Urinary Tract Infections Ravi Gudavalli Anatomy Lower urinary tract ( superficial ) Urethra Bladder Upper urinary tract ( tissue invasion) Prostate Kidney : Acute Pyelonephritis, abscess UTI’s Asymptomatic Bacturia Uncomplicated/Complicated Cystitis Acute/Chronic Prostatitis Uncomplicated/Complicated Pyelo Intrarenal and Perinephric Abscesses Nosocomial 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 Sexual Intercourse – esp. with spermicide MSM - unprotected Lack of Circumcision AIDS and CD4<200 Diabetes (only in females, not males) Post-menopausal State BPH Pregnancy (mostly for asxatic bacturia) Risk Factors: Anatomic abnormalities: Vesicoureteral Reflux Ureteral Obstruction Foreign Body BPH Incomplete Bladder Emptying Instrumentation Signs and Symptoms UTI’s – Signs and Symptoms Dysuria, 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. UTI’s - Urinalysis Growth 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. 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? Urine 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. 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 Recurrent Infection : Counseling – post-coital voiding, cranberry juice, change BC from spermicide. 3 or more episodes in one year: ___________________ ___________________ ___________________ 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 Uncomplicated Pyelo: Not too sick, No N/V: Cipro/other FQ 7 days. Bactrim reasonable, too. Sicker, 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. Complicated UTI: Treat only if symptomatic, unless preg. Sterilize urine if planning on instrumentation. Broad spectrum, and tailor to cultures. Try to correct underlying abnormality. X-ray evaluation: IVP,Voiding cystourethrogram, Ultrasound, Helical CT (with and without contrast Catheter-associated: 40% 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.
Pages to are hidden for
"Urinary Tract Infections - PowerPoint"Please download to view full document