Urinary tract infection Dr AMMAR FADHIL Bacteriology E

Urinary tract infection Dr. AMMAR FADHIL

Bacteriology E. Coli is the most common bacteria causing UTI. Others, proteus mirablis, strebtococcus faecalis & staphylococcus. Pseudomonas usually in complicated UTI. Routes: Ascending

Predisposing factors of UTI • Incomplete emptying of bladder. Calculus, foreign body, neoplasm • Incomplete emptying of upper tract vur, preg • Estrogen deficiency • D. M • Immunodeficiency. • Colonization of perineal skin by E. Coli

Cystitis • Irritative voiding symptoms. • Suprapubic pain & hematuria. • Foul smell urine. • Fever & systemic symptoms are rare

Cystitis • Cystitis is infection and/or infl ammation of the bladder. • Presentation • There is frequent voiding of small volumes, dysuria, urgency, offensive • urine, suprapubic pain, hematuria, fever (uncommon), and incontinence. • 50% of women will have an episode in their lifetime. .

Investigation urinalysis urine culture repeated attacks of UTI single attack in a man or child of either sex U/S VCUG

Treatment • Increase oral fluid intake • TMP SMX • Quinolones • Nitrofurantoin Short oral course 3 -5? Days for adult and child

Recurrent cystitis • Bacterial persistence such as calculi, VVF. Removal of infected source is curative. • Re infection: low dose continuous prophylactic ABS has been shown to reduce the recurrence rate of UTI by 95%.

Women with recurrent cystitis • Have higher adherence of bacteria to their mucosal cells in vitro compared to women who never had UTI. • More binding sites for bacteria • or may not secret soluble compounds which normally compete for the same receptors

Newer modalities for treatment of recurrent UTI • Cranberry juice taken orally. • Lactbacillus vaginal suppository. • Intravaginal oestriol.

Infection in child Incidence is higher in male infant as underlying abnormalities are more frequent. Complicated or recurrent UTI prompt ABS & investigation to exclude underlying cause

Infection in pregnancy • Asymptomatic bacteruria in pregnant women is twice as high as in non pregnant women. • Simple infection treated with ampicilline or cephalosporine. • Pyelonephritis or complicated infections need I. V ABS and close observation.

Antibiotics in urology • TMP SMX: highly effective against many uropathogenes except pseudomonas & entreococcus. interfere with bacterial metabolism of folate. SE: rash, GIT upset, leukopenia. CI: G 6 PD, pregnant, AIDS. • Quinolones : broad spectrum, interfere with bacterial DNA.

• Nitrofurantoin has good activity against most gram –ve except Pseudomonas & proteus. It inhibit bacterial enzymes & DNA activity. SE: polyneuropathy, hepatotoxicity. • Aminoglycosides: used for complicated UTI. When combined with ampicilline act against enterococci

Cephalosporine Have good activity against most uropathogene. 1 st generation gram positive & E. Coli. 2 nd generation anaerobic & H. influenze. 3 rd generation boader coverage against G –ve less against G+ve Children with febrile UTI oral 3 rd such as cefixime safe &effective

Penicilline • Are ineffective against uropathogene. • Ampicilline & amoxicilline have good activity against uropathogene but Gve bacteria quickly develop resistance. • Addition of B lactamase inhibitor such as clavulanic acid makes combination more active against G -ve bacteria.

Acute hemorrhagic cystitis • Sever symptoms of UTI. Pyuria but no organism can be detected…… • Sexually acquired. Mycoplasma or herpes simplex causative factors • Treatment supportive

Frequency dysuria syndrome urethral syndrome Common in women. Symptoms suggest UTI but –ve culture & absent pus cells. Exclude T. B, C. A in situ, interstitial cystitis R: perineal hygiene, voiding after intercourse ABS? urethral dilatation?

T. B of bladder Secondary to T. B of kidney. Frequency, dysuria, sterile pyuria. Cystoscopy: T. B granuloma around the ureteric orifice. Long standing cases…fibrosis & ↓ bladder capacity. R: chemotherapy. Bladder augmentation, ileocystoplasty

Interstitial cystitis • Confined to women. • Symptoms: frequency, dysuria, urgency & SUPRAPUBIC PAIN RELIEVED relieved by voiding commence in her 40 s. • Pathology: as result of pancystitis, fibrosis of vesical muscle. Ulceration of mucosa occure in the fundus. Contracture of bladder, ↓ bladder capacity to 60 ml.

Interstitial cystitis Pyuria & UTI are absent. Cystoscopy: characteristic ulcer is found in the fundus. R: Hydrostatic dilatation under G. A. Diathermy fulguration of the ulcer. Instillation of DMSO (dimethyl sulphoxide) Oral rantidine, steroid therapy. Intravesical heparine. Cystectomy & bladder substitution.

Alkaline encrusting cystitis • Is rare, due to urea splitting organism causing phosphate on the bladder of elderly♀. • X ray show bladder outline. • R: ABS encrustation removed by bladder irrigation

Cystitis cystica • Normally glands are not found in bladder. • In chronic inflammation, the surface epithelium sends down buds, resulting in minute cysts filled with clear fluid, most abundant in trigone. • Adenocarcinoma of bladder may arise in

Shistosomiasis of bladder • Endemic in many parts of Africa, Syria, Iraq, Iran, Nile valley. • Marshes or slow running water provide a favorable habitat for the bulinus snail is the intermediate host.

Mode of infestation • The disease acquired while bathing in infected water. • Cercaria (bifid tailed embryo) penetrate the skin. Shedding their tail, enter blood vessels, flourish in the liver, lives in the erythrocyte, develop into ♀& ♂. • Sh. Hematobium has an affinity for the vesical venous plexus, which reach through the portosystemic anastomosis.

• Urinary schistosomiasis is caused by the trematode (or fl uke) Schistoma • haematobium. It is endemic in Africa, Egypt, and the Middle East. Fresh • water snails release the infective form of the parasite (cercariae), which • can penetrate skin, and migrate to the liver (as schistosomules), where • they mature. Adult fl ukes couple, migrate to vesical veins, and lay eggs

• The disease has two stages: active (when adult worms are actively laying • eggs) and inactive (when the adult has died, and there is a reaction to • the remaining eggs). • The development of squamous cell carcinoma of the bladder is result of the chronic inflammation.

• Females move towards submucosa venules lay about 20 ova. Infected subject passes hundred of ova a day. Miracedium to survive it must reach the intermediate snail with in 36 h

Clinical features • Swimmer’s itch. • after Incubation period 4 -12 weeks develop pyrexia, sweating & asthma • Painless terminal hematuria

• • • Diagnosis Urinalysis: Early morning urine specimen, to see ova with terminal spine. ELISA test is positive one month after infection. Cystoscopy: reveal one or more of the following. 1. Bilharzial pseudotubercules are the earliest specific appearance. pseudo. T. B Are larger, more prominent than those of T. B.

• Midday urine specimen; bladder and rectal biopsies may contain eggs (distinguished by having a terminal spine). • Serology tests (ELISA). • Cystoscopy identifies eggs in the trigone (“sandy patches”). • IVP or CT urogram may show a calcified, contracted bladder, and obstructive uropathy

2. bilharzial nodules: fusion of tubercles, are larger. 3. Sandy patches: calcified dead ova with degeneration of overlying epithelium. radiograph?

cystoscopy 4. Ulceration ulcer is shallow, bleeds readily. 5. Fibrosis is result of secondary infection. The capacity of bladder becomes much reduced. 6. Granulomas Due to an aggregation of nodules. Sessile, soft & bleed readily.

7. Papillomas being more pedunculated, single or multiple. 8. Carcinoma is common end result in bilharziasis. Squamous celled C. A (due tometaplasia)

• Chronic infection can lead to obstructive uropathy, ureteric stenosis, renal • failure, and bladder contraction, or ulceration. • The most significant and concerning complication is the development of squamous cell carcinoma of the bladder that often presents at an advanced stage

Complication 1. Secondary bacterial cystitis 2. Urinary calculi, vesical & ureteric. 3. Stricture of ureters affect the last inch of ureter. Respond to dilatation or re implanation.

4. Prostatoseminal vesiculitis, 5. Contracture of the bladder & bladder neck. 6. Urethral stricture.