended for patientswho have symptomatic cystitis or
pyelonephritis and for those who are at high risk for disseminated disease)
-Fluconazole (200–400 mg/d for 7–14 days)
For Candida isolates with high levels of resistance to fluconazole, oral flucytosine and/or
parenteral amphotericin B are options. Bladder irrigation with amphotericin B generally is not
recommended.
:PREVENTIO
N
1)Drink plenty of liquids, especially water.
2)Drink cranberry juice.
3)Wipe from front to back.
4)Empty your bladder soon after intercourse.
5)Avoid potentially irritating feminine products.
6)Change your birth control method.
THANK YOU

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