Renal_Urinary Tract Infections

7/27/2019 Renal_Urinary Tract Infections

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URINARY TRACT

INFECTIONS

Dr. K A W Karunasekera


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Definition

Presence of actively proliferating

organisms within the urinary tract


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Significance

UTI tend to recur

Troublesome symptoms Indicate underlying obstructions

Reveal vesicoureteral reflux and renal

damage


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Associated abnormalities

in the urinary tract

- 50% Normal Urinary Tract

33% VUR

12% Renal Scaring

4% Obstruction

5% Others with no VUR orobstruction; solitarykidney,horse shoe kidney


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Aetiology

E.coli

Klebsiella aerogenes

Proteus mirabilis

Strep. faecalis

Pseudomonas Viral - acute cystitis

TB


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Predisposing Factors

Urinary stasis

Outflow obstruction

mechanical

functional Vesicoureteral reflux

Infrequent or incomplete voiding

Poor intake

Constipation

Unstable bladder


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Host factors

Inflammation of bladder mucosa

Local trauma Impaired immunity


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Clinical Manifestations

Classical symptomsof UTI

Dysuria Frequency

Abdominal pain HaematuriaCloudy urine Offensive urineEnuresis Fever

commonly seen in older children


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Manifestations contd.

Non-specific symptoms

Feeding problem Failure to thrive

Irritability Excessive crying

Vomiting Diarrhoea

Fever Febrile convulsionscommon in infancy & early childhood


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Manifestations in newborn

Poor weight gain

Prolonged jaundice

VomitingDiarrhoea

Refusal of feeds

Irritability

Septicaemia


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Manifestations contd.

Asymptomatic bacteriuria


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Diagnosis

By significant bacteriuria in a culture

colony count 105 or more/ml

103/ml - not significant

104-5/ml - repeat culture

Single organism from SPA is UTI


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Collection of Urine

Urine culture bottle should be a sterile

bottle with a wide mouth and a screw capClean catch or mid stream sample

Bag urine collection Increase

risk of contamination


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Method of collection

Suprapubic Aspiration(SPA)

for sick infants and for those who

have repeated cultures with mixed

growth

Catheter specimenfor sick dehydrated pts


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Storage and Transport

Immediate transport and mount on

culture media, otherwise keep at 40

C


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Preliminary Tests

Urine FR HaematuriaPyuria 10 cells/cmm

or >50 in young femaleMotile bacteria

WBC/DC Leucocytosis in

Pyelonephritis


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Dipsticks for

Proteinuria, haematuria, pyuria Nitrite,

Nitrite dipstick(Ames test) Nitrate-------------->Nitrite in the

bladder

(by most coliforms ) Dipslide

Preliminary tests contd.


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Management

Treatment of acute infection

Investigations

Treatment of obstruction

Prevention of recurrence

Follow-up


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Treatment of Acute Infection

After history, examination and urine

taken for culture:

treat without delay if symptomatic

Antibiotics on emperical basis

until ABST available

D i t t t &


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Drugs use in treatment &

prophylaxis

Drug mg/kg/d prophylaxis

Nitrofurantoin 5 1

N.acid 25-50 15-20

Trimethoprim 4 1- 2

Co-trimoxazole 20/4 5/1

Gentamicin 2.5mg/dose -Amoxicillin 20-25 -

Amox-clav.a. 20/5-10 -

Cephalexin -


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Treat for 7-10 days oral/ sometimes iv

For neonates

Amoxicillin & Gentamicin or3rd generation cephalosporin

General measures: increase fluids,antipyretics & analgesics

Treatment of Acute

Infection contd.


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Aim of Investigation

To asses the anatomy and function of

kidney & UT

To find out underlying cause of

infection

To exclude UT obstruction To predict the prognosis


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Investigations

In the 1st attack :

Ultrasound scanning + MCUG

under 5 years (however the agelimit is controversial)

IVU if USS shows any abnormality


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Investigations contd.

Tc99 dimercaptosuccinic acid(DMSA)

scan - a better substitute for IVU to

detect scarring

Tc99 diethylene triamine penta-acetic

acid (DTPA) scan for outflowobstruction


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Relief of Obstruction

Posterior urethral valves, calculi


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Prevention of Further

Infection

Continuous AB prophylaxis Improve bladder emptying


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Low dose un-interrupted AB

Therapy

To prevent re-infection-effective drug

which has increased urinary

concentration, given daily normal UT


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Duration of treatment

For all patients until investigations areover

3/12 1st UTI & normal UT

6-12/12 recurrent UTI & normal UT

Until disappear / until 5yrs -VUR &UTI

Until adolescence - renal scarring


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Measures to improve

regular bladder emptying

Regular drinking

Regular complete voiding

Double micturation

Avoid constipation


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Acute infection while on

prophylaxis

Poor compliance/ too small dose

TREATMENT

as for acute infection & resume

to previous AB prophylaxis


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Follow up

Clinical assessment re:bowel & voiding habits,growth assessment

Continuation of propylaxis

Urine culturesonce a month when on

prophylaxis, then in first 3 months then every 3months in infants & young children until oneyear. Cultures to be done only If symptoms

present in older children Investigation

MCU 2-3 yr later if VURpresent

Renal_Urinary Tract Infections

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