URINARY TRACT INFECTION

Robab Maghsoudi

Assistant professor of Iran Medical Science University

Introduction

• Infections of the urinary tract pose a serious health problem, partly because of their frequent occurrence.

• Urinary tract infections are the second most common infections

• 150 million people per year become infected

Epidemiology of UTIs

● UTIs mainly contain gram negative aerobic organisms originating from the gut flora

● Proteus, other Enterobactericiae, S. saprophyticus, enterococci, group B Strep and Chlamydiae cause ~ 20% of uncomplicated UTIs

● In complicated UTIs E. coli cause ~ 20% of infections,

• Pseudomonas and Serratia cause ~ 80% of infections.

PHATHOLOGY

• Urinary Pathogen

• Routes of Infection

• Bacterial virulence

• Host Resistance

• Anatomic& Functional urinary tract abnormalities

• Facilitated bacterial ascent in to bladder

• UTI-causing E.coli need to be able to adhere to the urinary tract epithelium in order to prevent being washed out.

• E.coli expresses adherence factors to prevent being washed out.

E.coli

Pathogenesis

• Rectal and/or vaginal reservoirs• Colonization of perianal area• Bacterial migration to perivaginal area• Bacteria ascend through urethra to bladder• Intercourse may contribute urethral colonization and ascending infection

Virulence

● Infection is usually an interruptive aberration of the balance

● In order to exert damage, bacteria either invade normally sterile compartments of the body where they multiply, or they produce toxins with general or highly specific effects

Fimbriae- a proteinaceous hair like extensions from bacterial cells. These recognize specific receptors usually carbohydrates, glycolipids or glycoproteins and can be characterized by their ability to agglutinate RBCs

عفو ها انواع نت

• Isolated Infection

• Unresolved Infection

• Bacterial Persistence

• Reinfection

• Relapse

انواع عفونت ادراري

سيستيت حاد و مزمن•

پيلونفريت حاد ومزمن•

اورتريت باكتريال•

پروستاتيت•

اپيديديمواوركيت•

أبسه هاي رنال•

ارزيابي بيمار

شرح حال•

معاينه فيزيكي•

أزمايش ادرار•

تستهاي فونكسيونل كليه •

بررسي راديولوژيك•

تشخيص و درمان•

Urinary Tract Infection

Upper• Pyelonephritis (± bacteremia)

Lower• Cystitis• (approx. 30% occult pyelonephritis)• Asymptomatic bacteriuria (ASB)• Urethral syndrome

Clinically differentiating between upper and lower urinary tract infection may be difficult.

The best non-invasive technique for differentiating between bladder and kidney infections is the response to a short course of antibiotic therapy

Laboratory Diagnosis of UTI

Urinalysis• -+ Macro or microscopic hematuria• Alkaline PH with urea splitting bacteria • 10 WBC/hpf is the usual upper limit of normal – Positive result on leukocyte esterase dipstick test correlates well for detecting >10 WBC/hpf• Positive nitrate dipstick test result for bacteriuria – False-negative results are common• Urine cultures not necessary in women with uncomplicated UTI

Cystitis

• inflammation of the bladder, but known to patients as any UTI.

• Infection caused by bacterial infection mainly E. coli.

• Symptoms include painful, burning, urgent urination and WBC in urine.

• Women mainly get this because of the shorter urethra, which puts it closer to the anus where E.coli is found.

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 pyelonephritis

• caused by chronic inflammation of renal and tubular tissue with scarring and shrinkage secondary interstitial fibrosis.

Management of Recurrent UTI

Three treatment options:• Long-term, low-dose prophylaxis (usually 6–12 months) – TMP/SMX, TMP, nitrofurantoin, norfloxacin• Post intercourse, low-dose prophylaxis – Single dose of TMP/SMX, TMP, nitrofurantoin, cephalexin, fluoroquinolone• Self-treatment and diagnosis (3 days) – TMP/SMX, TMP, fluoroquinolone

Self-Diagnosis and Treatment of Recurrent UTIs

• Study to determine accuracy and efficacy of patient-initiated treatment of recurrent UTI Treated with ofloxacin 200 mg BID for 3 days

• Urine samples from 84% of self-diagnosed cases were culture positive, 11% were sterile pyuria

• Self-treated cases result in: 92% clinical cure 96% microbiological cure

Antibiotic Therapy

• 3-day course recommended – TMP/SMX – Fluoroquinolone• Single-dose therapy is less effective – Especially with β-lactams• 7-day regimens are no more effective than 3 days – Increased cost and side effects

Recommendations for antimicrobial prophylaxis of recurrent uncomplicated UTI

Agent Dose

Standard regimen

• Nitrofurantoin 50 mg/day• Nitrofurantoin macrocrystals 100 mg/day• TMP-SMX 40/200 mg/day or three times weekly

• TMP 100 mg/day• Fosfomycin trometamol 3 g/10 day

‘Breakthrough’ infections

• Ciprofloxacin 125 mg/day• Norfloxacin 200-400 mg/day• Pefloxacin 800 mg/weekDuring pregnancy

• Cephalexin 125 mg/day Cefaclor 250 mg/day

Non-drug measures

Randomised trials indicate that drinking 200 ml to 750 ml of cranberry juice, or taking of cranberry concentrate tablets, reduces the risk of symptomatic, recurrent infection.

Follow-up of patients with UTI

• For routine follow-up after uncomplicated UTI and pyelonephritis in women, dipstick urinanalysis is sufficient.

• In women with a recurrence of UTI within 2 weeks, repeated urinary culture with antimicrobial testing and urinary tract evaluation is recommended.

26

Pediatric Urinary Tract Infections

27

Introduction

• Pediatric UTIs often signal an underlying genitourinary tract abnormality

• Can lead to renal scarring with resultant hypertension and end stage renal failure

• Difficult to diagnose because symptoms are non-specific in this age group and testing is often invasive

28

Pediatric UTIs: Epidemiology• Prevalence in girls <1 is 6.5%, boys is 3.3%• Prevalence in girls >1 is 8.1%, boys is 1.9%• Before age 1, uncircumcised boys have a 10

fold increase in risk compared with circumcised boys

• Occurs in about 7% of children <2 who present with fever without a source

29

Epidemiology (continued)• Incidence and severity of vesicoureteral reflux

is highest in age <2• Early renal scarring is nearly twice as common in this

age group• Incidence of scarring increases with each subsequent

UTI

30

Risk Factors

• Age <1 year• Female gender• Uncircumcised males• Constipation• Voiding dysfunction

• Improper wiping• Genitourinary abnormalities• Colonization with virulent E. Coli

31

Signs and Symptoms – Newborns (<2 months)

• Fever • Jaundice• Sepsis• Failure to thrive• Vomiting

32

Signs and Symptoms – Children <2

• Fever• Vomiting and/or diarrhea• Abdominal Pain• Failure to thrive• Malodorous urine• Crying on urination

33

Signs and Symptoms – Children >2

• Fever• Vomiting and/or diarrhea• Abdominal pain• Malodorous urine• Frequency and/or urgency• Dysuria• New incontinence

34

Urine Collection: Suprapubic Aspirate

• “Gold standard” - >99% specificity• Percutaneously aspirating the bladder with a

22g needle 1-2 cm above the pubic symphysis• Positive culture: any number of g- bacilli or

>3000 CFU of g+ cocci

35

Urine Collection: Transuretheral Catherization

• >105 CFU - 95% specificity• 104 – 105 CFU – infection is likely• 103 – 104 CFU – Suspicious• <103 CFU – infection unlikely

36

Treatment - <2 months, toxic or dehydrated

• Requires parenteral treatment and likely hospitalization

• Broad spectrum coverage initially including ampicillin and aminoglycoside or 3rd generation cephalosporin

• Continue parenteral treatment until afebrile and clinically stable

• Complete a 7-14 day course of antibiotics

37

Treatment - >2 months, non-toxic and clinically stable

• May initiate treatment either orally or parenterally

• Oral antibiotic choices include a sulfonamide-containing antimicrobial, amoxicillin, or a cephalosporin

• If not having expected clinical response in 2 days, re-culture and re-evaluate

• Complete 7-14 day course of antibiotics

38

Prophylaxis

• After completion of initial antibiotics, children should be give a prophylactic dose of antibiotics until imaging studies complete

• Antibiotic should have high urinary excretion and low serum and fecal levels, thus minimizing the development of resistance.

39

Imaging

• Needs to be performed in all children <2 years old with initial UTI

• Need to perform at least 2 studies to image the upper and lower urinary tracts

• Acute imaging only necessary when appropriate clinical response is not achieve within 2 day, or pt has known urinary tract abnormality

40

Ultrasound

• Used to examine the kidneys for hydonephrosis, examine the ureters for dilatation, exmine the bladder for hypertrophy, ureteroceles and other abnormalities

• Has essentially replaced IVP • Cannot rule out reflux• Is not as sensitive as renal cortical scintigraphy

(DMSA) for detecting inflamation and scarring

41

Voiding Cystourethrography (VCUG)

• Useful for identifying and grading reflux• Also evaluates the urethra and bladder for

abnormalities – important for boys who may have posterior urethral valves and girls with voiding dysfunction

• Radionuclide cystography (RNC) – can also evaluate reflux, but does not delineate the lower tract anatomy well. Can be used for follow-up exams

42

Renal Cortical Scintigraphy (DMSA)

• Very sensitive for evaluating acute inflammation resulting from pyleonephritis as well as renal scarring

• Role in clinical management is still unclear

Sexually TransmittedInfections

What is a Sexually Transmitted Infection or STI?

• STI’s are infections that are spread from person to person through intimate sexual contact.

• STI’s are dangerous because they are easily spread and it is hard to tell just by looking who has an STI.

• 1 in 4 sexually active teens has an STI.

Prevention is the Key

• Abstinence, or not having oral, vaginal or anal sex, is the best way to protect.

• It is possible to get an STD even without having intercourse through skin-to-skin contact.

• Use latex condoms correctly for any type of sex (vaginal, oral or anal) from start to finish.

Common STI’s

• Chlamydia• Gonorrhea• Genital Herpes (HSV-

2)• Genital Warts (HPV)• Hepatitis B

• HIV and AIDS• Syphilis• Trichomoniasis

Common Symptoms• Sores, bumps or blisters near genitals• Burning or pain in urination• Itching, bad smell or unusual discharge from

vagina or anus• Bleeding from vagina between menstrual periods • Remember: Sometimes symptoms don't show up

for weeks or months or years.

Chlamydia

• Caused by bacteria called Chlamydia Trachomatis.

• Chlamydia is one of the most common sexually transmitted infections.

• Chlamydia is curable.

                                             

Gonorrhea

• Caused by a bacteria known as Neisseria gonorrhoeae.

• Gonorrhea is treatable.• antibiotics for treatment.• partner also need to be treated

www.afraidtoask.com

Genital Herpes (HSV-2)

• HSV-2 is caused by the herpes virus.• HSV-2 can still get even when use a

condom.• After contracting the herpes virus you will

have it FOREVER. There is NO cure.• antiviral medication to help control

recurring outbreaks and clear up painful sores.

Genital Warts (HPV)

• Genital warts are caused by human papillomavirus (HPV).

• There is NO cure for the virus. • HPV can still get even when use a condom.• Some warts can be dissolved with special

medication or the doctor can “freeze” them off with a special chemical.

www.skinchoice.com

Hepatitis B

• Hepatitis is a disease of the liver.• Hepatitis B is transmitted person to person

through blood and body fluids.• There is no treatment for the virus after it

has been contracted.• The only treatment is prevention:

– Abstain from sex– Always use latex condoms– Avoid contact with other people’s blood– Get immunized

HIV and AIDS

• AIDS is one of the most deadly diseases in history.

• AIDS is caused by HIV (Human immunodeficiency virus).

• HIV destroys the body’s defense system (the immune system).

• Thousands of teens in the U.S. become infected each year.

• HIV can be transmitted from an infected person to another person through blood, semen, vaginal fluids, and breast milk.

• People who have another STD are at higher risk for contracting HIV during sex with infected partners.

How do people know they have HIV?

• Many people do not know they have it.• Symptoms may not appear for up to 10 years.• Some people may feel and look healthy for

years while they are infected with HIV.• It is possible to infect others with HIV, even if

the person has absolutely no symptoms.

Symptoms of AIDS

• Extreme weakness and fatigue• Rapid weight loss• Frequent fevers with not explanation• Heavy sweating at night• Swollen lymph glands

• Minor infections that cause skin rashes and mouth, genital, and anal sores.

• White spots in the mouth• Chronic diarrhea• A cough that won’t go away• Short-term memory loss

Kaposi’s sarcoma

(Cancer associated with AIDS)

Oral Thrush (yeast infection)

Common infection associated with AIDS

Oral Leukoplakia

How is HIV treated?

• There is NO cure.

• Prevention is the only way to protection from contracting the virus.

Pubic Lice (Crabs)

• Pubic lice are tiny insects that can crawl from the pubic hair of one person to the pubic hair of another person during sex.

• dry clean or use very hot water to wash all of bedding, towels, or recently worn clothing to kill the lice.

• Pubic lice can be spread even when use a condom.

Syphilis

• Caused by bacteria called Trepenoma pallidum.

• If not treated Syphilis can be very dangerous and can cause brain damage and other serious health problems.

• disease can be treated with antibiotics.• Partner also need to be treated

Trichomoniasis• Sometimes called “trich” it is a parasite that

can be passed from person to person during sexual intercourse.

• One of the most common STD’s• Can be passed on via damp towels,

washcloths, and bathing suits if someone has the parasite.

• Partner also need to be treated.

STD complication?

– Infertility– Cancer– Long-term pain– pass disease from mother to baby– Death

Prevention

Bacterial STDs:Chlamydia, Gonorrhea and

Syphilis

Gonorrhea Chlamydia

Transmission Semen & vaginal fluids, mother to child

Youth Youth at greater risk because of cervicalectopy (immature cervix.)

Symptoms Discharge,painful urinationUsually asymptomaticin women and10-40% of time in men

Discharge,painful urinationUsuallyasymptomatic inmen and women

Time to onset 2-4 weeks 1-3 weeks

Pregnancy Perinatal infection may cause blindness

Diagnosis Genital swab or urine test

Treatment Antibiotics very effective

Complications PID and Epididymitis

• PelvicInflammatory Disease

• Symptoms:• pain, fever, chills

• Complications:• Ectopic pregnancy,

maternal death, sterility

• Treatment: antibiotics

Epididymitis

Symptoms:fever, chills,

pain

Complications:sterility

Treatment: antibiotics

PrimaryChancre appears at

site of infection

SecondaryOther symptoms appear--

rashes, fever, fatigue

Latent PhaseNo Symptoms

Late PhaseDamage to nervous system and death

Syphilis

•Transmission: contact with rash or chancre

•Symptoms: (at left)

•Time to onset: 10-90 days

•Pregnancy: perinatal infection may cause blindness or infant death

•Diagnosis: blood tests

•Treatment: antibiotics very effective

Genital Herpes (HSV)

• Transmission: skin to skin

• Symptoms: Prodrome--tingling in legs, buttocks or groinLesion--itching, blister at infection site;Recurrences vary in frequency and severity

• Time to onset: 2-20 days

• Pregnancy: 5% transmission when lesions present

• Diagnosis: culture, antibody test

• Treatment: symptom relief; antivirals effective

HPV (Human Papilloma Virus)

“Genital Warts”

• Transmission: skin to skin contact; not dependent on visible warts

• Symptoms: fleshy “warts” on genitals, perineum, anus;some strains cause no visible symptoms

• Time to onset: 1-20 months• Pregnancy: perinatal infection possible• Diagnosis: observation, PAP detects dysplasia• Treatment: remove visible warts

Hepatitis A Virus B Virus C Virus

SymptomsofInitialInfection

Some people have no symptoms (especially HCV) Eyes or skin may turn yellow (jaundice) Loss of appetite Nausea, vomiting, fever, stomach or joint pain Fatigue (can last weeks or months) Dark urine & pale bowel movements

ChronicInfection

(Infection forlife)

No chronic disease 15% Chronic

Can cause:Liver cell damageCirrhosisLiver cancer

85% Chronic

Can cause:Liver cell damageCirrhosisLiver cancer

How is itSpread?

Fecal/ oral Contaminated

food and water Oral/Anal sexual

contact

Blood and bodyfluid contact

Sex Needles Mother to baby Human bite

Blood and body fluidcontact

Needles Mother to baby Sex (minimal)

Vaccine Yes Yes No

Thank You