泌尿系统感染Urinarytractinfection课件

单击此处编辑母版标题样式,*,Urinary Tract Infections,Urinary Tract Infections,1,UTI,UTI - common affliction for which patients seek medical attention,UTI can occur from infancy through old age,more common in females than males 20% of all females will experience a UTI during,their lifetime,UTIUTI - common affliction for,2,UTI,Definitions,The term “UTI” represents a wide range of clinical syndromes,Bacteriuria: the presence of bacteria in urine - does not necessarily imply infection,Asymptomatic bacteriuria: presence of bacteria in the urinary tract in the absence of symptoms,- clinical significance controversial outside certain patient populations,- pregnant women,- patients undergoing invasive procedures,of the urinary tract,UTIDefinitionsThe term “UTI”,3,UTI,Definitions,Cystitis: UTI presumed to be confined to the bladder - painful/burning urination - urgency or frequency - absence of symptoms or physical signs suggesting inflammation at other sites within the urinary tract,Note: clinical criteria are notoriously inaccurate in identifying the actual anatomic site of infection,UTIDefinitionsCystitis: UTI p,4,UTI,Definitions,Pyelonephritis: clinical diagnosis which implies a more invasive infection- inflammation of the kidney and renal pelvis is assumed to be present when patients have pain or tenderness involving the flank, together with other clinical or laboratory evidence of UTI-fever, nausea, chills, malaise, headache, etc,UTIDefinitionsPyelonephritis:,5,UTI,Definitions,Prostatitis: inflammation / infection of the prostate gland - may present as acute or chronic,Intrarenal abscess / perinephric abscess: collection of pus in the kidney or in the soft tissue surrounding the kidney,UTIDefinitionsProstatitis: in,6,UTI,Definitions,Complicated infections,- underlying abnormality that predisposes patient to UTI or makes UTI more difficult to treat effectively,Recurrent Infections Relapse - recurrence of infection by same organism after discontinuation of treatment Reinfection - recurrence of infection by a different organism after discontinuation of treatment,UTIDefinitionsComplicated inf,7,UTI,Pathogenesis,UTI usually due to patients own intestinal flora - ascending route of infection - organisms enter the urinary tract in a retrograde fashion via the urethra,Complicating factors such as catheters, nephrostomy tubes, surgery, urinary stones, etc - allow organisms to enter and persist in urinary tract - alter the typical spectrum of organisms - may have multiple etiologies,UTIPathogenesisUTI usually du,8,UTI,Pathogenesis,Elderly patients - incontinant - functionally impaired - postmenopausal changes - neurological alterations,Pregnant women - altered anatomy,Hematogenous route - endocarditis, bacteremias, tuberculosis - disseminated infections,UTIPathogenesisElderly patien,9,UTIEtiology,Majority of UTI are due to a single pathogen,The Enterobacteriaceae responsible for 90% of all UTI- gram negative bacilli- facultatively anaerobic- common intestinal flora,Escherichia coli,most commonly isolated pathogen 80% of all UTI,UTIEtiologyMajority of UTI ar,10,Community-Acquired UTI,E.coli,K.pneumoniae,Proteus,S.saprophyticus,S.epi &,gm - enterics,Enterococcus,Community-Acquired UTIE.coliK.,11,Uro-pathogens,E.coli, Klebsiella spp.-intrinsic gut organisms-highly motile-produce fimbriae (pili) attachment,Proteus, Morganella, Providencia-Urease producing organisms-increases urinary pH - leads to crystal formation biofilmscolonization of catheterprotects bacteria from host defenses & antibiotics,Uro-pathogensE.coli, Klebsiell,12,Nosocomial UTIcatheter associated,Short Term,Long Term,E.coli,E.coli,Pseudomonas,Pseudomonas,Proteus,Proteus,Enterobacter,Candida,Providencia,Morganella,S.aureus,Enterococcus,Nosocomial UTIcatheter associ,13,Urinalysis,usually have increased numbers of WBC,leukocyte esterase test is often positive,nitrate test is often positive,Urinalysisusually have increas,14,Urinalysis,Urine culture: significant bacteriuria usually defined as 10,5,bacteria / ml. (10,8,/ litre),lower numbers may be significant in children and in catheter collected specimens,UrinalysisUrine culture: signi,15,Specimen collection,Should all patients with a suspected UTI be cultured?,Community acquired vs nosocomial?,Should all isolates be identified?Susceptibility testing?,Specimen collectionShould all,16,Specimen collection,Clean catch mid stream specimens,- most frequently used method - urethra cleaned prior to collection - first void urine allowed to pass to clear urethra - mid-stream collected in sterile container,Collection bags (children),- used in young children lacking bladder control - often contaminated - most meaningful result is a negative culture,Specimen collectionClean catch,17,Specimen collection,Suprapubic aspiration / straight catheters,- invasive - specimen obtained directly from bladder,Indwelling catheters,- urine obtained by inserting needle into catheter or through diaphram - preferable to obtain specimen from new catheter, rather than old catheter,Specimen collectionSuprapubic,18,Specimen transport,Sent to and processed by lab as quickly as possible- Require: method of collection time of collection patients antibiotics,Specimens not received by lab in 1-2 hours,MUST,be refridgerated,Urines not received within 24 hours or not refridgerated will be rejected by laboratory,Specimen transportSent to and,19,Antimicrobial Therapy,Empiric Therapy - based on most probable pathogens - local rates of resistance - acute infection vs chronic - reinfection or relapse - indwelling catheter etc,Antimicrobial TherapyEmpiric T,20,Management of UTI,Anatomical/Functional Predisposition to UTI,Impaired bladder emptying,Dysfunction,Neuropathy,VUR,BOO,Diverticulum,Management of UTIAnatomical/Fu,21,Management of UTI,Anatomical/Functional Predisposition to UTI,Obstruction,Any level,VUR,Calculi,very difficult to eradicate if UTI and stones,Management of UTIAnatomical/Fu,22,Management of UTI,Anatomical/Functional Predisposition to UTI,Intrarenal,Renal scars,Interstitial nephritis,Papillary necrosis,Medullary sponge kidney,APKD,Congenital calyceal obstruction,Management of UTIAnatomical/Fu,23,Management of UTI,Anatomical/Functional Predisposition to UTI,Associated conditions,Diabetes mellitus,Pregnancy,Immunosuppression,Elderly,Management of UTIAnatomical/Fu,24,Management of Female UTI,Bacterial Factors,Adherence,Adhesins,Fimbriae,Non-fimbrial Adhesins,Biofilms,Important in catheter UTI,Soluble Virulence Factor Production,Disrupt bladder protective mucus layer,Management of Female UTIBacter,25,Management of Female UTI,Bacterial Factors,Iron Acquisition Mechanisms,Siderophores and Haemolysins,Allow growth,Serogroup and Serum R,O ag LPS outer G -ve,Prevent complement destruction,Capsules,K ag covers bacteria capsule,Protects v phagocytosis and complement attack,Management of Female UTI Bacte,26,Management of Female UTI,Bacterial Factors,Ig Proteases,Cleave gut IgA,Ureteric Paralysis,P. Fimbriae and endotoxin,Motility,Ascent of LUT,Urease Production,Hydrolyse urea and increases ammonia which increases bacterial adherence,Management of Female UTI Bacte,27,Management of Female UTI,Host Factors,Colonisation of vagina, introitus, urethra,Biological predisposition,Hormone deficiency vaginal atrophy,Spermicidal jelly increases vaginal pH,Antibiotics reduce vaginal lactobacilli and increase pH,Ascent to bladder,Sexual milkback,Catheterisation,Management of Female UTIHost F,28,Management of Female UTI,Host Factors,Establishment of bacteria in bladder,Urine composition (extremes inhibit bacterial growth),Reduced IgA and IgG,Reduced GAG layer in the bladder,Low urine flow,Incomplete emptying,Management of Female UTIHost F,29,Management of Female UTI,MSSU when symptomatic,USS renal tract with post void residual,KUB,Targeted flexible cystoscopy (8% yield),macroscopic haematuria,microscopic haematuria between UTIs,persistent UTI,Management of Female UTIMSSU w,30,Management of Female UTI,3 days oral antibiotics or x1 high dose if compliance poor,14 days antibiotics if pyelonephritis,Address any underlying cause (rare),General advice,increase fluid intake,cranberry juice,void before and after si,Management of Female UTI3 days,31,Management of Female UTI,Hygiene,wash without soap,pat or air dry,cotton pants,6 months low dose prophylactic antibiotics,alter gut flora,may affect COCP,Self-start antibiotic therapy,Management of Female UTIHygien,32,Management of Male UTI,MSSU when symptomatic,USS renal tract with flow rate and post void residual,KUB,Flexible cystoscopy,macroscopic haematuria,microscopic haematuria,persistent UTI,Management of Male UTIMSSU whe,33,Management of Male UTI,UTI - 7 days oral antibiotics,Address underlying cause,Management of Male UTIUTI - 7,34,Management of Childhood UTI,History,fevers and rigors,irritative LUTS,incontinence,change in voiding pattern,bowel dysfunction,Examination,including neurology,Management of Childhood UTIHis,35,Management of Childhood UTI,TREAT IMMEDIATELY AFTER MSSU COLLECTED WITH THERAPEUTIC ANTIBIOTICS AND CONTINUE PROPHYLACTIC ANTIBIOTICS UNTIL INVESTIGATIONS COMPLETED,ONLY DISCONTINUE IF ALL INVESTIGATIONS NEGATIVE,Management of Childhood UTITRE,36,Management of Childhood UTI,MSSU/Suprapubic aspiration/Bladder catheterisation when symptomatic,USS renal tract with post void residual,DMSA/MAG3 (if hydronephrosis),VCUG (if DMSA or MAG3 +ve),at least 6 weeks post UTI,KUB (if ? SB/sacral agenesis),MRI (if spinal anomalies),Management of Childhood UTIMSS,37,Management of Childhood UTI,UTI,3-5 days antibiotics,Pyelonephritis,non-toxic/ 3 months : im ab x1 + 10-14 days antibiotics,toxic/ 3 months: iv antibiotics + 10-14 days antibiotics when stable,Asymptomatic bacteriuria: no treatment unless have VUR,Management of Childhood UTIUTI,38,Thank you!,Thank you!,39,