urinarytractinfection-1803050842402.pptx

urinarytractinfection-1803050842402.pptx

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  URINARY TRACT INFECTION Drbadriya al-mahrouqi 12/11/2017
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  OBJECTIVES  By theend of this presentation the participants will be able to:  list lower and upper urinary tract parts.  Define urinary tract infection.  Explain the pathophysiology of urinary tract infection  List the most risk factors for urinary tract infection  Diagnose urinary tract infection  Manage urinary tract infection in different sex and age category.
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  INTRODUCTION  A urinarytract infection (UTI) is an infection in any part of your urinary system — your kidneys, ureters, bladder and urethra. Most infections involve the lower urinary tract — the bladder and the urethra.  Women are at greater risk of developing a UTI than are men. Among adults aged 20 to 50 years, UTIs are about 50-fold more common in women.
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  In women inthis age group, most UTIs are cystitis or pyelonephritis.  In men of the same age, most UTIs are urethritis or prostatitis. The incidence of UTI increases in patients > 50 years, but the female: male ratio decreases because of the increasing frequency of prostate enlargement and instrumentation in men. Introduction
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  URINARYTRACT ANATOMY
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  PATHOPHYSIOLOGY
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   Etiology  Thebacteria that most often cause cystitis and pyelonephritis are the following:  Enteric, usually gram-negative aerobic bacteria (most often)  Escherichia coli : 75 to 95% of cases.  Klebsiella  Proteus mirabilis  Pseudomonas aeruginosa.  Gram-positive bacteria (less often)  Staphylococcus saprophyticus is isolated in 5 to 10% of bacterial UTIs.  Enterococcus faecalis (group D streptococci)  Streptococcus agalactiae (group B streptococci)  In hospitalized patients, E. coli accounts for about 50% of cases. The gram-negative species Klebsiella, Proteus, Enterobacter, Pseudomonas, and Serratia account for about 40%, and the gram- positive bacterial cocci, E. faecalis, S. saprophyticus, and Staphylococcus aureus account for the remainder.
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  Part of urinarytract affected Signs and symptoms Kidneys (acute pyelonephritis) •Upper back and side (flank) pain •High fever •Shaking and chills •Nausea •Vomiting Bladder (cystitis) •Pelvic pressure •Lower abdomen discomfort •Frequent, painful urination •Blood in urine Urethra (urethritis) •Burning with urination •Discharge
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  Uncomplicated UTI isusually considered to be cystitis or pyelonephritis that occurs in premenopausal adult women with no structural or functional abnormality of the urinary tract and who are not pregnant and have no significant comorbidity that could lead to more serious outcomes.
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  Complicated UTI caninvolve either sex at any age. A UTI is considered complicated if: 1. the patient is a child, is pregnant, 2. the patient has any of the following: A structural or functional urinary tract abnormality and obstruction of urine flow A comorbidity that increases risk of acquiring infection or or resistance to treatment, such as poorly controlled diabetes, chronic kidney disease, or immunocompromise.
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  COMPLICATION  Recurrent infections,especially in women who experience two or more UTIs in a six-month period or four or more within a year.  Permanent kidney damage from an acute or chronic kidney infection (pyelonephritis) due to an untreated UTI.  Increased risk in pregnant women of delivering low birth weight or premature infants.  Urethral narrowing (stricture) in men from recurrent urethritis, previously seen with gonococcal urethritis.  Sepsis, a potentially life-threatening complication of an infection, especially if the infection works its way up your urinary tract to your kidneys.
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  DIAGNOSIS - Urinary tractinfection - Upper or lower - Simple or complicated
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  Urine collection clean-catch, midstreamspecimen, A specimen obtained by catheterization If a sexually transmitted disease (STD) is suspected, a urethral swab for STD testing is obtained prior to voiding.
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   Urine testing: Dipstick tests:  tested rapidly  Nitrate positive: is highly specific for UTI, but the test is not very sensitive.  The leukocyte esterase test is very specific for the presence of > 10 WBCs/μL and is fairly sensitive.  Microscopic examination:  Pyuria : Most truly infected patients have > 10 WBCs/μL.  The presence of bacteria in the absence of pyuria:due to contamination during sampling.  Microscopic hematuria occurs in up to 50% of patients, but gross hematuria is uncommon.  WBC casts: pyelonephritis, glomerulonephritis, and noninfective tubulointerstitial nephritis.  Pyuria in the absence of bacteriuria and of UTI is possible, for example, if patients have nephrolithiasis, a uroepithelial tumor, appendicitis, or inflammatory bowel disease or if the sample is contaminated by vaginal WBCs.
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   Cultures arerecommended in complicated UTI or an indication for treatment of bacteriuria. Common examples include the following:  Pregnant women  Postmenopausal women  Men  Prepubertal children  Patients with urinary tract abnormalities or recent instrumentation  Patients with immunosuppression or significant comorbidities  Patients whose symptoms suggest pyelonephritis or sepsis  Patients with recurrent UTIs (≥ 3/yr)
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  Urinary tract imagingchoices include ultrasonography, CT, and IVU. Occasionally, voiding cystourethrography, retrograde urethrography, or cystoscopy is warranted.  Children with UTI often require imaging. Most adults do not require assessment for structural abnormalities unless the following occur: The patient has ≥ 2 episodes of pyelonephritis. Infections are complicated. Nephrolithiasis is suspected. There is painless gross hematuria or new renal insufficiency. Fever persists for ≥ 72 h.
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  KUB ultrasound First-line, non-invasiveimaging MCUG Contrast radiographic imaging Nuclear scans DMSA and MAG3Radioisotope nuclear imaging Uses Assess •Fluid collections •Bladder volume •Kidney: size, shape, location •Urinary tract: obstructions, dilatations Confirm •Posterior urethral valves •Obstructive Uropathies •Gold standard for VUR diagnosis Confirm Suspicion of renal damage DMSA: Gold standard for renal scar detection MAG3: •Faster, less radiation •Renal excretion enables micturition study Indications •Concurrent bacteraemia •Atypical UTI organisms • Staphylococcus aureus • Pseudomonas •UTI <3 years old •Non/inadequate response to 48hrs of IV antibiotics •Abdominal mass •Abnormal voiding •Recurrent UTI •First febrile UTI and no prompt follow up assured •Renal impairment •Significant electrolyte derangement •No antenatal renal tract imaging in second to third trimester •Abnormal renal ultrasound • Hydronephrosis • Thick bladder wall • Renal scarring •Abnormal voiding post-febrile UTI •Post-second febrile UTI •Suspicion of • VUR • posterior urethral valves •Clinical suspicion of renal injury •Reduced renal function •Suspicion of VUR •Suspicion of obstructive uropathy on ultrasound in older toilet-trained children Limitations •Does not asses function •Operator dependent •Cannot diagnose VUR •Radiation exposure ~1 mSv •Invasive •Unpleasant to perform post-infancy •May require sedation •Dynamic renal excretion study requires toilet training •False positives if <3 months post-UTI, therefore can’t use in acute phase (0–4 weeks) •May require sedation
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  DIFFERENTIAL DIAGNOSIS  Acuteurethral syndrome: which occurs in women, is a syndrome involving dysuria, frequency, and pyuria (dysuria-pyuria syndrome), which thus resembles cystitis. However, in acute urethral syndrome (unlike in cystitis), routine urine cultures are either negative  Urethritis: is a possible cause because causative organisms include Chlamydia trachomatis and Ureaplasma urealyticum, which are not detected on routine urine culture.  Noninfectious causes:  anatomic abnormalities (eg, urethral stenosis),  physiologic abnormalities (eg, pelvic floor muscle dysfunction),  hormonal imbalances (eg, atrophic urethritis),  localized trauma,  GI system symptoms, and inflammation.
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  MANAGEMENT  Urethritis  Sexuallyactive patients with symptoms are usually treated presumptively for STDs pending test results. A typical regimen is ceftriaxone 250 mg IM plus either azithromycin 1 g po once or doxycycline 100 mg po bid for 7 days.  Cystitis  First-line treatment of uncomplicated cystitis is nitrofurantoin 100 mg po bid for 3 days (it is contraindicated if creatinine clearance is < 60 mL/min),  trimethoprim/sulfamethoxazole (TMP/SMX) 160/800 mg po bid for 3 days,
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  MANAGEMENT  Acute pyelonephritis Antibiotics are required. Outpatient treatment with oral antibiotics is possible if all of the following criteria are satisfied:  Patients are expected to be adherent  Patients are immunocompetent  Patients have no nausea or vomiting or evidence of volume depletion or septicemia  Patients have no factors suggesting complicated UTI  Ciprofloxacin 500 mg po bid for 7 days  A 2nd option is usually trimethoprim/sulfamethoxazole (TMP/SMX) 160/800 mg po bid for 14 days.
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  Alternative management cranberry concentrates: for adult Increase fluid intake Ural : urine alkiniser 
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  CHILDREN
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  Antibiotics that canbe used to treat UTI in children Therapeutic dose Trimethoprim (TMP) ‘Alprim’ •4 mg/kg BD Max: 150 mg BD Trimethoprim–sulfamethoxazole (TMP–SMX) ‘Bactrim’ •4 + 20 mg/kg BD Max: 16 0+ 180mg BD Cephalexin ‘Keflex’ •12.5mg/kg QID Max: 500 mg QID Amoxycillin and Clavulanic acid ‘Augmentin’ •22.5 + 3.2 mg/kg BD Max: 875 + 125 mg BD Nitrofurantonin ‘Macrodantin’ •Not recommended for therapeutic UTI treatment in children
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  ADULT
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  NON-PREGNANT WOMEN  Considerempirical treatment with an antibiotic for otherwise healthy women aged less than 65 years presenting with severe or ≥ 3 symptoms of UTI.  Explore alternative diagnoses and consider pelvic examination for women with symptoms of vaginal itch or discharge.  Use dipstick tests to guide treatment decisions in otherwise healthy women under 65 years of age presenting with mild or ≤2 symptoms of UTI.
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  Antibiotic treatment ofLUTI Do not treat non-pregnant women (of any age) with asymptomatic bacteriuria with an antibiotic. Treat non-pregnant women of any age with symptoms or signs of acute LUTI with a three day course of trimethoprim or nitrofurantoin.  Particular care should be taken when prescribing nitrofurantoin in the elderly, who may be at increased risk of toxicity. Take urine for culture to guide change of antibiotic for patients who do not respond to trimethoprim or nitrofurantoin.
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  PREGNANT WOMEN Symptomatic bacteriuria Standardquantitative urine culture should be performed routinely at first antenatal visit. Confirm the presence of bacteriuria in urine with a second urine culture. Do not use dipstick testing to screen for bacterial UTI at the first or subsequent antenatal visits. Treat asymptomatic bacteruria in pregnant women with antibiotics
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  PREGNANT WOMEN Antibiotic treatment Treatsymptomatic UTI in pregnant women with an antibiotic.  Take a single urine sample for culture before empiric antibiotic treatment is started. A seven day course of treatment (amoxicillin – cephalexin- augmentin)is normally sufficient.  Given the risks of symptomatic bacteriuria in pregnancy, a urine culture should be performed seven days after completion of antibiotic treatment as a test of cure.
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  MEN  Urinary tractinfections in men are generally viewed as complicated because they result from an anatomic or functional anomaly or instrumentation of the genitourinary tract.  Conditions like prostatitis, chlamydial infection and epididymitis should be considered in the differential diagnosis of men with acute dysuria or frequency and appropriate diagnostic tests should be considered.  In all men with symptoms of UTI a urine sample should be taken for culture.   Antibiotic treatment  Due to their ability to penetrate prostatic fluid, quinolones (ciprofloxacillin) rather than nitrofurantoin or cephalosporins are indicated.  Treat bacterial UTI empirically with a quinolone in men with symptoms suggestive of prostatitis.  four week course is appropriate for men with symptoms suggestive of prostatitis.  Refer men for urological investigation if they have symptoms of upper urinary tract infection, fail to respond to appropriate antibiotics or have recurrent UTI.
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  PATIENTS ON CATHETER  Donot rely on classical clinical symptoms or signs for predicting the likelihood of symptomatic UTI in catheterised patients.  Signs and symptoms compatible with catheter- associated UTI include:  new onset or worsening of fever, rigors  altered mental status, malaise, or lethargy  flank pain or costovertebral angle tenderness  acute haematuria
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  PATIENTS ON CATHETER  Donot use dipstick testing to diagnose UTI in patients with catheters.  Antibiotic treatment  Do not treat catheterised patients with asymptomatic bacteriuria with an antibiotic.  Do not routinely prescribe antibiotic prophylaxis to prevent symptomatic UTI in patients with catheters.
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  PREVENTION Drink plenty ofliquids, especially water. Drink cranberry juice. Wipe from front to back. Empty your bladder soon after intercourse. Avoid potentially irritating feminine products. Change your birth control method.
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   In womenwho experience ≥ 3 UTIs/yr, behavioral measures are recommended, If these techniques are unsuccessful, antibiotic prophylaxis should be considered. Common options are continuous and postcoital prophylaxis.  Continuous prophylaxis commonly begins with a 6 mo trial. If UTI recurs after 6 mo of prophylactic therapy, prophylaxis may be reinstituted for 2 or 3 yr.  TMP/SMX 40/200 mg po once/day or 3 times/wk,  nitrofurantoin 50 or 100 mg po once/day, cephalexin 125 to 250 mg po once/day, Prevention
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   Postcoital prophylaxisin women may be more effective if UTIs are temporally related to sexual intercourse. Usually, a single dose of one of the drugs used for continuous prophylaxis is effective.  In postmenopausal women, antibiotic prophylaxis is similar to that described previously. Additionally, topical estrogen therapy markedly reduces the incidence of recurrent UTI in women with atrophic vaginitis or atrophic urethritis. Prevention
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  SUMMARY  Refer infantless than 3 months with UTI  Treat children 3 months and older with UTI using Amoxicillin/ Augmnetin, send culture and consider request for ultrasound  Treat non-pregnant women with 3 days Nitrofurantoin  Treat asymptomatic bacteruria in pregnant women  Consider STI and prostitis in male  Do not give prophylaxis for adult with catheter and do not treat asymptomatic bacteruria
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  CASE 1 1 month-oldboy presented with fever of one day duration. He has no associated symptoms. The child is stable but look irritable. Vitals normal apart from temperature 38.5. systemic examination is unremarkable. What is your management ? A. Ask for urine sample B. Prescribe Antibiotics C. Prescribe Paracetamol D. Refer for admission
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  CASE 1 Answer: D. Referfor admission
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  CASE 2  5year-old girl presents with abdominal pain and fever for the last 2 days. You want o role out urinary tract infection in this girl. Which one is the most suitable test for this purpose? A. Urine dipstick B. Urine microscopy C. Urine culture  What is the positive test finding ?
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  CASE 2 Urine dipstick Positivefinding : positive nitrate and leukocytes esterase
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  CASE 3  25year-old pregnant lady. She is 10 weeks gestation. She presents for booking visit. You reviewed her booking investigations. They are normal apart from bacteruria. Patient has no symptoms suggestive of urinary tract infection. What is management? A. Reassure and advice her to increase fluid intake B. Repeat urine microscopy for confirmation C. Send for urine culture and manage accordingly D. Send urine culture and start antibiotics
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  CASE 3 C. Sendfor urine culture and manage accordingly
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  CASE 4  20year-old male present with dysuria of two days duration. He has no fever or abdominal pain. Urine microscopy shows:  WBC 20 , RBC 4. What is most appropriate management: A. Do sexual transmitted infection screening B. Request for ultrasound C. Send for urine culture for sensitivity and Start antibiotics D. Start antibiotics and repeat urine microcopy after one week
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  CASE 4 Answer: C. Sendfor urine culture for sensitivity and Start antibiotics
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  CASE 5  28year-old non-pregnant women presents with dysuria and lower abdominal pain for the last 3 days. Urine microscopy shows: WBC 40, RBS: 2 . what the is the best antibiotics for this patiatent: A. Amoxicillin 500 mg tid 3 days B. Augmentin 275/125 tid 7days C. Ceftriaxone 125 mg iv single dose D. Nitrofurantoin 100 mg bid 3 days
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  CASE 5  Answer: D.Nitrofurantoin 100 mg bid 3 days
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  REFERENCES  http://www.pathophys.org/uti/  https://www.mayoclinic.org/diseases-conditions/urinary-tract-infection/symptoms- causes/syc-20353447 http://www.merckmanuals.com/professional/genitourinary-disorders/urinary-tract- infections-utis/bacterial-urinary-tract-infections-utis  http://www.sign.ac.uk/sign-88-management-of-suspected-bacterial-urinary-tract- infection-in-adults.html  https://www.nice.org.uk/guidance/cg54/evidence