URINARY TRACT INFECTIONS

1. URINARY TRACT INFECTIONS By Dr Dave Maharajh MD

2. Bacteria Preparing to Attack

3. URINARY TRACT INFECTIONS MISURY

4. URINARY TRACT INFECTIONS MISURY

5. MISURY

6. MISURY

7. PREGNANCY

8. CLASSIFICATIONS • UPPER URINARY TRACT • Complicated and Uncomplicated • LOWER URINARY TRACT • Complicated and Uncomplicated • COMBINED UPPER AND LOWER TRACTS • Complicated and Uncomplicated

9. Epidiemiology • Adults: F>M 18-60 yrs (11%/yr) • Children: F>M 5-Puberty • Approx. 50-60% of Adult Women report a urinary tract infection during lifetime • Adult Female: 3UTI/yr. > refer and inv. • Adult Male: 1 infection. Refer and inv. • Children: M(1) and F(>3 refer and inv.) • Children: F>M except neonates < 5yrs refer

10. WHEN LENGTH MATTERS

11. MECHANISMS OF ACTION • Direct Contamination:invasive procedures • Migration • Hematogenous ( TB and Staph. ) • Ascending Infection • Foreign Bodies ( Catheters and others) • Coexisting Conditions • Fistulas, Crohn’s/UC, Diverticular disease • IBS, DM, Neurogenic bladder, Calculi. • Immunosuppression, • Nonsecretors of blood group substances (Toll-like receptors (TLR-1 and TLR-4> Chemokines CXCL8

12. URINARY TRACT INFECTIONS CLINICAL VARIATIONS

13. Clinical Symptoms • Upper Tract: • Flank Pain, Fever, Chills, nausea/vomitting • Lower Tract: • Frequency, Urgency, Dysuria, Hematuria, Odour, Cloudy urine, Suprapubic pain, Sense of incomplete emptying. • Constitutional symptoms: Malaiase, lack of energy and appetitite, confusion.

14. DIFFERENTIAL DIAGNOSIS • Vulvovaginitis ( Yeast, Trichomonas etc) • Urethritis ( Chlamydia, GC) • STD’s • Sterile Pyuria • Postmenopausal atrophic vaginitis

15. LABORATORY INVESTIGATIONS • Urinalysis: • Urine dipstick • MSU • Urine Culture and Sensitivity • Catheterized urine • Suprapubic aspirate • Nephrostomy tube collection

16. DIAGNOSTICS • Urine dipstick: RBC/ WBC and Nitrites • Usually detects >10/`5 colony/ml • Beware of sterile pyuria, age of sticks • Evaluate with clinical scenario • Must do MSU or centrifuged urine • Treat and await culture/sensitivity • Repeat MSU not dipstick after Rx.

17. DIAGNOSTICS • MSU: • Colony count > 10`5 or 10`8 • Culture and Sensitivity to follow • Contamination (Multiple bact. Identified) • Fungi and Chlamydia need different media, suspect if neg. culture and symptomatic

18. Diagnostics • Radiological Investigations: • Ultrasound ( Kidney and Bladder) • CT Scan ( Abd/Pelvis) • VCUG • MRI • Non Radiological: • Cystoscopy • Urodynamics and Uroflow

19. ORGANISMS COMMONLY FOUND • E. Coli >70% • Klebsiella Pneumoniae • Proteus Mirabilis • Enterococcus Fecalis • Staphylococcus Saprophyticus • Enterobactae

20. URINARY TRACT INFECTIONS Non Antimicrobial Therapies • Personal Hygiene • Avoid Bubble Baths and Hot Tubs • Beware of Spermicide Use • Cranberry Juice • Increased daily Fluid Intakes • Development of a Vaccine

21. Simple measures Increase Fluid intake Void before and after intercourse Personal Hygiene (wipe front to back) Avoid feminine hygiene sprays Take showers instead of baths Cranberries / Juice Assess voiding pattern Cranberries Strategies to Prevent UTI

22. Young Woman first episode Single dose Young Male first episode Treat , investigate and refer TMP-SMZ 320/1600mg, 2 double strength tabs Amoxicillin 3gm Cephaloridine 2gm Gentamycin 5mg/kg Doxycycline 300mg Quinolones TREATMENT Uncomplicated UTI

23. Young woman first episode Short course 3-5days 10-14 days Treat according to sensitivity Repeat urine culture after treatment TMP-SMZ Nitrofurantoin/ Macrobid Ciprofloxacin Noroxin Amoxil Quinolones TREATMENT Uncomplicated UTI

24. TREATMENT COMPLICATED UTI • Specific Pharmacotherapy • Investigate with Radiology • Refer to appropriate specialty • Consider low dose prophylaxis while awaiting referral and diagnostics • Admit patient if not responding to treatment and refer

25. Common Scenarios • Young female with recurrent UTI and relapses after treatments >3 • Simple measures as discussed • Do U/S kidney and bladder with PVR • May need VCUG • Refer to Specialty • Consider low dose prophylaxis

26. COMMON SCENARIOS • Young Females (Pediatric age group) • Avoid excessive baths • Treat and eliminate constipation • Encourage frequent voids • Proper Potty Training • Proper Genital Hygeine • Recurrent UTI (Investigate and refer) • U/S, VCUG

27. Common Scenarios • Postmenopausal woman with recurrent UTI. • Simple measures as discussed • Treat constipation and avoid baths • Use Premarin/ estrogen cream locally • Consider low dose prophylaxis • Do U/S kidney and Bladder with PVR • Refer to Specialty

28. Common Scenarios • Chronic indwelling catheters • No need for Rx. Unless symptomatic • Change catheter every 4-6 weeks • Use of Silastic catheters less infection • Local hygiene to the catheter and Urethral meatus helpful • Irrigation of the Catheter helpful in certain situations. ( Mucus production and sediments)

29. Common Scenarios • Pregnancy • Treat all Asymptomatic Bacteruria with the appropriate antibiotic for trimester of Pregnancy • Always do and U/S Kidney and bladder with PVR • Refer to specialty if needed

30. Common Scenarios • Young and Old Males • Treat with appropriate antibiotics • Always do diagnostic Imaging (U/S or CT) • Examine Genitalia and Prostate • Refer to Specialty

31. Common Scenarios • Patients with Neurogenic Bladders • Do appropriate Imaging • Personal Hygiene • Techniques of Clean Intermittent Catherizations) • Treat with culture sensitive antibiotics • Refer to Specialty as needed • Beware Autonomic dysreflexia

32. References • Update in Adult Urinary Tract Infection • Lindsay Nicolle Curr. Infect. Dis.Rep • (2011) 13:552-560 • Dept. Of Internal Medicine and Medical Microbiology . U. Of Manitoba • An Update on Uncomplictaed UTI in Women • Current Opinion in Urology 2009 19:368-374 Florian. M. Wagenlehner

33. Urinary Tract Infections • QUESTIONS

34. Structural and functional abnormalities of the genitourinary tract associated with complicated urinary infection • ObstructionUreteric or urethral stricturesTumours of the urinary tractUrolithiasisProstatic hypertrophyDiverticulaePelvicalyceal obstructionRenal cystsCongenital abnormalitiesInstrumentationIndwelling urethral catheterIntermittent catheterizationUreteric stentNephrostomy tubeUrological proceduresImpaired voidingNeurogenic bladderCystoceleVesicoureteral refluxIleal conduitMetabolic abnormalitiesNephrocalcinosisMedullary sponge kidneyRenal failureImmunocompromisedRenal transplant

36. The diagnosis of symptomatic urinary tract infection in patients without indwelling urological devices should be considered only when localizing genitourinary signs or symptoms are present (AII). For patients with indwelling urological devices, systemic symptoms, such as fever in the absence of localizing genitourinary signs and symptoms, may be consistent with symptomatic urinary tract infection (AII). A urine specimen should be obtained for culture and susceptibility testing before institution of antimicrobial therapy for every episode of complicated urinary tract infection (AI). A single urine specimen with a quantitative count of at least 108 cfu/L (at least 105 cfu/mL) is consistent with urinary infection in symptomatic subjects (AII). A quantitative count of at least 108 cfu/L (at least 105 cfu/mL) on two consecutive specimens is the appropriate diagnostic criteria to identify asymptomatic bacteriuria in women (BII). Any quantitative count of organisms is consistent with bacteriuria for individuals with urine specimens obtained by bladder catheterization (AII).