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Urinary Tract Infections - PowerPoint by AmnaKhan

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									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.

								
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