Urinary Tract Infection Dr Abdulmalik Tayib Consultant Assistant

Urinary Tract Infection Dr. Abdulmalik Tayib Consultant & Assistant Professor. Department of Urology

Non specific Urinary Tract Infection Common Organisms: -Aerobic gram negative rods : E. Coli(most common), klebsiella sp, Proteus sp(mirabilis), Pseudomonas aerugenosa. -Gram-positive cocci: enterococci, Staphylococcus aureus. -Other pathogens: Clamydiae(chlamydia trachomatis). Myocoplasmas(Ureaplasma urealyticum).

Diagnosis Urine collection: In men: voided urine is generally adequate for diagnostic purposes, no cleaning required in circumcised men: 1 st 10 mls represent urethral specimen. Midstream represents bladder specimen. In female: Contamination is more common. Careful spread of labia, wash the introitus and periurethral area before collecting a mid stream urine. Some time may require mid catheterized specimen.

DIAGNOSIS In infants or patients with spinal cord injury catheter specimen is advisable. Urinalysis: Cloudy urine commonly used to represent pyuria or large amount of amorphous phosphate. The odor rarely clinically significant. Bacteria and leukocyte: Nitrite: when +ve it suggests the presence of more than 100, 000 organisms/ml, 40 -60% accurate. False +ve test may occur in patients taking vit C. Leukocyte estrase: It is good indicator of pyuria.

Diagnosis Urinalysis Microscopic examination: WBC >5 -8/hpf. RBCs. Urine culture: 70% of patients with UTI will have 100 000 CFU (colony forming unit) /ml. 30% 100 - 10 000 CFU/ml.

Classification Natural History: 1 st Infection. Recurrent Infection. -Unresolved bacteruria. -Bacterial persistance. -Reinfection(most common cause). Clinical and pathological presentation: Specific: caused by specific organisms, each of which causes a clinically unique disease that lead to specific pathological tissue reaction.

Classification Non Specific: Organisms causing common clinical and tissue reactions.

Modes of Bacterial Entry 4 modes of bacterial entry: 1 -Ascending infection from the urethra: more in women: short urethra. Rectal bacterial colonization in the perineum and vaginal vestibule. 2 -Hematogenous spread: T. B. staphylococci causing pri renal, renal abscesses. Less common in adult. 3 -Lymphatogenous: Little evidence lymphatic route play role in UTI. 4 -Direct extension from neighboring organs: V. V. F Vesico-intestinal fistula, inflammatory bowel or pelvic diseases.

Acute pyelonephritis Definition: bacterial infection causing inflammation of the parenchyma and pelvis of the kidney. E. coli (80%), Klebsiella, Proteus, Pseudomonas, Serratia… Mode of infection: Ascending from lower urinary tract as in VUR, urinary obstruction. Hematogenous: staphylococi. Clinical features: Fever(high), chills. Flank pain. Lower urinary tract symptoms. Nausea, vomiting. Physical Exam; Tachycardia, tender flank, paralytic ilius.

Diagnosis CBC: Leucocytosis. Urinalysis: numerous WBCs, RBCs, Leucocyte casts, bacteria. Urine culture: always positive. Blood culture: Imaging Techniques: IVP. U. S: rule out obstruction. C. T : to diagnose intrarenal , perirenal abscess formation. U. Cyst.

Management In toxic patient: Hospitalization. Bed rest. I. V fluids. Parentral antibiotics(Ampicillin, Aminoglycosides), to cover both enterococci and pseudomonas spp. In resistant cases Trimethoprim-Sulfamethoxazole combined with aminoglycoside or fluoroquinolones or parentral third generation cephalosporins, for 1015 days. As out patient flouroquinolone or TMP-SMX.

Management Renal abscess requiring drainage. Complications: Septicemia. Schock.

Emphysematous Pyelonephritis Definition: -Necrotizing renal infection characterized by gas within the renal parenchyma or perinephric tissue. -80 -90% D. M. -Urinary tract infection from stone or papillary necrosis in all cases. -Mortality 43% - E. coli most common. -Klebsiella and proteus less common.

Emphysematous Pyelonephritis Symptoms: Flank pain. Fever. Vomiting. Failed initial management. Pneumaturia. Signs: Tender flank. Sick patient. Septic. Laboratory: Urine and blood culture almost +ve. Radiological: Plain X-ray: gas shadow over the affected area.

Emphysematous Pyelonephritis -U. S: Obstruction. -IVP of limited value. -C. T: presence of air inside the collecting system. Management: Fluids IV Antibiotics. Relieve obstruction. Percutaneous drainage. Nephrectomy.

Chronic Pyelonephritis Definition: Process of renal scarification and atrophy resulting in renal insufficiency. Cause: Repeated infections in presence of urinary tract abnormalities either structural or functional: D. M Calculi Analgesic nephropathy. Obstructive nephropathy. In children VUR.

Chronic Pyelonephritis Symptoms: Acute infection. Asymptomatic. Hypertension. Renal failure. Diagnosis: Urinalysis: Pyuria, Bacteriuria, Proteinuria. Positive urine culture in acute attack. IVU:

VCUG:

Chronic Pyelonephritis Management: Identifying the abnormality and correcting it. Preventing recurrence of UTIs. Nephrectomy in unilateral atrophy causing hypertension.

Renal Abscess Collection of purulent material confined to the renal parenchyma. Due to hematogenous seeding by Staphylococci or Gram-Negative organisms. Symptoms: Fever. Chills. Abdominal pain. Vague symptoms. Laboratory: Leukocytosis, positive blood culture. Radiological: U. S , CT. Management: Drainage. Antimicrobial.

Perinephric Abscess Collections of purulent material within the perinephric space (between the kidney and Gerota's fascia). Paranephric if extend beyond Gerota‘s fascia. Organism: E. Coli by ascending infection. Predisposing Factors: Urinary stasis. Obstruction, calculi, Neurogenic bladders. DM. Diagnosis: same as Renal abscess. Management: same as Renal abscess.

Cystitis: Bladder infection. Acute cystitis: Common in females(20 -40 yrs old). Uncomplicated occur with any anatomical or functional abnormalities. Mode of infection: Ascending fecal-perineal urethral route. Causative organism: E. coli Staphylococcus.

Cystitis Symptoms: Frequency, urgency, dysuria, occasionally hematuria. Diagnosis: Urinalysis: bacteruria, hematuria, pyuria. Urine culture: Management: TMP-SMX. Amoxacillin. Cephalosporins. Fluroquinolones.

Cystitis Reccurent infection: Bacterial persistence: surgical removal of the infectious source(stones). Bacterial re infection: Fistulae between bladder and bowel or vagina, pelvic surgey or irradiation. Diagnosis: U. S IVU. Cystoscopy. Management: ESWL. Correction of other abnormalities. Antibiotics.

Prostatitis Acute Prostatitis: Ascending infection. Symptoms: Fever, chills, rectal, low back pain, Dysuria, urgency, arthralgia, Malaise. Diagnosis: DRE extremely tender. Urinalysis: pyuria, microscopic hematuria. Urine culture. Management: Hydration, bed rest, analgesic, antipyretics. Fluouroquinolone, TMP-SMX(4 -6 weeks).

Chronic Prostatitis Bacterial: Same organisms as acute. Non bacterial: Chlamydial.

Epidydmitis Inflamation of the epidydmis. Ascending infection. C. Trachomatis in men less than 40 yrs. E. coli in older men. in severe epidydmitis may lead to epididymo-orchitis. Symptoms: Severe scrotal pain radiate to inguinal area and may be to the flank. O/E tender swallowed epidydmis.

Epidydmitis Diagnosis: CBC: Leukocytosis. Urine analysis & C. S. Management: Antibiotics. Epididymectomy.

Specific Infections Caused by specific organisms, each of which causes clinically unique disease that lead to specific pathological tissue reaction such as: -Tuberculosis. -Shistosomiasis. -Filariasis. -Echinococcosis.

Tuberculosis Caused by Mycobacterium tuberculosis. Hematogenous from the lung. The kidney and the prostate are the 1 ry site in G. U. tract. Kidney infection decent to the ureter and bladder, Prostate to epidydmis and epidydmis to testis. Age: 20 -40. Sex: little common in male than females. Tuberculosis of the kidney may progress slowly(1520 yrs).

Tuberculosis Symptoms: Asymptomatic. Flank pain. Vague generalized malaise, fatigability. Low grade persistent fever. night sweets. Symptoms of cystitis not responding to therapy. Chronic draining scrotal sinus. Gross or microscopic hematuria. Active T. B else were in the body in less than 50%.

Tuberculosis - Signs: Evidence of Extragenital T. B(Lung, LNs, Tonsils, Intestine) Usually there is no enlarged or tenderness of the kidney. Thickened non tender or slightly tender epidydmis. Vas deferns is beaded and thickened. Chronic draining sinus through the scrotal skin. Hydrocele. Nodular indurated prostate.

Diagnosis Laboratory Findings: Persistent Pyuria without organisms on culture. Acid fast stains positive in 60% of the patients. 1 st morning urine culture. Anemia. High sedimentation rate. X-Ray findings: Chest X-ray. Abdominal X-R-ray: punctate calcification in the area of the kidney, may be calcification of ureter.

IVP - Moth-eaten appearance of the involved ulcerated calyces. - Obliteration of one or more calyces. - Dilatation of the calyces. - Abscess cavity connect to the calyces. - Single or multiple ureteral stricture. -Nonfunctioning kidney.

Tuberculosis Urethrocystoscopy: Ulcers, severe contracted bladder. Cystogram: VUR. Medical treatment: Isoniazid 200 -300 mg daily. Rifampin 600 mg daily. Ethambutol 25 mg/Kg daily for 2 month then 15 mg/kg. Streptomycin 1 Gm IM daily. Pyrazinamide 1. 5 -2 Gm daily. Treatment of the complications.