Urinary Tract Infections

Urinary Tract Infections Ravi Gudavalli Anatomy Lower urinary tract ( superficial ) Urethra Bladder  Upper urinary tract ( tissue invasion) Prostate Kidney : Acute Pyelonephritis, abscess  UTI’s Bacturia  Uncomplicated/Complicated Cystitis  Acute/Chronic Prostatitis  Uncomplicated/Complicated Pyelo  Intrarenal and Perinephric Abscesses  Nosocomial  Asymptomatic vs. Community-Acquired Epidemiology Catheter associated ( nosocomial)  Non-catheter associated (community acquired)  Young sexually active women  Where are the bugs coming from ???? Etiology/Microbiology  Gram –ve rods 70-95% of episodes.  Staphylococcus saprophyticus: most of remainder.  Proteus, Klebsiella ( stones) , enterococci, Serratia, Pseudomonas ( instrumentation)  _____________:  Don’t forget Chlamydia, Niesseria, Herpes simplex ( urethritis ) in young sexually active patients with sterile pyuria  Why does voiding after sexual intercourse reduce incidence of UTI’s ?? Pathogenesis Normal flora  Altered flora  Females with short urethra (4 cm), proximity of the urethra to the anus  Use of spermicidal agents (change in flora)  Males more than 50 – BPH Obstruction  Pregnancy : decreased ureteral tone, peristalsis, increased vesicoureteral reflux  Obstruction: tumor, stricture, stone, BPH  ( important to recognize any obstruction as this can cause rapid destruction of tissue when complicated with infection)  Neurogenic bladder  Vesico-ureteral reflux  Virulence factors Uropathogenic strains P-factor UTI’s – Risk Factors Intercourse – esp. with spermicide  MSM - unprotected  Lack of Circumcision  AIDS and CD4<200  Diabetes (only in females, not males)  Post-menopausal State  BPH  Pregnancy  Sexual (mostly for asxatic bacturia) Risk Factors: abnormalities:  Vesicoureteral Reflux  Ureteral Obstruction  Foreign Body  BPH  Incomplete Bladder Emptying  Instrumentation  Anatomic Signs and Symptoms UTI’s – Signs and Symptoms Frequency, Nocturia, Urgency, Suprapubic/Back pain, Malodorous Urine, Hematuria, Cloudy urine.  Pyelo: Fever, Chills, Nausea, Vomiting, Loin Pain, with or without above symptoms. CVA tenderness, tachycardia.  Prostatitis: Chills, dysuria, urgency, frequency, perineal/back/pelvic pain. Prostate tender/enlarged/indurated. Chronic is much more occult.  Dysuria, UTI’s - Urinalysis of _____ organisms/ml from a clean catch specimen.  102 – 104 colonies significant with SP catheter aspiration, straight cath, or typical symptoms.  Pyuria, Microscopic/Gross Hematuria, Bacteriuria, WBC Casts.  Unspun midstream urine: >10 WBC/hpf considered abnormal.  Growth  Pyuria and Hematuria  Dipstick UA:  Detect pyuria by _____________and Enterobacteriaceae via____________.  Both fairly sensitive for “high count” UTIs, LE better for intermediate (Bacteriuria <105 colonies.) UTI’s – What about Cultures? cultures:  Not necessary in routine uncomplicated cystitis.  Role of pre-treatment cultures currently being evaluated because of emerging resistance among uropathogens.  _____________ 15 – 50 y/o should have cultures.  Urine UTI’s – Therapy  Depends on clinical situation:  Male vs. Female  Young vs. Old  Catheter-associated or not  Hx of recurrent infections or not  Lower vs. Upper Urinary Tract Acute Cystitis:         Usually a ________ regimen ____________________________________________________ _______________________ are good choices empirically. One day regimens, even with the new drug Fosfomycin, not as effective as 3 days of above meds. Nitrofurantoin not unreasonable, but is a 7-day regimen. Increased hydration may dilute the antibiotic so is not recommended. Cranberry juice IS an effective for prophylaxis, but shows no benefit in treatment. Phenazopyridine – Pyridium. Culture IF symptoms fail to resolve. UTI’s - Therapy Infection :  Counseling – post-coital voiding, cranberry juice, change BC from spermicide. or more episodes in one year:  ___________________  ___________________ 3  Recurrent  ___________________  Relapsing Infection  Same strain – Radiologic/Urologic Eval. UTI’s - Therapy    Men with UTI: NO short-course therapy. 7-14 days of Bactrim or a Quinolone. >50, check the prostate.  Acute prostatitis:  4 wks Bactrim, 2 wks FQ.  Recurrence – treat 4 – 6 weeks. Recurrent recurrence treat 12 weeks.  Rec. Rec. Recurrence? Tx again, Long-term suppression, Prostatectomy Acute cystitis in Pregnancy:         ____________ the Urine! Treat Asymptomatic Bacteriuria. Watch closely for pyelo – Admit in this case. Treat for 3-7 days. Reasonable regimens: Amoxicillin, Nitrofurantoin, Cephalexin. Also Augmentin, Bactrim (not 3rd trimester), Cefpodoxime. Not quinolones. _________________________ in one to two weeks. UTI’s - Therapy  Post-menopausal Women: * Evaluate for need for ________________ preparations. Complicated cystitis Resistant organisms  Empirically : quinolones, tailor to culture result  Failure to respond clinically within 24 – 48 hours requires UT imaging and repeat cultures.  Duration usually 7 – 14 days.   Acute  Not Uncomplicated Pyelo: too sick, No N/V:  Cipro/other FQ 7 days.  Bactrim reasonable, too. N/V:  Admit, IV AB: Amp+Gent, IV Bactrim, FQ, 3rd Gen. Cephalosporin.  D/C once afebrile for 24 hours.  Switch to oral – total of 14 days.  Sicker,  Complicated  Treat UTI: only if symptomatic, unless preg.  Sterilize urine if planning on instrumentation.  Broad spectrum, and tailor to cultures.  Try to correct underlying abnormality.  X-ray  IVP, evaluation: Voiding cystourethrogram, Ultrasound, Helical CT (with and without contrast Catheter-associated: of nosocomial infections  Prevention BIG TIME! (Proper technique, isolation, closed system, etc.)  Symptomatic: treat, change out catheter, and culture.  Therapy for asymptomatic patients just selects for resistant organisms, so just watch and hope for the best.  40%