URINARY TRACT INFECTION
Contents
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IntroductionTerminology
Classification of UTI
Epidemiology
Etiology
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PathogenesisRisk factors
Clinical presentation
Diagnosis
Treatment
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ConclusionIntroduction
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? Symptomatic presence ofmicro organisms within
the urinary tract
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i.e., kidney, ureters,
bladder and urethra.
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? Associated withinflammation of
urinary tract.
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Anatomy
vThe upper urinary tract,
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composed of the kidneys,renal pelvis, and ureters.
v the lower urinary tract
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that consists of the
urinary bladder and the
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urethra.24-03-2022
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v Upper urinary tract infections affect the ureters(ureteritis) or the renal parenchyma (pyelonephritis).
v Lower urinary tract infections may affect the urethra
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(urethritis), the bladder (cystitis), or the prostate in
males (prostatitis).
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UTI - Terminology
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v Significant bacteriuria: presence of at least 105
bacteria/ml of urine.
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v Asymptomatic bacteriuria : bacteriuria with No symptoms.v Uncomplicated: UTI without underlying renal or
neurologic disease.
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v Complicated: UTI with underlying structural, medical or
neurologic disease.
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v Recurrent : > 3 symptomatic UTIs within 12 monthsfollowing clinical therapy.
v Reinfection: recurrent UTI caused by a different pathogen
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at any time
v Relapse: recurrent UTI caused by same species
causing original UTI within 2 wks after therapy.
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v Urethritis: infection of anterior urethral tract
v Cystitis: infection to urinary bladder
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v Acute pyelonephritis: infection of one/both kidneys;sometimes lower tract also.
v Chronic pyelonephritis: particular type of pathology of
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kidney; may/may not be due to infection.
vPyuria
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? the presence of 10 WBC/cumm in a urine specimen,? 1-5 white cel s per high-power field of uncentrifuged
urine,
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? or a urinary dipstick test that is positive for leukocyte
esterase.
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vSterile pyuria- the persistent finding of white cel s in the urine in the
absence of bacteria.
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UTI
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Upper
Lower
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?Acute pyelonephritis?Cystitis
?Chronic pyelonephri tis
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?Prostatitis
?Interstitial pyelonephritis
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?Urethritis?Renal abscess
?Perirenal abscess
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?Both upper & lower UTI are further divided into
complicated and uncomplicated.
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EpidemiologySeen in al age groups
Infants up to 6 months ? 2/1000
More common in boys than girls
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Women ? at greater risk than men; prevalence 40-50% in
women and 0.04% in men.
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10% women have recurrent UTI in their life7 million new cases of lower UTI / year
1 million hospitalizations / year
Incidence of UTI increases in old age; 10% of men and 20%
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of women are infected.
Criteria for Classification of Urinary Tract Infections by
Clinical Syndrome
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Etiology
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Acute uncomplicated UTI: Infection in a structural y andneurological y normal urinary tract.
? 80% by Escherichia coli
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? 20% by :
Gram negative enteric bacteria ? Klebsiel a
Gram positive cocci ? Streptococcus faecalis
Staphylococcus saprophyticus
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? S.saprophyticus ? restricted to infections in young sexual y
active women.
Complicated UTI : Infection in a urinary tract
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with functional or structural abnormalities
Proteus
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PseudomonasKlebsiel a
Enterobacter
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Flores-Mireles AL, Walker JN, Caparon M, Hultgren SJ. Urinary tract infections: epidemiology, mechanisms of infection and treatment
options. Nature reviews microbiology. 2015 May;13(5):269.
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Flores-Mireles AL, Walker JN, Caparon M, Hultgren SJ. Urinary tract infections: epidemiology, mechanisms of infection and treatmentoptions. Nature reviews microbiology. 2015 May;13(5):269.
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Resident microflora of urinary tractvCoagulase-negative staphylococci (excluding
Staphylococcus saprophyticus)
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vViridans and nonhemolytic streptococci Lactobacil i
(adult females)
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vDiphtheroids (Corynebacterium spp.)vNonpathogenic (saprobic) Neisseria spp. (adult women)
v Anaerobic cocci
vPropionibacterium spp. (adult patients)
vCommensal Mycobacterium spp.
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vCommensal Mycoplasma spp.vYeasts (pregnant, adult females)
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15Hospital Acquired UTI (HAUTI)
? 80 % because of indwel ing catheters.
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? Organisms responsible are :E.coli
Klebsiel a
Proteus
Staphylococci
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PseudomonasEnterococci
Candida
Catheter Associated UTI (CAUTI)
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? 10-30% of catheterized patients developed bacteriuria.
? After hospitalization, patient become colonized with bacteria
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endemic to the institution, often gram negative aerobic andfacultative bacil i carrying resistance markers.
Pathogenesis
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? 4 routes of bacterial entry to urinary tract.
1. Ascending infection
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2. Descending infection (Blood borne spread)3. Lymphatogenous spread
4. Direct extension from other organs
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ASCENDING INFECTION
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? Most common route.? Organisms ascend through urethra into
bladder.
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DESCENDING INFECTIONCaused by hematogenous route
Common organisms:
staphylococcus aureus,
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mycobacterium tuberculosis,salmonel a sp,
leptospira,
yeast (candida albicans),
rickettsia
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? LYMPHATOGENOUS SPREAD
Men- Through rectal and colonic lymphatic vessels
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to prostate and bladder.Women- Through periuterine lymphatics to urinary
tract.
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? DIRECT EXTENSION FROM OTHER ORGANSPelvic inflammatory diseases
Genito-urinary tract fistulas
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BACTERIAL VIRULENCE FACTORSUTI
HOST BEHAVIOR HOST CHARACTERISTICS
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UTI ? RISK FACTORS1. Aging:
diabetes mel itus
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urine retention
impaired immune system
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2. Females:shorter urethra
sexual intercourse contraceptives
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incomplete bladder emptying with age
3. Males: prostatic hypertrophy
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bacterial prostatis ageRisk factors for complicated UTI
? Functional/structural abnormalities of urinary tract
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? Recent urinary tract instrumentation? Recent antimicrobial use
? Diabetes mellitus
? Immunosuppression
? Pregnancy
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? Hospital acquired infectionUTI-CLINICAL PRESENTATION
? Clinical manifestations depending on site of infection
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? Clinical manifestations depending on age of patientClinical manifestations depending on site of
infection
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? Urethritis:
Discomfort in voiding
Dysuria
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Urgencyfrequency
? Cystitis:
dysuria, urgency and frequent urination t
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Pelvic discomfort
Abdominal pain
Pyuria
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? Hemorrhagic cystitis:Visible blood in urine.
Irritating voiding symptoms
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? Pyelonephritis:Invasive nature
Suprapubic tenderness
Fever and chills
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White blood cell casts in urineBack pain
Nausea and vomiting
Complications include sepsis, septic shock and death.
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Clinical manifestations depending on age? infants :
Failure to thrive
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Fever
Apathy
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Diarrhoea? Children:
Dysuria, urgency, frequency
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Haematuria
Acute abdominal pain
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Vomiting? Adults:
Lower UTI- frequency, urgency, dysuria,
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haematuria
Upper UTI- fever, rigor and loin pain and symptoms
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of lower UTI.? Elderly patients:
Mostly asymptomatic
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Not diagnostic as the symptoms are common withage.
DIAGNOSIS
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macroscopymicroscopy
UTI
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Culture
&Antibiotic
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sensitivityImaging
Specimen Col ection
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Male
MSU
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FemaleDuring
CSU
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cystoscopy
Specimen
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Children,collection-
Suprapubic aspirate
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infants, older
Urine
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womenTB of urinary tract
EMU
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(3 specimen)
Urethritis,
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Initial flowprostatitis
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Clean-Catch Midstream Urine
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Catheter specimen of Urine
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Suprapubic Bladder Aspiration
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vGold standard for obtaining urinespecimens for culture in children
under 2 years.
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vSuprapubic aspirate is a simple,
safe, rapid and effective procedure.
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vThe use of ultrasound increases thesuccess of the procedure.
vAny growth of pathogenic bacteria
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in an SPA specimen is significant.
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35In Infants
vSuprapubic aspiration
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vNon-invasive-
vBy tapping just above the pubis
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with 2 fingers at 1h after feed,v1tap/sec for 1 min, then 1min
interval .
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For infants - the `Quick-wee' method can be
considered to increase the voiding and success
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rate of a `clean-catch' urineThis method uses gentle cutaneous suprapubic
stimulation with gauze soaked in cold 0.9%
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saline to trigger faster voiding.
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36UTI- URINALYSIS
1. Appearance of the sample- colour of specimen
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whether clear or turbid2. Microscopic examination of urine as wet preparation to
detect ?
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WBCsRBCs
Yeast
Casts/Crystals
Bacteria
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Trophozoites-trichomonas vaginalisEgg
Epithelial cells
3. Gram Stain: Should be done when bacteria or pus cel s are seen in wet
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mount.Laboratory findings
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Normal Findings
Abnormal findings
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? pH - 4.6 ? 8.0?pH ? Alkaline(increases)
? Appearance- clear
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? Color ? pale to amber
?Appearance ? cloudy
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yellow? Color - deep amber
? Odor ? aromatic
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? Blood ? none
? Odor ? foul smel ing
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? Leukocyte esterase ? none ?Blood ? maybe present?Leukocyte esterase - present
? WBC- absent
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?WBC- present
? Bacteria- absent
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?Bacteria- presentBIOCHEMICAL TESTS
a) Protein- Proteinuria is found in most bacterial urinary tract
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infections.b) Nitrite- detected by Greiss Test or nitrite reagent strip test. This
test is positive with infection by E.coli, Klebsiel a, Proteus and
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negative with infection caused by Enterococcus faecalis,Staphylococcus, Candida, Pseudomonas sp.
c) Leukocyte esterase enzyme test which detects the presence of
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pus cells (pyuria).False negative results occur when urine contains boric acid as
preservative.
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Urine culture :
Not a rapid diagnostic tool
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>105 bacteria /mlDifferential leukocyte count-
Urine culture
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increased neutrophils
GENERAL INTERPRETATIVE GUIDELINES FOR URINE
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CULTURES
EXAMINE AND REPORT THE CULTURES
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If colonies are < 103 CFU/ml ? No significant Growth--- Content provided by FirstRanker.com ---
? If >103 and < 105 CFU/ml --- No Significance
Significant
? Patients on antimicrobials,
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? Female patients with urethritis,? Symptomatic males,
? Presence of pus cells and absence of epithelial cells,
? Sample collected by suprapubic aspiration and
? from freshly inserted urinary catheter,
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? Single type of growth from non-contaminated sample .Clinical correlation is very important.
Organism identification
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>105 CFU/ml --- Significant BacteriuriaOrganism identification
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Diagnostic tests for adults withrecurrent UTI
? INDICATIONS:
? H/O Calculus
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? H/O surgery? Polycystic kidneys
? Potential ureteral obstruction
? Neuropathic bladder
? Unusual infecting organism
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? Poor response to treatment? Diabetes mellitus
? IVP/CT SCAN
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? Voiding cystourethrography? Cystoscopy
? Manual pelvic and
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Digital Rectal examination
UTI
urinalysis
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Urine microscopy and culture
Further investigation
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Adult femaleMale
pyelonephritis Children
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Lower UTI
Any UTI
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ComplicatedAny UTI
Treat without
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Blood
further
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Ultrasoundcultures
cystourethro
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investigation
cystoscopy
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CT scangraphy
Check renal
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UTI - management
? Symptomatic UTI- antibiotic therapy
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? Asymptomatic UTI- no treatment required except inspecial situations.
? Non- specific therapy:
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? more water intake.
? Maintaining acidity of urine by fluids like canberry
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juice.Anti-microbial therapy
? Goals of therapy:
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Elimination of infectionRelief of acute symptoms
Prevention of recurrence and long term
complications
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? Decision to hospitalize ?
? Treatment considerations ?
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? Ideal antibiotic for UTI :Adequate coverage over E.coli
Concentration in urine
Duration of therapy
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Low resistanceCost
Low adverse effect profile
Principles of anti microbial therapy
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? Levels of antibiotic in urine but not in blood? Blood levels of antibiotic ? important in pyleonephritis
? Penicillins and cephalosporins ? drugs of choice for UTI
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with renal failure.
Treatment duration
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? Single dose therapy? 3 day course
? 7 day course
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? 10 ? 14 day course
Single dose therapy
o Trimethoprim- sulfamethaxole
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? Amoxicillin- clavulnate 500mg
? Ciprofloxacin 500mg
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? Norfloxacin 400mg? For uncomplicated UTI
? Not for patients with
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1. past history of complicated UTI
2. history of antibiotic resistance
3. history of relapse with single dose
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? advantages: compliance, cost, less side effects, lessresistance
? Disadvantages: increased recurrence or relapse
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3 day therapy
? Efficacy same as 7 day therapy with less adverse
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effects? Drugs used include
1. quinolines
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2. TMP-SMZ3. betalactam antibiotics
? Extended release ciprofloxacin 500mg for
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uncomplicated UTI 1000mg for complicated UTI7 day therapy
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? Used less for uncomplicated UTI? Useful in
1. recurrent cases
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2. pregnancy3. UTI with other risk factors
14 day therapy
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? For complicated UTI? High risk of mortality and morbidity
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Pathogen specific treatmentPathogen
Treatment options
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Escherichia coli
Ceftriaxone 50mg/kg
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i.v/I.M Qday
Pseudomonas
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Gentamycin 6-7.5mg /kg
aeroginosa
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i.v Q8hr / QdayKlebsiel a sps
Enterobacter sps Proteus
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Ceftadizine 100-
sps
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150mg/kg/day i.v Q8hrEnterococcus sps
Ampicil in 100-
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200mg/kg/day Q6hr
Acute pyelonephritis
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? Parenteral antibiotics? Cefuroxime ? 750mg i.v. Q8h Gentamycin - 80-120g
i.v. Q12h Ciprofloxacin ? 200mg i.v. Q12h
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? 10-14 days treatment
? Ceftazimide, imipenam, ciprofloxacin ? for hospital
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acquired pyelonephritisAsymptomatic bacteriuria
? Children ? treatment same as symptomatic bacteriuria
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? Adults ?treatment required in cases of
a. pregnancy
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b. patient with obstructive structural abnormalitiesBacteriuria in pregnancy
? To prevent risk of pyelonephritis
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? 7 day course with following antibiotics
Cephalaxin
Nitrofurantoin
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Amoxicil in? Therapy continued at regular intervals of
pregnancy.
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Relapsing UTI? 7-10 day course
? If fails ? 2week course / 6week course
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? Structural abnormalities corrected by surgery? 6week course ?
a. children
b. adults with continuous symptoms
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c. high risk of renal damageProphylaxis for urinary tract infection
Given when:
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? Women of child bearing age have recurrent cystitis.
? Catheterization or instrumentation inflicting trauma to
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the lining of the urinary tract is performed; bacteremiafrequently occurs and injured lining is especial y
susceptible.
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? Indwel ing catheters are placed.
? Uncorrectable abnormalities of the urinary tract are
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present.? Inoperable prostate enlargement or other chronic
obstruction causes urinary stasis.
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The most frequently used drugs for prophylaxis of lower
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UTI are:
? Cotrimoxazole 480 mg*
? Nitrofurantoin 100 mg*
? Norfloxacin 400 mg*
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? Cephalexin 250 mg** Al drugs are given once daily at bed time.
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65Surgical treatment
v Surgical removal of renal calculi,
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bladder calculi
v Treatment of anatomic obstruction
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b) Ureteroplastyc) Reimplatation of ureters if VUR
present
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ConclusionUrinary tract infections are the 2nd most common
bacterial infections.
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Women are the most infected subjects in the
population.
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Development of resistance to antibiotics by thebacteria result in problems during the treatment
and lead to relapse or recurrence.
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Recent advances such as development of
immunologicals like intranasal vaccines may result
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in life time cure of the infection