Urinary tract infection

uti

1. URINARY TRACT INFECTION Dr . PRATEEK SINGH PGY1 MEDICINE

2. INTRODUCTION first documentation in the  Ebers Papyrus in egypt  dated to 1550 BC About 150 million people per year more common in women than men.  m/c form of bacterial infection in women

3. Half of women having at least one infection at some point in their lives Most frequent in female 20-36 Risk increases after menopause 20-40 % have recurren Up to 10% of women have UTI in a given year

4. HOSPITAL ACQUIRED UTIs 600k / year 40% of hospital acquired infections CAUTIs – 80 % of hospital acquired UTIs Catheterization increases risk by 10 fold Pyelonephritis common in pts catheterized over a month .

5. GENDER AND SEX DIFFERENCES Neonate : M > F Adolescent to menopause : F > M Older age : M=F Female : short urethra , sexual contact and spermicidal Male : prostate infections , circumcision , homosexuals , anatomical defects

6. Classification of UTI Location Upper ( pyelonepritis , interrenal and peri-nephric abscess ) Lower ( cystitis , uretheritis ) Symptoms Asymptomatic – bacteriuria in absence of symptoms Symptomatic- bacteruria with symptoms

7. Recurrences Sporadic < 2 /6 months Reccurent >_ 2 /6 months or >_3/1year Complicating factors Uncomplicated- episode of cysto-urethritis following bacterial colonisation of urethral and bladder mucosa Complicated- infection involving parenvchyma ( pyelonephritis or prostatitis .) in obstructive uropathy or instrumantation Setting Hospital acquired UTIs

8. ETIOLOGY Common pathogens of UTI E. Coli (80 % of outpatient UTIs) Klebsiella Proteus Enterobactor pseudomonas Staph. Saphropyticus (5-15% ) Enterococcus Candida Staph . Aureus

9. Pathogenesis

10. Pathogenesis of UTI Ascending route – m/c Initial event – colonisation of uretheral and peri-uretheral tissues Once in bladder – multiplies – pass up ureter if VUR – renal pelvis and parenchyma Healthcare infections – instrumentation ( catheterisation , cystoscopy )

11. Hematogenous – less frquent ( MTB , salmonella ) Common site of abscess formation in Staph. aureus bacteremia , less often in candidemia and rarely with gram negative Source of uropathogens – enteric bacteria

12. HOST PROTECTIVE FACTORS IN UTI Flushing mechanism (during micturation ) Acidic pH of urine ( 4.6-6 ) – anti-bacterial Acidic vaginal pH(3.5-4.5) – inhibits colonization THF protein –attach to p.fimbre and blocks E.coli colonisation Chemo tactic factors IL-8

13. Bacterial factors in UTI E.coli strains expressing O Ag – most of UTI Expressing capsular Ag – antiphagocytic – clinical severity P- fimbriae – enhance attachment of E.coli to uroepithelial cells Motility – ascend against urine flow

14. Proteus – urease producing –NH4 – alkaline urine - struvite stones Endotoxins of Gram negative – decreases ureteral peristalsis Hemolysin – damage tubular epithelium – promotes invasion Aerobactin of E.coli – promote iron accumulation for bacterial replication

15. Risk factors for UTI Reduced Urine Flow outflow obstruction (BPH , carcinoma, urethral stricture, foreign body, calculus) neurogenic bladder inadequate fluid uptake

16. Promote Colonization sexual activity – increased inoculation spermicide – increased binding estrogen depletion – increased binding antimicrobial agents – decreased indigenous flora

17. Facilitate Ascent catheterization urinary incontinence fecal incontinence residual urine with ischemia of bladder wall

18. TYPES OF UTI AND SOME RELATED TERMS

19. Uncomplicated UTI OPD visit Non-pregnant female Anatomically and functionally normal urinary tract

20. Complicated UTI Male Pregnant female Anatomic or functional abnormality of urinary tract Immuno -compromised host Metabolic abnormality Instrumentation Multi-drug resistant bacteria

21. ASYMPTOMATIC BACTERIURIA Positive urine culture( Ucx >_10(5)CFU/ml ) in the absence of infection Investigate and treat only in Pregnant women Renal transplant pts About to undergo urinary tract procedures.

22. Acute uretheral syndrome Lower UTI symptoms and pyuria with < 10(5) bacteria/ml urine mos - Chlaymdia trachomatis , ureaplasma urealyticum , N.gonorrhoea If no specific etiology – empirical t/t with doxycycline 1oo mg PO bd for 7 days or azithromycin 1 g po single dose

23. Catheter asc . UTI Risk of bacteriuria is 5%/day , 25%/wk and 100%/month. 40% of nosocomial infections m/c source of gram negative bacteremia . Dx : 10(2) CFU/ml mo – E.coli , proteus , enterococcus , enterobactor , serratia ,pseudomonas , candida .

24. RECURRENT UTI 27% of young women >_ 3 episodes/year >_ 2 episodes/6 months Identify organism by culture RELAPSE : infection with same organism RECURENCE : infection with different organisms

25. PREVENTION : Frequent and complete voiding Avoidance of spermicide and/or diaphragm Immediate voiding after intercourse Good hydration 5. Low dose antibiotic prophylaxis

26. Recommendations for recurrent UTI Urinalysis and midstream urine culture and sensitivity should be performed with the first presentation of symptoms in order to establish a correct diagnosis of recurrent UTI Patients with persistent hematuria or persistent growth of bacteria aside from Escherichia coli should undergo cystoscopy and imaging of the upper urinary tract. SOGC CLINICAL PRACTICE GUIDELINE 1088 NOVEMBER JOGC NOVEMBRE 2010

27. 3. Sexually active women suffering from recurrent UTI and using spermicide should be encouraged to consider an alternative form of contraception. 4. Prophylaxis for recurrent UTI should not be undertaken until a negative culture 1 to 2 weeks after treatment has confirmed eradication of the urinary tract infection.

28. 5. Continuous daily antibiotic prophylaxis using cotri - moxazole , nitrofurantoin , cephalexin , trimethoprim , trimethoprim-sulfamethoxazole , or a quinolone for recurrent UTI 6. Women with recurrent UTI associated with sexual intercourse should be offered post-coital prophylaxis as an alternative to continuous therapy in order to minimize cost and side effects

29. 7. Acute self-treatment should be restricted to compliant and motivated patients in whom recurrent UTI have been clearly documented . 8. Vaginal estrogen should be offered to postmenopausa l women who experience recurrent UTI. 9. Cranberry products are effective in reducing recurrent UTI.

30. 10. Acupuncture may be considered as an alternative in the prevention of recurrent UTI in women who are unresponsive to or intolerant of antibiotic prophylaxis . 11. Probiotics are of no proven therapy for recurrent UTI 12. Pregnant women at risk of recurrent UTI should be offered continuous or post-coital prophylaxis with nitrofurantoin or cephalexin , except during the last 4 weeks of pregnancy

31. Acute prostatitis Fever with chills, dysuria , and a boggy, tender prostate on examination Diagnosis - physical exam and urine Gram stain and culture. Enteric gram negatives are the usual causative organism

32. Chronic prostatitis low back pain, perineal , testicular, or penile pain, dysuria , ejaculatory pain, recurrent UTIs with the same organism, or hematospermia frequently abacterial Dx - quantitative urine cultures before and after prostatic massage TRUS if abscess suspected.

33. Acute epididymitis unilateral scrotal ache with swollen and tender epididymis on exam Causative org. N. gonorrhoeae or C. trachomatis in sexually active young men gram-negative enteric organisms in older men

34. PYELONEPHRITIS Fever with chills and rigors N/V , diarrhoea ,tachycardia CV or renal angle tenderness Leucocytosis Urine microscopy : pyuria + WBC casts + hematuria Gram negative sepsis

35. COMPLICATION : Sepsis Papillary necrosis Abscess Ureteral obstruction Impaired function if scarring Pregnany – preterm labour

36. Rapid increase in Sr. Creatine may indicate PAPILLARY NECROSIS ( sickle cell ds , DM, analgesic nephropathy ) INTRAPARENCHYML ABSCESS s/b suspected when pt has continued fever and bacteremia despite antibiotic therapy .

37. EMPHYSEMATOUS PYELONEPHRITIS Severe acute necrotizing parenchymal renal infection caused by gas-forming bacteria . Much higher mortality . No specific symptoms and signs, and can be present in the absence of a septic physiology.

38. EPN should be suspected in patients who are not responding to therapy unexplained abnormal gas formation in the body, especially in diabetic patients with poor glycemic control . High-dose antibiotic therapy alone or with percutaneous drainage in contrast to bilateral nephrectomy may be a preferable approach to salvage kidney function

39. EPN classification by Huang and Tseng Class Description Class I Gas in collecting system only Class II Parenchymal gas only Class III a Extension into perinephric tissue Class III b Extension into pararenal space Class IV EPN in solitary kidney , or bilateral disease

40. XANTHOGRANULOMATOUS PYELONEPHRITIS Rare , serious, chronic inflammatory disorder characterized by destructive mass that invades renal parenchyma. Defect in microbial processing Deposition of lipid laden macrophages Middle aged women with recurrent UTI Mo : E.coli , proteus , kliebsella , pseudomonas , E. fecalis t/t : iv antibiotics , partial/total neprectomy Consider RCC (XGP share characteristics with, radiographic appearance, and ability to involve adjacent structures

41. Xanthogranulomatous pyelonephritis

42. DIAGNOSIS OF UTI History Physical examination Urine-analysis Imaging

43. Clinical symptoms of UTI CYSTITIS - dysuria ,urgency , frequency , suprapubic pain , cloudy urine , strangury PYELONEPHRITIS – fever with chills , N/V , flank pain , CV tenderness UROSEPSIS – + shock

44. Physical Exam : CVA tenderness ( pyelonephritis ) Urethral discharge ( urethritis ) Tender prostate on DRE ( prostatitis )

45. Urinalysis Leukocyte esterase Nitrites More likely gram-negative rods WBCs ( >_ 10 /HPF ) RBCs ( stones , obstructive lesions , mallignancy ) C/S

46. Collecting urine sample MSU Samples from urinary bags and bed-pans should not be used Suprapubic puncture – most reliable Urine in bladder > 4 hrs

47. Dx -Interpretation Urine culture 10(5) CFU/ml – standard 10(3) -10(4) significant if symptomatic Several strains – likely contamination

48. Indications for Radiologic Imaging with UTI non responsive to treatment with predisposing factors Imaging modalities X-ray KUB USG abdomen and pelvis Non-contrast CT abdomen and pelvis Cystoscopic or ureteroscopic evaluation of the urinary tract (rarely )

49. DIAGNOSTIC FLOWCHART FOR UTI

50. Differential diagnosis Herpes genitalis   (HSV) N. Gonorrhoeae Chlamydia Trichomonas Vaginitis Prostatitis Nephrolithiasis Trauma Urinary tract tuberculosis Urinary tract neoplasm Intra-abdominal abscess Sepsis – source other than GU system Overactive bladder

51. MANAGEMENT Principles of management : hydration relief of urinary tract obstruction removal of foreign body or catheter if feasible correctable cause of GU abnormalities and metabolic abnormality judicious use of antibiotics

52. ANTIBIOTICS Highest mean urine concentration (from highest to lowest): Cabrenicillin > Cephalexin > Ampicillin > TMP/SMX > Ciprofloxacin > Nitrofurantoin

53. Uncomplicated UTI (cystitis, some pyelonephritis ) Nitrofuratoin 100 mg BID x 5 days or a 3 day course of oral TMP/SMX - 95% effective If TMP/SMX resistance is > 10 – 20% - consider fluoroquinolones . Only use fluoroquinolones or beta- lactams if one of these recommended antibiotics cannot be used due to availability, allergy, or tolerance

54. Other Uncomplicated UTI 7 – 10 day antibiotic course diabetes symptom duration before treatment of > 7 days pregnancy age >65 years past history of pyelonephritis UTI with resistant organisms

55. Antibiotic therapy for recurrent UTI

56. Take home message Accurate diagnosis Correct treatment to prevent antimicrobial resistance

57. REFERENCES Davidson’s Principles and Practice of Medicine 22E Harrison’s Principles of Internal Medicine 20E THE WASHINGTON MANUAL OF MEDICAL THERAPEUTICS 34E American society of urology 2016

58. THANK YOU