You are on page 1of 46

Urinary tract infection

Dr. Mai Banakhar

UTI
• inflammatory response of urothelium to
bacterial invasion.




Bacteriuria : bacteria in urine
Asymptomatic or symptomatic
Bacteriuria + pyuria= infection
Bacteriuria NO pyuria = colonization





Pyuria :
WBCs in urine.
Infection
T.B
Bladder stone.

Complicated VS uncomplicated • Un complicated UTI: • UTI structurally & functionally normal urinary tract. • Respond to short course of antibiotic • Complicated UTI: • Anatomical or funtional abnormality. • Longer time to respond to ttt . • Female. • Male.

.• Isolated UTI: • 6 months between infections.

Fistula Urethral diverticulum. Persistence : same organism from focus within the urinary tract. Bacterial prostatitis. . atrophic infected kidney. Struvate stone.• • • • • • • • • Recurrent UTI:>2 infections in 6 months 3 UTI in 12 months. Reinfection by different bacteria.

bacterial resistance to ttt. .• Unresolved infection: • in adequate therapy .

• FC • • • • • Stone GU malignancy. Voiding dysfunction. Institutionalized elderly . • D.M • Previous UTI.Risk factors to bacteriuria • Female • Age • Low estrogen ( menopause) • Pregnancy. Obstruction.

Microbiology Faecal-drived bacteria Uncomplicated UTI E. (85%. G-ve baccillus.50%) Staph saprophyticus Enterococ faecalis Proteus Klebsiella. Staph aureus Staph epidermidis Pseudomonas aeruginosa .coli 505 Enterococ faecalis. • • • • • • Complicated UTI E.Coli.

Pregnancy Obstruction G-ve .Route of infection • • • • • • • • Ascending Short urethra Reflux Impair urteric peristalisis. Edotoxins Organism P pili .

Route of infection • • • • • Haematogenous: Uncommon. Candida fungemia. reteroperitoneal abscess .B • Lymphatics: • Rarely in inflammatory bowel disease. Staph aureus. T.

• Increase UTI risk • Protect against UTI • Increase bacterial virulence • Host defences .

Factors increasing bacterial virulence • • • • Adhesion factors Toxins Enzyme production. Avoidance of host defense mechanisms .

• Single type or different types e.Factors increasing bacterial virulence • Adhesion factors • G-ve bacteria.coli mannose resistant pili ( pyelonephritis) . Pili • Attachment to host urothelial cells.coli • Defined functionally be mediating hemagglutination (HA) of specific erythrocytes • Mannose –sensitive • (type 1) • Produced by all strains E.x E.coli • Certain pathogenic types of E.

coli • Extracellular capsule • Immunogenisity • Toxins: • E.Factors increasing bacterial virulence • Avoidance of host defense mechanisms • E.coli cytokines. pathogenic effect on host tissues phagocytosis • M.Tuberculosis reisit phagocytosis by preventing phagolysosome fusion • Enzyme production: • Proteus ureases • Ammonia struvite stone formation .

Host defences • Protective • Mechanical (flushing of urine) antegrade flow of urine • Tamm-Horsfall protein (mucopolysaccharide coating bladder prevent bacterial attachment) • chemical : Low Urine PH & high osmolality • Urinary Immunoglobulin I gA inhibit adherence .

fever & incontinence. haematuria. offensive urine SP pain. urgency. samll volumes. dysuria. .Lower UTI • Cystitis: infection& inflammation of the bladder • Frequency.

infection --------infection .Investigation • Dipstick of MSU • WBC ( pyuria ) • 75 -95% sensitivity infection • False –ve • False +ve • Other causes of pyuria • • • • • • Nitrite testing: Bacteriuria.85% + test ------. Specificity >90% Sensitivity 35.

Investigation • • • • Microscopy : Bacteria : False –ve low bacterial count False +ve contamination (lactobacilli & corynebacteria ) epithelial cells • RBCs & pyuria .

• Symptoms of Upper UTI.Investigation Indications for further investigations in LUTI. • Recurrent UTI. • Pregnancy • Unusal infecting organism ( proteus suggest infection stone) • • • • KUB Ultrasound IVU cystoscopy .

DD • • • • • Non-infective cystitis: radiation cystitis Drud cystitis ( cyclophosphamide ) Haemorrhagic cystitis Urethritis .

• Empirical ttt before culture & sensitivity for the most likely organism.Treatment • Aim : • Eliminate bacterial growth from urine. . • Adgusted according to the culture & sensitivity. • Resistance : • Intrinsic (proteus) • Genetically transferred between bacteria by R plasmids.

Recurrent UTI • >2 in 6 months or 3 within 12 months Reinfection Bacterial persistence .

treated urethral stricture .Recurrent UTI • Reinfection ( different • Bacterial persistance bacteria) ( same organism from a focus within • After prolonged tract) within short interval with interval adifferent organism • Reinfection in females • Functional or anatomical problem. • No anatomical nor • The underlying functional pathology problem should be • In males BOO.

Ultrasound. cystoscopy • Simple Reinfection TTT Avoid spermicides Estrogen replacement therapy Low dose antibiotic prophylaxis .Management Reinfection UTI • Females • KUB.

Female recurrent reinfection • Prophylactic antibiotic: • Reduce infection 90% at bed time 6-12 months • Symptomatic reinfection • Trimethoprim • Nitrofurantoin • Cephalexin • Fluoroquinolones .

Female recurrent reinfection • Natural youghart • Post-intercourse antibiotic prophylactic • Self-started therapy .

IVU Cystoscopy • Treatment : • For the functional or anatomical anomaly . renal ultrasound.Management of bacteria persistance • • • • Investigations: Kub. C.T.

Antibiotics • Empirical therapy. • Bacterial resistance to drug therapy. . • Definitive therapy.

• Pancreatitis.Acute pyelonephritis • • • • Clinical Dx: Flank pain Fever. Elevated WBCs • DD: • acute cholecystitis. .

Acute pyelonephritis • • • • • • • • Risk factors: VUR UTO Spinal cord injury D.M Malformation pregnancy FC .

. • 80% E.coli.Acute pyelonephritis • Pathogenisis : • Initially patchy • Inflammatory bands from renal papilla to cortex. others klebsiella. proteus& pseudomonas.

Acute pyelonephritis • Urine analysis & culture.V antibiotic for 3 days go for CTU . • CBC . U&E • KUB & ultrasoundif no response with I.

ultrasound PC drainage .T.Perinephric abscess • • • • • Pathogenesis. Open surgical . Suspected?? C.

T Management: PCN. Pus accumulation Causes Ultrasound.V fluids.V antibiotic. . C. I.Pyonephrosis • • • • • Infected hydronephrosis. I.

CO2 production . abdominal pain with radiographic evidence of gas within the kidney. • High glucose level-------fermentation.M • Urinary obstruction. • D.Emphysematous pyelonephritis • Severe form of acute pyelonephritis • Gas forming organism • Fever.

coli. commonly. Klebsiella & proteus less frequent .Emphysematous pyelonephritis • • • • Presentation: sever acute pyelonephritis High fever & systemic upset E.

T Patients are unwell Mortality is high . C.Management • • • • KUB Ultrasound.

M • Sepsis is poorly controlled • Nephrectomy .V antibiotic . IVF PC drainage Control D.Management • • • • Conservative ? I.

perinephric fat . Result in non-functioning kidney E.Xanthogranulomatous pyelonephritis • • • • • Severe renal infection Renal calculi & obstruction. Macrophage full of fat deposit around the abscess • Kidney.coli & proteus common.

T . Ultrasound • Stone .Xanthogranulomatous pyelonephritis • Acute flank pain • Fever & tender flank mass • C. mass ?? RCC .

Xanthogranulomatous pyelonephritis • IV antibiotic . • Nephrectomy .