Urinary Tract Infection

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Urinary Tract Infection

• Dr.Abdulmalik Tayib
• Consultant Assistant Professor.
• Department of Urology

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Non specific Urinary Tract Infection

• Common Organisms
• -Aerobic gram negative rods
  E.Coli(most common),
• klebsiella sp,Proteus sp(mirabilis),Pseudomona
  s
• aerugenosa.
• -Gram-positive coccienterococci,Staphylococcus
• aureus.
• -Other pathogens
• Clamydiae(chlamydia trachomatis).
• Myocoplasmas(Ureaplasma urealyticum).

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Diagnosis

• Urine collection
• In men
  
  voided urine is generally adequate for
  diagnostic purposes,no cleaning required in
  circumcised men
• 1st 10 mls represent urethral specimen.
• Midstream represents bladder specimen.
• In female
• Contamination is more common.
• Careful spread of labia, wash the introitus
  and periurethral area before collecting a mid
  stream urine.
• Some time may require mid catheterized
  specimen.

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DIAGNOSIS

• In infants or patients with spinal cord
  injury catheter specimen is advisable.
• Urinalysis
• Cloudy urine commonly used to represent
  pyuria or large amount of amorphous phosphate.
• The odor rarely clinically significant.
• Bacteria and leukocyte
• Nitrite when ve it suggests the presence
  of more than 100,000 organisms/ml,40-60
  accurate.
• False ve test may occur in patients taking
  vit C.
• Leukocyte estraseIt is good indicator of
  pyuria.

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DiagnosisUrinalysis

• Microscopic examination
• WBC gt5-8/hpf. RBCs.
• Urine culture
• 70 of patients with UTI will have 100 000
  CFU (colony forming unit) /ml.
• 30 100 - 10 000 CFU/ml.

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Classification

• Natural History
• 1st Infection.
• Recurrent Infection.
• -Unresolved bacteruria.
• -Bacterial persistance.
• -Reinfection(most common cause).
• Clinical and pathological presentation
  
• Specific caused by specific organisms,each of
  
• which causes a clinically
  unique disease
• that lead to specific
  pathological tissue
• reaction.

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Classification

• Non Specific
• Organisms causing common clinical and tissue
• reactions.

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Modes of Bacterial Entry

• 4 modes of bacterial entry
• 1-Ascending infection from the urethra
• more in women short urethra.
• Rectal
  bacterial colonization in the
• perineum and
  vaginal vestibule.
• 2-Hematogenous spread T.B.
• staphylococci causing pri renal, renal
  abscesses.
• Less common in adult.
• 3-Lymphatogenous
• Little evidence lymphatic route play role
  in UTI.
• 4-Direct extension from neighboring organs
  V.V.F
• Vesico-intestinal fistula, inflammatory
  bowel
• or pelvic diseases.
  

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Acute pyelonephritis

• Definition bacterial infection causing
  inflammation of the parenchyma and pelvis of the
  kidney.
• E.coli (80),Klebsiella,Proteus,Pseudomonas,Se
  rratia
• Mode of infection
• Ascending from lower urinary tract as in
  VUR,urinary obstruction.
• Hematogenousstaphylococi.
• Clinical features
• Fever(high),chills.
  Flank pain.
• Lower urinary tract symptoms. Nausea,
  vomiting.
• Physical Exam Tachycardia, tender flank,
  paralytic ilius.

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Diagnosis

• CBCLeucocytosis.
• Urinalysis numerous WBCs,RBCs,Leucocyte casts,
  bacteria.
• Urine culture always positive.
• Blood culture
• Imaging Techniques
• IVP.
• U.Srule out obstruction.
• C.T to diagnose intrarenal ,
  perirenal abscess
  formation.
• U.Cyst.

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Management

• In toxic patient
• Hospitalization. Bed rest.
• I.V fluids.
• Parentral antibiotics(Ampicillin,Aminoglycosi
  des),
• to cover both enterococci and pseudomonas
  spp.
• In resistant cases Trimethoprim-Sulfamethoxaz
  ole
• combined with aminoglycoside or
  fluoroquinolones
• or parentral third generation
  cephalosporins,for 10-15days.
• As out patient flouroquinolone or TMP-SMX.

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Management

• Renal abscess requiring drainage.
• Complications Septicemia.
• Schock.

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Emphysematous Pyelonephritis

• Definition
• -Necrotizing renal infection characterized by
  gas within the renal parenchyma or perinephric
  tissue.
• -80-90 D.M.
• -Urinary tract infection from stone or
  papillary necrosis in all cases.
• -Mortality 43
• - E.coli most common.
• -Klebsiella and proteus less common.

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Emphysematous Pyelonephritis

• Symptoms
• Flank pain. Fever.
  Vomiting.
• Failed initial management.
• Pneumaturia.
• Signs
  Tender flank .
  Sick patient.
• Septic.
• Laboratory
• Urine and blood culture almost ve.
• Radiological
• Plain X-ray gas shadow over the affected
  area.

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Emphysematous Pyelonephritis

• -U.S Obstruction.
• -IVP of limited value.
• -C.T presence of air inside the collecting
  system.
• Management
• Fluids IV Antibiotics.
  Relieve obstruction.
• Percutaneous drainage.
• Nephrectomy.

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Chronic Pyelonephritis

• Definition
• Process of renal scarification and atrophy
  resulting in renal insufficiency.
• Cause
• Repeated infections in presence of urinary
  tract
• abnormalities either structural or
  functional
• D.M Calculi Analgesic
  nephropathy.
• Obstructive nephropathy.
• In children VUR.

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Chronic Pyelonephritis

• Symptoms
• Acute infection.
• Asymptomatic.
• Hypertension.
• Renal failure.
• Diagnosis
• UrinalysisPyuria,Bacteriuria,Proteinuria.
• Positive urine culture in acute attack.
• IVU

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• VCUG

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Chronic Pyelonephritis

• Management
• Identifying the abnormality and correcting
  it.
• Preventing recurrence of UTIs.
• Nephrectomy in unilateral atrophy causing
  hypertension.

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Renal Abscess

• Collection of purulent material confined to the
  renal parenchyma.
• Due to hematogenous seeding by Staphylococci or
• Gram-Negative organisms.
• Symptoms Fever. Chills. Abdominal pain. Vague
  symptoms.
• LaboratoryLeukocytosis,positive blood culture.
• RadiologicalU.S , CT.
• Management
• Drainage.
• Antimicrobial.

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Perinephric Abscess

• Collections of purulent material within the
  perinephric space (between the kidney and
  Gerota's fascia).
• Paranephric if extend beyond Gerotas fascia.
• Organism
• E.Coli by ascending infection.
• Predisposing Factors
• Urinary stasis.
  Obstruction,calculi,
  
• Neurogenic bladders. DM.
• Diagnosis same as Renal abscess.
• Management same as Renal abscess.

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Cystitis

• CystitisBladder infection.
• Acute cystitis
• Common in females(20-40yrs old).
• Uncomplicated occur with any anatomical or
  functional
• abnormalities.
• Mode of infection
• Ascending fecal-perineal urethral route.
• Causative organism
• E.coli
• Staphylococcus.

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Cystitis

• Symptoms
• Frequency, urgency, dysuria, occasionally
  hematuria.
• Diagnosis
• Urinalysisbacteruria,hematuria,pyuria.
• Urine culture
• Management
• TMP-SMX. Amoxacillin.
• Cephalosporins. Fluroquinolones.

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Cystitis

• Reccurent infection
• Bacterial persistence surgical removal of
  the infectious
• source(stones).
• Bacterial re infection Fistulae between
  bladder and
• bowel or vagina,pelvic surgey or
  irradiation.
• Diagnosis
• U.S IVU.
  Cystoscopy.
• Management
• ESWL. Correction of other
  abnormalities.
• Antibiotics.

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Prostatitis

• Acute Prostatitis
• Ascending infection.
• SymptomsFever, chills, rectal, low back
  pain, Dysuria, urgency,arthralgia,Malaise.
• Diagnosis
• DRE extremely tender.
• Urinalysispyuria,microscopic hematuria.
• Urine culture.
• Management
• Hydration,bed rest, analgesic,antipyretics.
• Fluouroquinolone,TMP-SMX(4-6 weeks).

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Chronic Prostatitis

• Bacterial
• Same organisms as acute.
• Non bacterial
• Chlamydial.

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Epidydmitis

• Inflamation of the epidydmis.
• Ascending infection.
• C.Trachomatis in men less than 40yrs.
• E.coli in older men.
• in severe epidydmitis may lead to
  epididymo-orchitis.
• Symptoms
• Severe scrotal pain radiate to inguinal area
  and may be
• to the flank.
• O/E tender swallowed epidydmis.

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Epidydmitis

• Diagnosis
• CBC Leukocytosis.
• Urine analysis C.S.
• Management
• Antibiotics.
• Epididymectomy.

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Specific Infections

• Caused by specific organisms,each of which causes
• clinically unique disease that lead to
  specific pathological tissue reaction such as
• -Tuberculosis.
• -Shistosomiasis.
• -Filariasis.
• -Echinococcosis.

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Tuberculosis

• Caused by Mycobacterium tuberculosis.
• Hematogenous from the lung.
• The kidney and the prostate are the 1ry site in
  G.U.tract.
• Kidney infection decent to the ureter and
  bladder,
• Prostate to epidydmis and epidydmis to
  testis.
• Age 20-40.
• Sex little common in male than females.
• Tuberculosis of the kidney may progress
  slowly(15-20yrs).

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Tuberculosis

• Symptoms
• Asymptomatic.
• Flank pain.
• Vague generalized malaise,fatigability.
• Low grade persistent fever.night sweets.
• Symptoms of cystitis not responding to
  therapy.
• Chronic draining scrotal sinus.
• Gross or microscopic hematuria.
• Active T.B else were in the body in less
  than 50.

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Tuberculosis

• Signs
• - Evidence of Extragenital T.B(Lung,LNs,Tonsils,
  Intestine)
• - Usually there is no enlarged or tenderness of
  the kidney.
• - Thickened non tender or slightly tender
  epidydmis.
• - Vas deferns is beaded and thickened.
• - Chronic draining sinus through the scrotal
  skin.
• - Hydrocele.
• - Nodular indurated prostate.

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Diagnosis

• Laboratory Findings
  Persistent Pyuria without
  organisms on culture.
• Acid fast stains positive in 60 of the
  patients.
• 1st morning urine culture.
• Anemia.
• High sedimentation rate.
• X-Ray findings
• Chest X-ray.
• Abdominal X-R-raypunctate calcification in the
  area of the kidney,may be calcification of
  ureter.

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IVP

• - Moth-eaten appearance of the involved
  ulcerated
• calyces.
• - Obliteration of one or more calyces.
• - Dilatation of the calyces.
• - Abscess cavity connect to the calyces.
• - Single or multiple ureteral stricture.
• -Nonfunctioning kidney.

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Tuberculosis

• Urethrocystoscopy
• Ulcers, severe contracted bladder.
• CystogramVUR.
• Medical treatment
• Isoniazid 200-300mg daily.
• Rifampin 600 mg daily.
• Ethambutol 25mg/Kg daily for 2month then
  15mg/kg.
• Streptomycin 1Gm IM daily.
• Pyrazinamide 1.5-2 Gm daily.
• Treatment of the complications.