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1、UrinaryTractInfectionWuYitaiDepartmentofNephrologyTongjiHospital,TongjiUniversity,UrinaryTractInfection,Content,DefinitionsEpidemiologyEtiologyPathogenesis PathologyClinical presentation DiagnosisTreatmentsComplicationPrevention,ContentDefinitions,Definition of UTI,UTI is defined as the presence of
2、micro-organisms in the urinary tract. Most patients with UTI have significant bacteriuria, i.e. bacterial colony counts 105 /ml, in a mid-stream “clean catch” urine. Conversely, colony counts 105/ml of midstream urine are occasionally due to specimen contamination.Acute urethral syndrome: dysuria, u
3、rgency, and frequency, but without bacteriuria.,Definition of UTIUTI is defi,AnatomicLower UTI:urethritiscystitis(mucosal infection)Upper UTI:pyelonephritisprostatitisintrarenal and perinephric abscesses (tissue invasion),Classification of UTIs（1）,AnatomicClassification of UTIs,Classification of UTI
4、s（2）,ClinicalUncomplicated UTI:Lack structural or functional abnormalities of the urinary tractNormal flow of urineNO interference with the normal defensesComplicated UTI:Predisposing lesion of the urinary tract, structural or functional abnormalities, e.g. congenital abnormality of the urinary trac
5、t, stone, obstruction, catheter.Interference with the normal defenses, e.g. immunosuppression, renal disease, or diabetes.,Classification of UTIs（2）Clini,Classification of UTIs（3）,EpidemiologyCatheter-associated（nosocomial）infections: Symptomatic Asymptomtic Non Catheter-associated（community-acquire
6、d）infections:Symptomatic Asymptomtic,Classification of UTIs（3）Epid,Epidemiology,Almost half of all women will have at least one UTI in their lives.UTI is uncommon in men under the age of 50, but very common among women.Asymptomatic bacteriuria is more common among elderly men and women.,Epidemiology
7、Almost half of all,Etiology（1）,Community-Acquired UTIgram-negative bacilli is the most common agent,E. coli,Enterobacter,Enterococcus,Proteus,Staphylococcus,Klebsiella,E. coli,Etiology（1） Community-Acquired,Etiology（2）,Causative organisms: Escherichia coli Klebsiella, proteus and pseudomonas 1- Bact
8、eria S. aureus, Staphylococcus epidermidis and S. saprophyticus Enterococci (Streptococcus faecalis粪链球菌) Mycobacterium tuberculosis Chlamydia trachomatis, Neisseria gonorrhoeae 2- Virus Herpes simplex virus , HIV 3- Fungus Candida, Histoplasma capsulatum 4- Protozoon Trichomonas vaginalis, Schistoma
9、 haematobium,Etiology（2） Causative organ,CASE 1 32 year-old woman;Dysuria and frequency; Pyuria in the urine sediment;Gram negative bacilli. Escherichia coli (E. coli) .,CASE 2 65 year-old woman;Dysuria and frequency; Pyuria; Gram positive cocci. Enterococcus faecalis,CASE 1 CASE 2,CASE 318 year-old
10、 woman Dysuria and frequency;Pyuria; Gram positive cocci;Staphylococcus.,CASE 4 42 year-old diabetic woman with a catheter. Gram positive yeasts. Candida grew.,CASE 3 CASE 4,Route of Infection,Ascending route (the most common),Colonization of urethra,Route of InfectionAscending ro,Pathogenesis,Patho
11、genesis,Pathogenesis（1）,The urinary tract above the urethra is normally sterile.The urethral meatus and surrounding perineum are colonized with a mixture of skin and bowel flora.Vaginal flora or pathogens may contaminate the urethra.,Pathogenesis（1）The urinary tra,Pathogenesis （2）,Host defense mecha
12、nisms:1. Urine: low pH, high osmolality, high urea & organic acid concentration inhibit and kill microorganisms2. Regular urine flow: dilute and expel pathogens3. Bladder epithelial cells: coated with mucus (glycosaminoglycan) prevent bacteria from adhering to bladder wall,Pathogenesis （2）Host defen
13、se,Conditions affecting pathogenesis,Gender and sexual activity. Pregnancy.Obstruction. （tumor, stricture, stone, BPH）Neurogenic bladder dysfunction.Vesicoureteral refluxBacterial virulence factorsGenetic factors（details in the following）,Conditions affecting pathogene,Conditions affecting pathogene
14、sis（1）,Gender and sexual activity The female urethra appears to be prone to colonization with colonic gram-negative bacilli because of its proximity to the anus, its short length , and its termination beneath the labia. Voiding after intercourse reduces the risk of cystitis.An important factor predi
15、sposing to bacteriuria in men is urethral obstruction due to prostatic hypertrophy.,Conditions affecting pathogene,Conditions affecting pathogenesis（2）,PregnancyUTIs are detected in 2 to 8% of pregnant women.Pregnant women with asymptomatic bacteriuria.Bladder catheterization during or after deliver
16、y causes additional infections.,Conditions affecting pathogene,Conditions affecting pathogenesis（3）,Obstruction TumorStrictureStoneBenign prostatic hypertrophy (BPH)These conditions result in hydronephrosis and increase frequency of UTI.,Conditions affecting pathogene,Conditions affecting pathogenes
17、is（4）,Neurogenic Bladder DysfunctionInterference with bladder enervation, as in spinal cord injury, multiple sclerosis, diabetes.The infection may be initiated by the use of catheters for bladder drainage.The infection is favored by the prolonged stasis of urine in the bladder.,Conditions affecting
18、pathogene,Conditions affecting pathogenesis（5）,Vesicoureteral RefluxVesicoureteral reflux occurs during voiding or with elevation of pressure in the bladder.Common among children with anatomic abnormalities of the urinary tract.Renal damage correlates with marked reflux, not with infection.,Conditio
19、ns affecting pathogene,Conditions affecting pathogenesis（6）,Bacterial Virulence factorsSpecific O, K, and H serogroups.Adherence of bacteria to uroepithelial cells is a critical first step in the initiation of infection. Fimbriae mediate the attachment of bacteria to specific receptors on epithelial
20、 cells.E. coli strains usually produce hemolysin and aerobactin.,Conditions affecting pathogene,Conditions affecting pathogenesis（7）,Genetic factorsHost genetic factors influence susceptibility to UTI.The number and type of receptors on uroepithelial cells are in part genetically determined.,Conditi
21、ons affecting pathogene,Conditions affecting pathogenesis,Gender and sexual activity. Pregnancy.Obstruction. （tumor, stricture, stone, BPH）Neurogenic Bladder Dysfunction.Vesicoureteral RefluxBacterial Virulence factorsGenetic factors,Conditions affecting pathogene,Pathology,Cystitis,Mucosal hyperemi
22、aEdemaLeukocyte infiltrationEasy bleedingGranular surfaceSuperficial ulcerPurulent exudate,PathologyCystitisMucosal hype,Pathology,Acute Pyelonephritis,Acute inflammationHyperemia and edemaVolume increase Red colour Yellowish abscess Purulent exudate,PathologyAcute Pyelonephritis,Pathology,Chronic P
23、yelonephritis,Chronic inflammationPelvis deformed Cortex scarsVolume shrink Asymmetric Parenchyma atrophy,PathologyChronic Pyelonephri,Pathology,Interstitial edema Neutrophil infiltration White blood cell cast,In microscopy,PathologyInterstitial edema,Clinical Presentation,Clinical Presentation,Clin
24、ical presentation（1）,CystitisBurning painFrequency, urgencySuprapubic painDysuria,Clinical presentation（1）Cystit,Clinical presentation（2）,Urethritis Burning painFrequency, urgencyDysuriaInfected with sexually transmitted pathogens,Clinical presentation（2）Urethr,Clinical presentation（3）,Acute Pyelone
25、phritisAll cystitis symptoms（+）or（-）Fever, shaking chillsNausea, vomiting, diarrheaTachycardia, hypotentionMuscle tendernessCostovertebral angle（CVA） painGram-negative sepsis , LeukocytosisLeukocyte casts in the urine,Clinical presentation（3）Acute,Clinical presentation（4）,Catheter-Associated UTIs Ba
26、cteriuria develops in at least 10 to 15% of hospitalized patients with indwelling urethral catheters.The risk of infection is 3 to 5% per day of catheterization. Many infecting bacteria display markedly great antimicrobial resistance.,Clinical presentation（4）Cathet,How is it diagnosed?,Diagnosis,Pat
27、ient history Complete physical examination Urine culture Urine analysis Other examinations,How is it diagnosed?DiagnosisP,Microscopic Examination,Pyuria WBC 5 / HP,Bacterial colony counts 105 / ml,Diagnosis,Microscopic ExaminationPyuria,DiagnosisDipstick Methods,Leukocyte esterase +Nitrite +,Urine r
28、outine: pH, sg, protein, glucose, blood, ket, etc.,DiagnosisLeukocyte esterase,Clean urine culture: bacterial counts 105 /mlSuprapubic puncture, catheter collected urine 102/mlSignificant bacteriuria Microscopic bacteriuria,Urine Culture Test (very important),Diagnosis,Clean urine culture: bacter,Lo
29、calization of UTI,（No definite standard method）,Ultrasonography Intravenous pyelography（IVP） Abdominal CT / MRI,Localization of UTI（No defini,Treatments for different types of UTIs,Treatments for different typ,Acute uncomplicated cystitisPathogens,Staphylococcus saprophyticus (5-15%)Enterobacteriace
30、ae E. coli (86%)Klebsiella pneumoniaeProteus Enterococcus,Acute uncomplicated cystitisP,Single-dose therapy is less effectiveEspecially with -lactams3-day course recommendedTMP-SMX, fluoroquinolone, nitrofurantoinNOT appropriate for male patients and complicated UTIs7-day course: Diabetes , age 65 y
31、ears, MalesIf untreated: may lead to acute uncomplicated pyelonephritis treatment,Acute uncomplicated cystitisTreatment - Antibiotic Therapy,Single-dose therapy is less,Acute uncomplicated pyelonephritisPathogens,EnterobacteriaceaeE. coli Klebsiella pneumoniaeProteus Staphylococcus saprophyticus,Acu
32、te uncomplicated pyelonephr,Mild or moderate symptoms:Outpatient treatment ( 714 days) Oral treatment: Fluoroquinolone, TMP/SMX, third generation cephalosporinSevere ill patient: Hospitalization requiredParenteral therapy (14 days) Broad-spectrum cephalosporins or Fluoroquinolones,Acute uncomplicate
33、d pyelonephritisTreatment ( 714 days),Mild or moderate symptoms:Acut,Complicated UTIsPathogens,EnterobacteriaceaeE. Coli Klebsiella pneumoniaeProteusEnterococciPseudomonasStaphylococci,Complicated UTIsPathogensEn,Minimal or mild symptoms (10-14d).Oral therapy: fluoroquinolone (ciprofloxacin or oflox
34、acin)Severe ill patient, parenteral therapy (10-21d).Hospitalization required, Imipenem alone Penicillin or cephalosporin plus aminoglycoside Third generation cephalosporin: Ceftriaxone or ceftazidime,Complicated UTIsTreatment,Minimal or mild symptoms (1,Low urinary tract infection (acute cystitis)
35、: 7 days course antibiotics Amoxicillin, cephalosporine, nitrofurantoinPyelonephritis: 2-4 weeks course antibiotics Cephalosporins, extended spectrum penicillins Parenteral treatment Follow-up urine culture tests, monthly Low-dose prophylaxis to recurrent infectionsAsymptimatic bacteriuria Antibioti
36、cs treatments are needed.,UTI in Pregnant womenTreatment,Low urinary tract infection,UTI in catheterized patientsTreatment,For bacteriuria in asymptomatic catheterized patient:Catheter removed as soon as possible.The bacteriuria should be ignored.If becomes symptomatic:Remove catheterTreatment as de
37、scribed for complicated infectionsIf the catheter cannot be removed, antibiotic therapy usually proves to be unsuccessful.,UTI in catheterized patients,Complications,Renal Papillary necrosisPatients with diabetes, sickle cell disease, chronic alcoholism, and vascular diseaseHematuria, pain in the fl
38、ank or abdomen, chills and feverAcute renal failure with oliguria or anuriaIVP: ring shadowOften bilateral,ComplicationsRenal Papillary n,Prevention,Drink plenty of fluids and frequent urination.Keeping the perineal area clean.Do not take invasive method of examination if possible. Prophylactic low-
39、dose antibiotics, daily or thrice-weekly administration of a single dose of TMP-SMX, TMP, nitrofurantoin, fluoroquinolone.Patient who suffer refluence of bladder-ureter should change the urination habit（twice urination，i.e. after urination for several minutes, to urinate again）,PreventionDrink plenty of,THANKS,THANKS,
