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URINARY TRACT INFECTION
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Clinical Presentation of Renal Disease
• Chronic renal failure (CRF)
• Acute renal failure (ARF)
• Hyertension
• Asy!to!atic roteinuria an" ersistent urinary
a#nor!alities
• Nehrotic syn"ro!e (N$)
• Urinary tract infection (UTI)
• Acute nehritis (Acute %lo!erulonehritis)
• O#structi&e nehroathy
• Renal stones
• Renal tu#ular "efects
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Urinary Tract Infections (UTI)Urinary Tract Infections (UTI)
Fre'uent clinical ro#le!Fre'uent clinical ro#le!
Any site in the urinary tract !ay #e in&ol&e" the urethra rostateAny site in the urinary tract !ay #e in&ol&e" the urethra rostate
#la""er ureter *i"ney an" erinehric sace+#la""er ureter *i"ney an" erinehric sace+
,acterial infection is !ost co!!on #ut fun-i chla!y"ia &iruses,acterial infection is !ost co!!on #ut fun-i chla!y"ia &iruses
an" arasites !ay #e resonsi#le in so!e atientsan" arasites !ay #e resonsi#le in so!e atients
.o!en /// 0en.o!en /// 0en
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Ter!inolo-y of Urinary Tract Infections (1)
Bacteriuria : Presence of bacteria in the urine.
Asymptomatic bacteriuria : 105 CFU/ml urine ith or ithout pyuria! in a patient
ithout symptoms of U"#.
Cystitis : inflammation of the bla$$er
• Bacterial cystitis• Abacterial cystitis %urethral syn$rome&
Acute pyelonephritis: acute bacterial infection of the 'i$ney characteri(e$ by
chills an$ fe)er %often hi*h& an$ flan' pain %usually unilateral&! as ell as
ten$erness.
Ribeiro RM, et al. Int Urogynecol 2002;13:1
Chronic pyelonephritis : +a$iolo*ical $ia*nosis here there is e)i$ence of focal
scarrin* of the 'i$neys ith associate$ calyceal abnormality in$icatin* renal
$ama*e $ue to a combination of reccurent infection ith obstruction of the
pel)iocalyceal system %chronic obstructi)e nephropathy& or )esicoureteral
reflu, %reflu, nephropathy&.
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+einfection : An infection ith a $ifferent strain of microor*anism or a $ifferent
serolo*ical type after %en$ of therapy& era$ication of pre)ious infection.
-ost li'ely represent infections of the bla$$er! occur ee's to months after-ost li'ely represent infections of the bla$$er! occur ee's to months after
treatment of the pre)ious infection! response ell to therapy!treatment of the pre)ious infection! response ell to therapy!
usually associate$ ith a normal urinary tractusually associate$ ith a normal urinary tract
+elapse : A consecuti)e urinary infection cause$ by the same strain or serotype of
bacteria! usually represent infection of the 'i$ney or prostat! often recurusually represent infection of the 'i$ney or prostat! often recur
ithin 1 ee's after antimicrobials ha)e been $iscontinue$! some casesithin 1 ee's after antimicrobials ha)e been $iscontinue$! some cases
represent persistent infection! anatomic abnormalities or renal insuficiencyrepresent persistent infection! anatomic abnormalities or renal insuficiencyare more common ith relapsin* or persistent infection! a lon* course ofare more common ith relapsin* or persistent infection! a lon* course of
antimicrobials or sur*ery may be reuire$ if the urine is to be permanentlyantimicrobials or sur*ery may be reuire$ if the urine is to be permanently
sterili(e$sterili(e$
Ribeiro RM, et al. Int Urogynecol J 2002;13:
Ter!inolo-y of Urinary Tract Infections (2)
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+ecurrent U"#: patients ith at least to infections ithin months or three or
more $urin* a sin*le year! in hich the initial episo$e is resol)e$ an$
is folloe$ by another infection.
Ribeiro RM, et al. Int Urogynecol J 2002;13:
Ter!inolo-y of Urinary Tract Infections (3)
Persistence : the continue$ presence of the microor*anisms isolate$ at the be*innin*
of the treatment! oin* to resistance to antimicrobial therapy! ina$euate
$ru* $osa*e! or a urolo*ical abnormality. "hese unresol)e$ infections may
be also in conseuence of the patients non2compliance in ta'in* me$ication!
mi,e$ infections ith to $ifferent bacterial strains ith mutually e,clusi)esusceptibilities! or renal insufficiency %lea$in* to an ina$euate $ru*
concentration in the urine&.
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Classification
• Upper UTI = Pyelonephritis
• Lower UTI = Cystitis
• Complicated UTI
• Uncomplicated UTI
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I+ Unco!licate" urinary tract infectionI+ Unco!licate" urinary tract infection
• 3ccurs in in$i)i$uals ith structurally an$ functionally normal *enitourinary
tracts
• -ost common bacterial infection that occurs in omen! but is uncommon in
men• -ay in)ol)e the bla$$er or the 'i$neys an$ may be symptomatic or
asymptomatic
II+ Co!licate" urinary tract infectionII+ Co!licate" urinary tract infection
• As acute or chronic parenchymal infection associate$ ith a functional orstructural urinary tract abnormality
Classification of Urinary Tract InfectionClassification of Urinary Tract Infection
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Un"erlyin- factors associate"4ith 5co!licate"6 urinary tract infection
$yste!ic Con"itionsDia#etes !ellitusPaillary necrosis (e+-+ anal-esic nehroathy)I!!uno"eficient states (inclu"in- i!!unosuressi&e
"ru- theray)
A#nor!al "raina-e of urineRenal calculiUrinary o#struction7esicoureteric reflu8
Pel&ioureteric 9unction o#structionInstru!entation of the urinary tract (inclu"in- catheters)Pre-nancy
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Clincial UTI
Patterns of In&esti-ation in Urinary Tract Infection
Urinalysis
Urine !icroscoy culture an""eter!ination of anti#iotic sensiti&ity
Further in&sti-ation
A"ult fe!ale
(lo4er UTI)
Treat 4ithoutfurther
in&esti-ation
0ale
(Any UTI)
Ultrasoun": CystoscoyChec* renal
cunction
Chil"ren
(Any UTI)
Ultrasoun": 0CU
Uer UTIor
Co!licate" UTI
,loo" culturesUltrasoun"
: I7PChec* renal function
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Dia-nosis Urinary Tract InfectionDia-nosis Urinary Tract Infection
1+1+ $y!to!s $y!to!s • Lower UTILower UTI• Upper UTIUpper UTI
2+2+ UrinalysisUrinalysis
3+3+ CultureCulture
• "he presence of ≥ 10 4BC / mm fresh un2spun mi$stream urine• "he presence of ≥ 10 4BC / hi*h2poer fiel$ se$iment mi$stream
urine
;+;+ Ra"iolo-ical e&aluationRa"iolo-ical e&aluation• Ultrosoun$• Plain ab$ominal ra$io*raphy• #ntra)enous uro*raphy• C" scannin*
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Clinical features of acute lo4er an"uer urinary tract infection in a"ult
Lower UTI Upper UTI
Dysuria
Frequency
Suprapuic pain
!alodorous urine
"aematuria
#ormal temperature
Systemically unwell
Fe$er % ri&ors
Loin pain and tenderness
#ausea and $omitin&
"ypotension and shoc'
Features of lower urinarytract infection
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(ariation in the si&nificant acterial count in urine
accordin& to the technique used for urine collection
Type of collectionSignificant bacterial
count (cells/ml)
!idstream urine ) *++,+++
Slide-hole catheter ).+,+++
/pen % end catheter *+++
Suprapuic aspiration *
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Criteria for "ia-nosis of si-nificant #acteriuriaCriteria for "ia-nosis of si-nificant #acteriuria
$y!to!atic 4o!en $y!to!atic 4o!en
• ≥≥ 101066 coliform or*anisms/ml urine plus pyuria! orcoliform or*anisms/ml urine plus pyuria! or
• ≥≥ 101055 of any patho*enic or*anism/ml urine! orof any patho*enic or*anism/ml urine! or
• Any *roth of a patho*enic or*anism from urine obtaine$ byAny *roth of a patho*enic or*anism from urine obtaine$ by
suprapubic aspirationsuprapubic aspiration
$y!to!atic !en $y!to!atic !en
• ≥≥ 1010 patho*enic or*anism/ml urinepatho*enic or*anism/ml urine
Asy!to!atic atients Asy!to!atic atients
• ≥≥ 101055 patho*enic or*anism/ml urine in to consecuti)e samplespatho*enic or*anism/ml urine in to consecuti)e samples
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,acterial etiolo-y of urinary tract infection,acterial etiolo-y of urinary tract infection
• E+ coliE+ coli : 702859 %uncomplicate$ U"#&! 61259 %complicate$&: 702859 %uncomplicate$ U"#&! 61259 %complicate$&
• ;. ;aprophyticus : 52609 %uncomplicate$&! 129 %complicate$&;. ;aprophyticus : 52609 %uncomplicate$&! 129 %complicate$&
• 19 %uncomplicate$&! 62189 %complicate$&
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Clinical Classification of Urinary Tract Infection
1+ Acute unco!licate" cystitis in 4o!en
6. Acute uncomplicate$ pyelonephritis in omen
. Complicate$ U"# in both se,es
. +ecurrent infections in omen
5. Asymptomatic bacteriuria
McBryde C, Redington. Primary Care Case Rev 2001 ;
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Acute uncomplicated cystitis in women
;in*le $ose or 2$ay course of treatment
Follo2up urine culture 721 $ays later
Cure$%sterile urine&
Failure or relapse%i$entical patho*ens&
+einfection%ne patho*en&
?o in)esti*ation Ultrasono*raphy urinary tract=UB ra$io*raph
Catel WR. Clin Drug Invest 199 ; 9 !"#$$l 1% :
"reatment for 6 ee's
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Clinical Classification of Urinary Tract Infection
1. Acute uncomplicate$ cystitis in omen
2+ Acute unco!licate" yelonehritis in 4o!en
. Complicate$ U"# in both se,es
. +ecurrent infections in omen
5. Asymptomatic bacteriuria
McBryde C, Redington. Primary Care Case Rev 2001 ;
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0o"erate se&erity$e&ere illness
3utpatients an$ oraltherapy possible
"reatment 1 $ays
@ospitali(ation ith initialparenteral therapy
3ral treatment 1 $ays orlon*er as reuire$
Acute unco!licate" yelonehritis in 4o!en
?o resolutionin 5 $ays
?o resolutionin 5 $ays
Urolo*ic e)aluation
+a$iolo*ic e)aluation
+esolutionin 5 $ays
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Clinical Classification of Urinary Tract Infection
1. Acute uncomplicate$ cystitis in omen
6. Acute uncomplicate$ pyelonephritis in omen
3+ Co!licate" UTI in #oth se8es
. +ecurrent infections in omen
5. Asymptomatic bacteriuria
McBryde C, Redington. Primary Care Case Rev 2001 ;
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@ospitali(e! urine culture! bloo$ culture@ospitali(e! urine culture! bloo$ culture
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Clinical Classification of Urinary Tract Infection
1. Acute uncomplicate$ cystitis in omen
6. Acute uncomplicate$ pyelonephritis in omen
. Complicate$ U"# in both se,es
;+ Recurrent infections in 4o!en
5. Asymptomatic bacteriuria
McBryde C, Redington. Primary Care Case Rev 2001 ;
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Recurrent infections in 4o!en
+eccurent U"# in omen
ia*nosis+elapse +einfection
Con)entional antibiotictherapy 62 ee's
D × year E 6 × year
;e,ually acti)e PostmenopausalCon)entional antibiotic
therapy 27 $ays
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Dru- re-i!ens for lon- !-
Tri!ethori!Tri!ethori! 1>> !-1>> !-
Co+2; -
Norflo8acinNorflo8acin 2>> !-2>> !-
Ciroflo8acinCiroflo8acin 12= !-12= !-
Cehale8inCehale8in 12= !-12= !-( useful if renal insufficiency)( useful if renal insufficiency)
He8a!ine hiurateHe8a!ine hiurate 1 -1 -
* Treatment is effective if taken each night, alternate nights, three times a week,* Treatment is effective if taken each night, alternate nights, three times a week,
or just after intercourseor just after intercourse
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Clinical Classification of Urinary Tract Infection
1. Acute uncomplicate$ cystitis in omen
6. Acute uncomplicate$ pyelonephritis in omen
. Complicate$ U"# in both se,es
. +ecurrent infections in omen
=+ Asy!to!atic #acteriuria
McBryde C, Redington. Primary Care Case Rev 2001 ;
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In"ication for the treat!ent of atients 4ith
asy!to!atic #acteriuria
Definiti&e Possi#le Not in"icate"
Pre*nancy iabetes mellitus
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T H A N KT H A N K
Y O UY O U