urinary tract infections urinary tract infections by by dr dave maharajh md dr dave maharajh md

URINARY TRACT INFECTIONSURINARY TRACT INFECTIONS

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Dr Dave Maharajh MDDr Dave Maharajh MD

http://catalog.nucleusinc.com/enlargeexhibit.php?ID=1959

Bacteria Preparing to Bacteria Preparing to AttackAttack


URINARY TRACT URINARY TRACT INFECTIONSINFECTIONS

MISURYMISURY

MISURYMISURY


PREGNANCYPREGNANCY


CLASSIFICATIONSCLASSIFICATIONS

• UPPER URINARY TRACTUPPER URINARY TRACT

• Complicated and UncomplicatedComplicated and Uncomplicated

• LOWER URINARY TRACTLOWER URINARY TRACT


• COMBINED UPPER AND LOWER COMBINED UPPER AND LOWER TRACTSTRACTS


EpidiemiologyEpidiemiology

• Adults: F>M 18-60 yrs (11%/yr)Adults: F>M 18-60 yrs (11%/yr)

• Children: F>M 5-PubertyChildren: F>M 5-Puberty

• Approx. 50-60% of Adult Women report a Approx. 50-60% of Adult Women report a urinary tract infection during lifetimeurinary tract infection during lifetime

• Adult Female: 3UTI/yr. > refer and inv.Adult Female: 3UTI/yr. > refer and inv.

• Adult Male: 1 infection. Refer and inv.Adult Male: 1 infection. Refer and inv.

• Children: M(1) and F(>3 refer and inv.)Children: M(1) and F(>3 refer and inv.)

• Children: F>M except neonates < 5yrs refer Children: F>M except neonates < 5yrs refer

WHEN LENGTH MATTERSWHEN LENGTH MATTERS

MECHANISMS OF ACTIONMECHANISMS OF ACTION

• Direct Contamination:invasive proceduresDirect Contamination:invasive procedures• MigrationMigration• Hematogenous ( TB and Staph. )Hematogenous ( TB and Staph. )• Ascending InfectionAscending Infection• Foreign Bodies ( Catheters and others)Foreign Bodies ( Catheters and others)• Coexisting ConditionsCoexisting Conditions• Fistulas, Crohn’s/UC, Diverticular diseaseFistulas, Crohn’s/UC, Diverticular disease• IBS, DM, Neurogenic bladder, Calculi.IBS, DM, Neurogenic bladder, Calculi.• Immunosuppression, Immunosuppression, • Nonsecretors of blood group substances (Toll-like Nonsecretors of blood group substances (Toll-like

receptors (TLR-1 and TLR-4> Chemokines CXCL8receptors (TLR-1 and TLR-4> Chemokines CXCL8

URINARY TRACT INFECTIONSURINARY TRACT INFECTIONS CLINICAL VARIATIONS CLINICAL VARIATIONS

Asymptomatic Bacteruria

Septic ShockTrivial Voiding

Irritation

Clinical SymptomsClinical Symptoms

• Upper Tract:Upper Tract:• Flank Pain, Fever, Chills, nausea/vomittingFlank Pain, Fever, Chills, nausea/vomitting• Lower Tract:Lower Tract:• Frequency, Urgency, Dysuria, Hematuria, Frequency, Urgency, Dysuria, Hematuria,

Odour, Cloudy urine, Suprapubic pain, Odour, Cloudy urine, Suprapubic pain, Sense of incomplete emptying.Sense of incomplete emptying.

• Constitutional symptoms: Malaiase, lack Constitutional symptoms: Malaiase, lack of energy and appetitite, confusion.of energy and appetitite, confusion.

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

• Vulvovaginitis ( Yeast, Trichomonas Vulvovaginitis ( Yeast, Trichomonas etc)etc)

• Urethritis ( Chlamydia, GC)Urethritis ( Chlamydia, GC)

• STD’sSTD’s

• Sterile PyuriaSterile Pyuria

• Postmenopausal atrophic vaginitisPostmenopausal atrophic vaginitis

LABORATORY LABORATORY INVESTIGATIONSINVESTIGATIONS

• Urinalysis:Urinalysis:

• Urine dipstickUrine dipstick

• MSUMSU

• Urine Culture and SensitivityUrine Culture and Sensitivity

• Catheterized urineCatheterized urine

• Suprapubic aspirateSuprapubic aspirate

• Nephrostomy tube collectionNephrostomy tube collection

DIAGNOSTICSDIAGNOSTICS

• Urine dipstick: RBC/ WBC and NitritesUrine dipstick: RBC/ WBC and Nitrites

• Usually detects >10/`5 colony/mlUsually detects >10/`5 colony/ml

• Beware of sterile pyuria, age of sticksBeware of sterile pyuria, age of sticks

• Evaluate with clinical scenarioEvaluate with clinical scenario

• Must do MSU or centrifuged urineMust do MSU or centrifuged urine

• Treat and await culture/sensitivityTreat and await culture/sensitivity

• Repeat MSU not dipstick after Rx.Repeat MSU not dipstick after Rx.

DIAGNOSTICSDIAGNOSTICS

• MSU:MSU:

• Colony count > 10`5 or 10`8Colony count > 10`5 or 10`8

• Culture and Sensitivity to followCulture and Sensitivity to follow

• Contamination (Multiple bact. Contamination (Multiple bact. Identified)Identified)

• Fungi and Chlamydia need different Fungi and Chlamydia need different media, suspect if neg. culture and media, suspect if neg. culture and symptomaticsymptomatic

DiagnosticsDiagnostics

• Radiological Investigations:Radiological Investigations:

• Ultrasound ( Kidney and Bladder)Ultrasound ( Kidney and Bladder)

• CT Scan ( Abd/Pelvis)CT Scan ( Abd/Pelvis)

• VCUGVCUG

• MRIMRI

• Non Radiological:Non Radiological:

• CystoscopyCystoscopy

• Urodynamics and UroflowUrodynamics and Uroflow

ORGANISMS COMMONLY ORGANISMS COMMONLY FOUNDFOUND

• E. Coli >70%E. Coli >70%

• Klebsiella Pneumoniae Klebsiella Pneumoniae

• Proteus MirabilisProteus Mirabilis

• Enterococcus FecalisEnterococcus Fecalis

• Staphylococcus SaprophyticusStaphylococcus Saprophyticus

• EnterobactaeEnterobactae

URINARY TRACT INFECTIONSURINARY TRACT INFECTIONS Non Antimicrobial Therapies Non Antimicrobial Therapies

• Personal HygienePersonal Hygiene

• Avoid Bubble Baths and Hot TubsAvoid Bubble Baths and Hot Tubs

• Beware of Spermicide UseBeware of Spermicide Use

• Cranberry JuiceCranberry Juice

• Increased daily Fluid IntakesIncreased daily Fluid Intakes

• Development of a VaccineDevelopment of a Vaccine

Strategies to Prevent UTIStrategies to Prevent UTI

• Simple measuresSimple measures• Increase Fluid intakeIncrease Fluid intake• Void before and after Void before and after

intercourseintercourse• Personal Hygiene Personal Hygiene

(wipe front to back)(wipe front to back)• Avoid feminine Avoid feminine

hygiene sprayshygiene sprays• Take showers instead Take showers instead

of bathsof baths• Cranberries / Juice Cranberries / Juice • Assess voiding patternAssess voiding pattern

• CranberriesCranberries


TREATMENTTREATMENT Uncomplicated UTI Uncomplicated UTI

• Young Woman first Young Woman first episodeepisode

• Single doseSingle dose

• Young Male first Young Male first episodeepisode

• Treat , investigate Treat , investigate and referand refer

• TMP-SMZTMP-SMZ

• 320/1600mg, 2 320/1600mg, 2 double strength tabsdouble strength tabs

• Amoxicillin 3gmAmoxicillin 3gm

• Cephaloridine 2gmCephaloridine 2gm

• Gentamycin 5mg/kgGentamycin 5mg/kg

• Doxycycline 300mgDoxycycline 300mg

• QuinolonesQuinolones

TREATMENTTREATMENT Uncomplicated UTI Uncomplicated UTI

• Young woman first Young woman first episodeepisode

• Short course 3-5daysShort course 3-5days

• 10-14 days10-14 days

• Treat according to Treat according to sensitivitysensitivity

• Repeat urine culture Repeat urine culture after treatmentafter treatment

• TMP-SMZTMP-SMZ

• Nitrofurantoin/ Nitrofurantoin/ MacrobidMacrobid

• CiprofloxacinCiprofloxacin

• NoroxinNoroxin

• AmoxilAmoxil

• QuinolonesQuinolones

TREATMENTTREATMENT COMPLICATED UTI COMPLICATED UTI

• Specific PharmacotherapySpecific Pharmacotherapy

• Investigate with RadiologyInvestigate with Radiology

• Refer to appropriate specialtyRefer to appropriate specialty

• Consider low dose prophylaxis while Consider low dose prophylaxis while awaiting referral and diagnosticsawaiting referral and diagnostics

• Admit patient if not responding to Admit patient if not responding to treatment and refertreatment and refer

Common Scenarios Common Scenarios

• Young female with recurrent UTI and Young female with recurrent UTI and relapses after treatments >3relapses after treatments >3

• Simple measures as discussedSimple measures as discussed

• Do U/S kidney and bladder with PVRDo U/S kidney and bladder with PVR

• May need VCUG May need VCUG

• Refer to SpecialtyRefer to Specialty

• Consider low dose prophylaxisConsider low dose prophylaxis

COMMON SCENARIOSCOMMON SCENARIOS

• Young Females (Pediatric age group)Young Females (Pediatric age group)

• Avoid excessive bathsAvoid excessive baths

• Treat and eliminate constipationTreat and eliminate constipation

• Encourage frequent voidsEncourage frequent voids

• Proper Potty Training Proper Potty Training

• Proper Genital HygeineProper Genital Hygeine

• Recurrent UTI (Investigate and refer)Recurrent UTI (Investigate and refer)

• U/S, VCUGU/S, VCUG

Common ScenariosCommon Scenarios

• Postmenopausal woman with recurrent Postmenopausal woman with recurrent UTI.UTI.

• Simple measures as discussedSimple measures as discussed

• Treat constipation and avoid bathsTreat constipation and avoid baths

• Use Premarin/ estrogen cream locallyUse Premarin/ estrogen cream locally

• Consider low dose prophylaxisConsider low dose prophylaxis

• Do U/S kidney and Bladder with PVRDo U/S kidney and Bladder with PVR



• Chronic indwelling cathetersChronic indwelling catheters

• No need for Rx. Unless symptomaticNo need for Rx. Unless symptomatic

• Change catheter every 4-6 weeksChange catheter every 4-6 weeks

• Use of Silastic catheters less infectionUse of Silastic catheters less infection

• Local hygiene to the catheter and Urethral Local hygiene to the catheter and Urethral meatus helpfulmeatus helpful

• Irrigation of the Catheter helpful in certain Irrigation of the Catheter helpful in certain situations. ( Mucus production and situations. ( Mucus production and sediments)sediments)


• PregnancyPregnancy

• Treat all Asymptomatic Bacteruria Treat all Asymptomatic Bacteruria with the appropriate antibiotic for with the appropriate antibiotic for trimester of Pregnancytrimester of Pregnancy

• Always do and U/S Kidney and Always do and U/S Kidney and bladder with PVRbladder with PVR

• Refer to specialty if neededRefer to specialty if needed


• Young and Old MalesYoung and Old Males

• Treat with appropriate antibioticsTreat with appropriate antibiotics

• Always do diagnostic Imaging (U/S or Always do diagnostic Imaging (U/S or CT)CT)

• Examine Genitalia and ProstateExamine Genitalia and Prostate



• Patients with Neurogenic BladdersPatients with Neurogenic Bladders

• Do appropriate ImagingDo appropriate Imaging

• Personal HygienePersonal Hygiene

• Techniques of Clean Intermittent Techniques of Clean Intermittent Catherizations)Catherizations)

• Treat with culture sensitive antibioticsTreat with culture sensitive antibiotics

• Refer to Specialty as neededRefer to Specialty as needed

• Beware Autonomic dysreflexiaBeware Autonomic dysreflexia

ReferencesReferences

• Update in Adult Urinary Tract InfectionUpdate in Adult Urinary Tract Infection

• Lindsay Nicolle Curr. Infect. Dis.RepLindsay Nicolle Curr. Infect. Dis.Rep

• (2011) 13:552-560(2011) 13:552-560

• Dept. Of Internal Medicine and Medical Dept. Of Internal Medicine and Medical Microbiology . U. Of ManitobaMicrobiology . U. Of Manitoba

• An Update on Uncomplictaed UTI in WomenAn Update on Uncomplictaed UTI in Women

• Current Opinion in Urology 2009 19:368-374 Current Opinion in Urology 2009 19:368-374 Florian. M. WagenlehnerFlorian. M. Wagenlehner

Urinary Tract InfectionsUrinary Tract Infections

• QUESTIONSQUESTIONS

• Structural and functional abnormalities of the Structural and functional abnormalities of the genitourinary tract associated with complicated genitourinary tract associated with complicated urinary infectionurinary infection

• ObstructionUreteric or urethral stricturesTumours of ObstructionUreteric or urethral stricturesTumours of the urinary tractUrolithiasisProstatic the urinary tractUrolithiasisProstatic hypertrophyDiverticulaePelvicalyceal obstructionRenal hypertrophyDiverticulaePelvicalyceal obstructionRenal cystsCongenital cystsCongenital abnormalitiesInstrumentationIndwelling urethral abnormalitiesInstrumentationIndwelling urethral catheterIntermittent catheterizationUreteric catheterIntermittent catheterizationUreteric stentNephrostomy tubeUrological proceduresImpaired stentNephrostomy tubeUrological proceduresImpaired voidingNeurogenic bladderCystoceleVesicoureteral voidingNeurogenic bladderCystoceleVesicoureteral refluxIleal conduitMetabolic refluxIleal conduitMetabolic abnormalitiesNephrocalcinosisMedullary sponge abnormalitiesNephrocalcinosisMedullary sponge kidneyRenal failureImmunocompromisedRenal kidneyRenal failureImmunocompromisedRenal transplanttransplant

• The diagnosis of symptomatic urinary tract infection in patients The diagnosis of symptomatic urinary tract infection in patients without indwelling urological devices should be considered only without indwelling urological devices should be considered only when localizing genitourinary signs or symptoms are present (AII).when localizing genitourinary signs or symptoms are present (AII).

• For patients with indwelling urological devices, systemic For patients with indwelling urological devices, systemic symptoms, such as fever in the absence of localizing symptoms, such as fever in the absence of localizing genitourinary signs and symptoms, may be consistent with genitourinary signs and symptoms, may be consistent with symptomatic urinary tract infection (AII).symptomatic urinary tract infection (AII).

• A urine specimen should be obtained for culture and A urine specimen should be obtained for culture and susceptibility testing before institution of antimicrobial susceptibility testing before institution of antimicrobial therapy for every episode of complicated urinary tract therapy for every episode of complicated urinary tract infection (AI).infection (AI).

• – A single urine specimen with a quantitative count of at least A single urine specimen with a quantitative count of at least

108 cfu/L (at least 105 cfu/mL) is consistent with urinary 108 cfu/L (at least 105 cfu/mL) is consistent with urinary infection in symptomatic subjects (AII).infection in symptomatic subjects (AII).

– A quantitative count of at least 108 cfu/L (at least 105 cfu/mL) A quantitative count of at least 108 cfu/L (at least 105 cfu/mL) on two consecutive specimens is the appropriate diagnostic on two consecutive specimens is the appropriate diagnostic criteria to identify asymptomatic bacteriuria in women (BII).criteria to identify asymptomatic bacteriuria in women (BII).

– Any quantitative count of organisms is consistent with Any quantitative count of organisms is consistent with bacteriuria for individuals with urine specimens obtained by bacteriuria for individuals with urine specimens obtained by bladder catheterization (AII).bladder catheterization (AII).

urinary tract infections urinary tract infections by by dr dave maharajh md dr dave maharajh md

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