Genital-Urinary Tract Infections - Risk Factors

1. Faculty of MedicineGenitourinary System 3150036 (2018/2019) Genital-Urinary Tract Infections - Risk Factors By HatimJaber MD MPH JBCM PhD 28 - 04 - 2019

2. Presentation outline28 - 4 - 2019

3. Structures of Urinary System • Kidneys • Nephrons are functional unit (1.25 million per kidney) • Ureters • Urinary bladder • Urethra • Much longer in males • Upper Urinary tract (Kidney, Ureter)- • Less common but More dangerous, • Long term therapy • Lower Urinary tract (Bladder, Urethra)- • More common but Less dangerous • Short term therapy

4. Urinary Tract Infection Pyelonephritis Upper UTI Ureteritis Cystitis Lower UTI Urethritis Vesico-ureteral Reflux

5. Urinary Tract Infection • Upper urinary tract Infections: • Pyelonephritis • Lower urinary tract infections • Cystitis(“traditional” UTI) • Urethritis(often sexually-transmitted) • Prostatitis

6. Organisms- • Mostly Gram Negative (E.coli, Klebsiella, Proteus, Pseudomonas, Enterobacter,) • Others- Staphylococcus, Viral, Fungal, … • Single in acute, mixed in chronic • Entry- • Mostly from lower to upper (Ascending ), • Some times • Directly from the surrounding sites or • From blood (bacterimia)

7. Bacteriuria : bacteria in urine • Asymptomatic or symptomatic • Bacteriuria + pyuria= infection • Bacteriuria NO pyuria = colonization Pyuria : WBCs in urine. Infection T.B Bladder stone.

8. Symptoms

9. Symptoms- (Severe Pain During UTI) • Systemic symptoms- myalgia, vomiting, weakness etc. • Pain (Pelvic, Rectal, lower abdomen or renal angle) • Pungent smell of urine • Dysuria (Burning), • Denies urination (Fear of Urination) • Discharge through urethra • Discoloration of urine (Haematuria, Pyuria, Haziness, Clouding) • Urgency • Temperature (Fever with chills) • Incomplete emptying (Retention) • Incontinence of urine

10. More common in Females- Anatomical differences • Other part involved - • Prostate, Epididymis • More common if- • Stones • Strictures • Stents (Urinary Catheter) • Structural abnormality • Straight entry of ureter • Sexually active • Store urine (Faulty urinary habit) • Surgical (abdomen) • Scantyfluid intake • Semiconscious (Unconscious), • Site trauma,

11. Symptoms of Urinary Tract Infection • Dysuria • Increased frequency • Hematuria • Fever • Nausea/Vomiting (pyelonephritis) • Flank pain (pyelonephritis)

12. Urinary tract infection (UTI) DEFINITIONS • Bacteriuria :the presence of bacteria in the urine from upper and lower urinary tract sources with the presence or absence of both pyuriaand symptoms. • Urinary tract infection (UTI) : occurs when a microbial agent, usually bacterial, invades and colonizes the urinary tract. • Uncomplicated UTIs(simple UTIs) : in a structurally and functionally normal urinary tract, when the patient is not pregnant, and when there is no history of recent antimicrobial use. • eg. most isolated or recurrent lower UTIs and acute pyelonephritis in female patients. • Uncomplicated pyelonephritis, as an example, accounts for approximately 25% of all UTI-related admissions for inpatient treatment. • Complicated UTIs : in a structurally and/or functionally abnormal urinary tract. • eg. secondary to urinary tract catheterization, urolithiasis, obstructive uropathy, instrumentation, diabetes mellitus, pregnancy, immunosuppression and congenital or secondary variations of urinary tract anatomy such as prune belly syndrome, ileal conduits and bladder augmentation

13. Complicated VS Uncomplicated Un-complicated UTI: • UTI structurally & functionally normal urinary tract. • Female. • Respond to short course of antibiotic • Complicated UTI: • Anatomical or functional abnormality. • Male. • Longer time to respond to ttt

14. Recurrent UTI:>2 infections in 6 months • 3 UTI in 12 months. • Reinfection by different bacteria. • Persistence : same organism from focus within the urinary tract.

15. Etiology of Uncomplicated Urinary Tract Infections in Sexually Active Women

16. UTI - INCIDENCE • Female : Male = ~30:1 • Young children : M > F ( up to approximately 6 months of age). • In female : the incidence of UTIs increases with advancing age. • Approximately 1% of girls 5-15 years of age (bacteriuria). • 5% in early adulthood (bacteriuria). • Up to 30% between 20 and 40 years :experience an acute bacterial UTI requiring treatment. • Approximately 20% of women and 10% of men over 70 years of age will have bacteriuria upon culture of their urine.

17. UTI - PATHOGENESIS • Ascending route : most commonly, bacteria enter the bladder via the urethra. • Large bowel commensal organisms colonizing the perineum, the perianal region • the prepuce in the male • Hematogenous and lymphatic pathways : far less common, the spread of bacteria from adjacent organs.

18. Urinary tract infections: epidemiology • Urinary tract infections (UTIs) are some of the most common bacterial infections, affecting 150 million people each year worldwide. • In 2007, in the United States alone, there were an estimated 10.5 million office visits for UTI symptoms (constituting 0.9% of all ambulatory visits)and 2–3 million emergency department visits. • Currently, the societal costs of these infections, including health care costs and time missed from work, are approximately US$3.5 billion per year in the United States alone. • UTIs are a significant cause of morbidity in infant boys, older men and females of all ages. • Serious sequelae include frequent recurrences, pyelonephritis with sepsis, renal damage in young children, pre-term birth and complications caused by frequent antimicrobial use, such as high-level antibiotic resistance and Clostridium difficile colitis.

19. The most common causative agent for both uncomplicated and complicated UTIs is uropathogenicEscherichia coli (UPEC).

20. Epidemiology of Urinary tract infection • All individuals are susceptible to UTIs; however the prevalence of infection differs with age, sex and certain predisposing factors. • Urinary tract infections are the most frequent bacterial infection in women. • They occur most frequently between the ages of 16 and 35 years, with 10% of women getting an infection yearly and 60% having an infection at some point in their lives. • Rates of bacteriuria increases with age from two to seven percent in women of child bearing age to as high as 50% in elderly women. • Among the most common infectious diseases, urinary tract infections (UTIs) are commonly encountered diseases by clinicians in developing countries with an estimated annual global incidence of at least 8.3 million doctor visit yearly . • They are important complications of diabetes, renal disease, renal transplantation and structural and neurologic abnormalities that interfere with urine flow and a source of bacteremia in these patients.

21. Prevalence of Urinary tract infection Women are especially more prone to developing UTI due to • anatomical factors that allows bacterial quick access to the bladder, • poor hygiene; • sexual intercourse and • use of contraceptive are also contributory factors. • Also hormonal changes such as menopause and estrogen loss are responsible for the high prevalence of UTI in older women. With estrogen loss, the system ability to resist bacterial colonization is reduced making it liable to infection . UTI in men are rare but when they occur it usually comes with severity and are most times refers to as complicated. Men who are not circumcised tend to be more prone to UTI because the bacterial build at the extra fold of their skin thus making them vulnerable . Also elderly men are at increased risk of developing UTI due to factors such as kidney stones or prostate problems. Any abnormality of the urinary tract that interferes with the flow of urine set the stage for increased risk of complicated UTI.

22. RISK FACTORS FOR URINARY TRACT INFECTION • Host factors • urinary stasis, local trauma, abnormal urinary tract anatomy and function, diabetes mellitus, immunosuppression, debility, poor hygiene and aging. • Factors specific to females • deficient estrogen status and short urethral length. • Mechanical and other factors mediate the ability of the enterobacteria to colonize, invade and damage the urinary tract. • In women : sexual intercourse, especially with a new partner, unusually vigorous intercourse, delayed postcoital micturition, history of previous UTIs, and the use of spermicide and contraceptive diaphragms. • Elderly patients have an increased incidence of asymptomatic bacteriuria and UTI : reduced urogenital estrogen, reduced nutritional status, an inability to maintain body homeostasis, poorer bowel function, increased comorbidities and a greater incidence of dysfunctional voiding.

23. RISK FACTORS FOR URINARY TRACT INFECTION (cont….) • Foreign bodies - breaching natural defense mechanisms • external urinary drainage devices such as indwelling urethral catheters, suprapubic catheters and nephrostomy drainage tubes. • Dysfunctional voiding in the male • high voiding pressures and grossly elevated residual volumes • Augmentation or substitution of the lower urinary tract with bowel segments

24. Risk factors to bacteriuria • Female • Age • Low estrogen ( menopause) • Pregnancy. • D.M • Previous UTI. • Stone • GU malignancy. • Obstruction. • Voiding dysfunction. • Institutionalized elderly

26. HOST FACTORS IN URINARY TRACT INFECTION Antibacterial Host Defenses in the Urinary tract • Urine osmolarity, pH, organic acids • Urine flow and micturition • Urinary inhibitors of bacterial adherence: Bladder mucopolysaccharides Secretoryimmunoglobulin A (SIgA) • Inflammatory response (PMNs, and cytokines) • Prostatic secretions • Humoral and cell-mediated immunity

27. DM & UTI • A common multisystem disease with potentially serious effects on urinary tract anatomy and function. • Complications • diabetic nephropathy, papillary necrosis, renal artery stenosis, and diabetic cystopathy. • Bacteriuria is twice as common in glycosuric and diabetic patients. • A higher incidence of complicated upper and lower UTIs, such as renal and perinephric abscesses, emphysematous pyelonephritis, emphysematous cystitis, xanthogranulomatous pyelonephritis and fungal infections. • A strong association with Fournier's gangrene, a life-threatening synergistic infection. • Morbidity and potential mortality is greater in diabetic patients with UTIs. • Added risk of contrast nephropathy, • especially in those patients with reduced renal function, dehydration, sepsis or treat with metformin (Glucophage or Glucomine). • The clinical condition of the diabetic patient may deteriorate rapidly and response may be suboptimal with more conservative treatment strategies.

28. Indwelling urinary catheters & UTI • Indwelling urinary catheters: the most common source of nosocomial infections and Gram-negative bacteremia in the hospital environment. • Approximately 1—2% risk of infection with a single catheter passage • Directly related to the duration of catheterization, with the risk of bacteriuria increasing by • ~10% per day postinsertion in women • ~3-4% per day in men. • Source of this infection – • via the catheter, the periurethral region, the drainage bag, or connector disruption with contamination. • Catheterization < 5 days - bacteriuria from short-term catheterization usually clears quickly. • Long-term catheterization – • Breach in the natural defense mechanisms • Direct reservoir for bacteria due to adherence to the catheter surface • Upon removal of a long-term catheter, clearance of bacteriuria may be improved by administering a short course of antimicrobials.

29. COMMON ORGANISMS - UTI • Commensal organisms in the large bowel , aerobic Gram-negative rods- most common. • Community or hospital acquired - different pathogenic organism and antibiotic sensitivity. • Community-acquired infections: • Most commonly: Escherichia coli(80%). • Other enterobacteria: Proteus mirabilis and Klebsielaspp. • Gram-positive organisms: Enterococcusfaecalisand Staphylococcus saprophyticus. • Nosocomial infections: • E. coli(50%), Pseudomonas aeruginosa, Klebsielaspp., Enterobacterspp., Citrobacter, Serratiamarcescens, Providenciastuartiiand S. epidermidis • Often more resistant to frequently prescribed antibiotics. • Less common causative organisms in the presence of a grossly abnormal urinary tract, immunosuppression or a foreign body. • Fungi such as Candida albicans, Mycoplasmaspecies including Ureaplasmaurealyticum, and viral organisms such as Adenovirus in immunosuppressed bone marrow transplant recipients. • Urethral infections • Chlamydia trachomatis, Neisseriagonorrhoeae, U. urealyticum, and occasionally Gardnerellavaginalis.

30. Risk Factors for Urinary-tract Infections by Age Group

31. DIAGNOSTIC MODALITIES- PRINCIPLES OF MANAGEMENT • Appropriate treatment of all UTIs requires accurate categorization of the disease process and exclusion of all complicating factors. • infection site • contributing anatomical variation • complexity of the infection • likelihood of recurrence • Investigations • REAGENT STRIPS • URINE CULTURE • URINARY TRACT IMAGING

32. Findings on Exam in UTI • Physical Exam: • tenderness (pyelonephritis) • Urethral discharge (urethritis) • Tender prostate (prostatitis) • Labs: Urinalysis • + leukocyte esterase • + nitrites • More likely gram-negative rods • + WBCs • + RBCs

33. Sexually transmitted infections (STIs) Reproductive Tract Infections (RTIs) Definition of STI • Sexually transmitted infections (STIs) are groups of infections that are predominantly transmitted through unprotected sexual contact with an infected person. Definition of RTIs • Reproductive Tract Infections (RTIs) are infections of the genital tract. They refer to the site where the infection develops. They may or not be transmitted through sexual contact.

34. Sexually transmitted infections (STIs) • More than 30 different bacteria, viruses and parasites are known to be transmitted through sexual contact. • Eight of these pathogens are linked to the greatest incidence of sexually transmitted disease. • Of these 8 infections, 4 are currently curable: syphilis, gonorrhoea, chlamydia and trichomoniasis. • The other 4 are viral infections and are incurable: hepatitis B?????,herpes simplex virus (HSV or herpes), HIV, and human papillomavirus (HPV). • Symptoms or disease due to the incurable viral infections can be reduced or modified through treatment.

35. Sexually transmitted infections (STIs) Key facts • More than 1 million sexually transmitted infections (STIs) are acquired every day worldwide. • Each year, there are an estimated 357 million new infections with 1 of 4 STIs: chlamydia, gonorrhoea, syphilis and trichomoniasis. • More than 500 million people are estimated to have genital infection with herpes simplex virus (HSV). • More than 290 million women have a human papillomavirus (HPV) infection.

36. Sexually transmitted infections (STIs) Key facts • The majority of STIs have no symptoms or only mild symptoms that may not be recognized as an STI. • STIs such as HSV type 2 and syphilis can increase the risk of HIV acquisition. • Over 900 000 pregnant women were infected with syphilis resulting in approximately 350 000 adverse birth outcomes including stillbirth in 2012. • In some cases, STIs can have serious reproductive health consequences beyond the immediate impact of the infection itself (e.g., infertility or mother-to-child transmission) • Drug resistance, especially for gonorrhoea, is a major threat to reducing the impact of STIs worldwide.

37. WHO estimates: 357 million new cases of curable sexually transmitted infections in 2012 • Curable STIs • chlamydia, • gonorrhoea, • syphilis, • trichomoniasis

38. Estimated incidences of four curable sexually transmitted infections, by region and sex, 2012

40. Methods of RTIs/STIs transmission • Endogenous infections • Organisms normally found in the vagina usually not • transmitted from person to person. They are normal • flora in the vagina e.g. bacterial vaginosis • Sexually transmitted infections • Transmitted through unprotected sexual contact e.g. gonococci, HIV, scabies, Trichomoniasis • Iatrogenic infections • Organisms could be found inside or outside the • body. They are introduced by contamination e.g. • aseptic medical procedures. • Vertical transmission • Mother to child infections during pregnancy, • delivery or breast feeding e.g. HIV infection, • congenital syphilis • Through unsafe blood transfusion or blood products • Transmitted from one person to another through • unsafe blood transfusion or contact with blood • products e.g. HIV infection, hepatitis B, and syphilis. Modes of transmission: • Unprotected penetrative sexual intercourse • Non-penetrative intimate contact and close physical contact • Through blood and/or its products • Unsafe blood transfusion • Sharing clothes, • Mother to child transmission.

41. Factors that facilitate STI/RTI transmission Factors • • Risky sexual behavior such as multiple sexual partners, unsafe sex. • • Social economic such as transactional sex, lack of information on STIs/RTIs • • Cultural such as female genital mutilation (FGM), ritual cleansing, and widow inheritance • • Biological such as age and sex. Adolescents and youth are at more risk. Females are more likely to be infected than males. • • Political war and political instability create mobility and migration that adversely influence change in sexual behavior. Lack of political commitment may cause policies not to be put in place. • • Unsterile procedures such as invasive procedures using unsterilized instruments e.g. uterine sound, vaginal speculum • • Environmental, hormonal and other factors e.g. yeast infections and bacterial vaginosis

42. Health consequences of STIs/RTIs Consequences • • Ectopic pregnancy • • Infertility in both men and women • • Urethral stricture in men • • Abortions • • Cancers • • Blindness • • Still birth • • Cardio – Vascular and Central Nervous System complications

43. Etiologies of Common STIs/RTIs • Fungal: • - Candida albicans • Protozoal: • - Trichomonasvaginalis • Parasitic: • - Phythurus pubis • - (pubic lice), Sarcoptesscabiei • Bacterial: • - Neisseriagonorrhoeae • - Chlamydia trachomatis • - Haemophilusducreyi • - Treponemapallidum • Viral: • - Herpes simplex virus, • - Human papilloma virus, • - Human Immuno Deficiency Virus

44. Clinical Presentation of STIs/RTIs • • Asymptomatic • • Symptomatic such as: • - Painful micturition • - Vaginal discharge • - Urethral discharge • - Genital ulceration • - Genital itching • - Swelling of inguinal lymph nodes • - Scrotal swelling • - Fever • - Abdominal pains or pains during sexual act

45. Definition of HIV infection • HIV infection is the state of being infected with the Human Immunodeficiency Virus without symptoms and signs Definition of AIDS • AIDS is a state of being HIV infected with presentation of symptoms and signs

46. Modes of transmission of HIV The modes of transmission of HIV • Unprotected penetrative sexual intercourse • Contact with infected blood or blood products • Vertical transmission – mother to child • Contaminated sharps • Getting contact with contaminated body fluids

47. Preventive and Control measures of STIs/RTIs • • Abstinence • • Fidelity • • Proper use of condoms • • Effective treatment of STIs/RTIs • • Screening and treatment of asymptomatic cases

48. Preventive methods • Delaying sexual activity for young people • Sexual and reproductive health education should be taught to young people in and out of school. This education will enable youth to understand their bodies and how to prevent themselves from getting STIs and unwanted pregnancy • Have one faithful uninfected partner • Sexual abstinence is another way to avoid risk of STIs although other RTIs are still possible. • Using condoms correctly and consistently. Condom have to be made accessible and in sufficient number. Any myths and misconceptions must be addressed adequately and condom negotiating skills be strengthened.

49. Prevention of STIs • Counsellingand behavioural approaches • Counselling and behavioural interventions offer primary prevention against STIs (including HIV), as well as against unintended pregnancies. These include: • comprehensive sexuality education, STI and HIV pre- and post-test counselling; • safer sex/risk-reduction counselling, condom promotion; • interventions targeted at key populations, such as sex workers, men who have sex with men and people who inject drugs; and • education and counselling tailored to the needs of adolescents.

50. GENITAL INFECTIONS FEMALE MALE • Vaginal Infections • Infections of the female pelvis • Post-Gynaelogical Surgery Infections • Pelvic Inflammatory Disease(Previous lecture) • Prostatitis • Epididymitis • Orchitis • Urethritis (Previous Lecture) • Balanitis