泌尿系統(tǒng)感染UrinaryTract-Infections-課件

Urinary

Tract

InfectionsUTIUTI

-

common

affliction

for

which

patients

seekmedical

attentionUTI

can

occur

from

infancy

through

old

agemore

common

in

females

than

males~20%

of

all

females

will

experience

a

UTIduring

their

lifetimeUTIDefinitionsThe

term

“UTI”

represents

a

wide

range

ofclinical

syndromesBacteriuria:

the

presence

of

bacteria

in

urine-

does

not

necessarily

imply

infectionAsymptomatic

bacteriuria:

presence

of

bacteriain

the

urinary

tract

in

the

absence

of

symptomsclinical

significance

controversial

outsidecertain

patient

populationspregnant

womenpatientsundergoing

invasive

procedures

of

the

urinarytractUTIDefinitionsCystitis:

UTI

presumed

to

be

confined

to

the

bladderpainful/burning

urinationurgency

or

frequencyabsence

of

symptoms

or

physical

signssuggestinginflammation

at

other

sites

within

the

urinarytractNote:

clinical

criteria

are

notoriously

inaccurateinidentifying

the

actual

anatomic

site

of

infectionUTIDefinitionsPyelonephritis:

clinical

diagnosis

which

implies

amoreinvasive

infection-

inflammation

of

the

kidney

and

renal

pelvis

is

assumedto

be

present

when

patients

have

pain

or

tendernessinvolving

the

flank,

together

with

other

clinical

orlaboratory

evidence

of

UTI-fever,

nausea,

chills,

malaise,

headache,

etcUTIDefinitionsProstatitis:

inflammation

/

infection

of

the

prostate

gland-

may

present

as

acute

or

chronicIntrarenal

abscess

/

perinephric

abscess:

collectionofpus

in

the

kidney

or

in

the

soft

tissue

surrounding

thekidneyUTIDefinitionsComplicated

infections-

underlying

abnormality

that

predisposes

patient

toUTIor

makes

UTI

more

difficult

to

treateffectivelyRecurrent

InfectionsRelapse

-

recurrence

of

infection

by

same

organismafter

discontinuation

of

treatmentReinfection

-

recurrence

of

infection

by

a

differentorganism

after

discontinuation

of

treatmentUTIPathogenesisUTI

usually

due

to

patients

own

intestinal

floraascending

route

of

infectionorganisms

enter

the

urinary

tract

in

a

retrogradefashion

via

the

urethraComplicating

factors

such

as

catheters,

nephrostomytubes,

surgery,

urinary

stones,etcallow

organisms

to

enter

and

persist

in

urinary

tractalter

the

typical

spectrum

oforganismsmay

have

multiple

etiologiesUTIPathogenesisElderly

patientsincontinantfunctionally

impairedpostmenopausal

changesneurological

alterationsPregnantwomenaltered

anatomyHematogenous

routeendocarditis,

bacteremias,

tuberculosisdisseminated

infectionsUTIEtiologyMajority

of

UTI

are

due

to

a

singlepathogenThe

Enterobacteriaceae

responsible

for

90%

of

all

UTIgram

negative

bacillifacultatively

anaerobiccommon

intestinal

floraEscherichia

coli

most

commonly

isolatedpathogen~80%

of

all

UTICommunity-Acquired

UTIE.coliS.epi

&gm

-entericsEnterococcusProteusK.pneumoniae

S.saprophyticusUro-pathogensE.coli,

Klebsiella

spp.-intrinsic

gutorganisms-highly

motile-produce

fimbriae

(pili)

>>attachmentProteus,

Morganella,

Providencia-Urease

producing

organisms-increases

urinary

pH

-

leads

to

crystal

formation>>biofilms>>colonization

of

catheter>>protects

bacteria

from

host

defenses

&

antibioticsNosocomial

UTIcatheter

associatedShortTermE.coliE.coliPseudomonasPseudomonasProteusLong

TermEnterobacterProteusCandidaProvidenciaMorganellaS.aureusEnterococcusUrinalysisusually

have

increased

numbers

ofWBCleukocyte

esterase

test

is

often

positivenitrate

test

is

often

positiveUrinalysisUrine

culture:

significant

bacteriuria

usually

defined

as>

105

bacteria/

ml.(108

/

litre)lower

numbers

may

be

significant

in

children

and

incatheter

collected

specimensSpecimen

collectionShould

all

patients

with

a

suspected

UTI

be

cultured?Community

acquired

vs

nosocomial?Should

all

isolates

be

identified?Susceptibility

testing?Specimen

collectionClean

catch

mid

stream

specimensmost

frequently

used

methodurethra

cleaned

prior

to

collectionfirst

void

urine

allowed

to

pass

to

clear

urethramid-stream

collected

in

sterile

containerCollection

bags

(children)used

in

young

children

lacking

bladder

controloften

contaminatedmost

meaningful

result

is

a

negativecultureSpecimen

collectionSuprapubic

aspiration

/

straight

cathetersinvasivespecimen

obtained

directly

from

bladderIndwelling

cathetersurine

obtained

by

inserting

needle

into

catheterorthrough

diaphrampreferable

to

obtain

specimen

from

new

catheter,rather

than

old

catheterSpecimen

transportSent

to

and

processed

by

lab

as

quickly

as

possible-

Require: method

of

collectiontime

of

collectionpatient’s

antibioticsSpecimens

not

received

by

lab

in

1-2

hours

MUST

berefridgeratedUrines

not

received

within

24

hours

or

notrefridgerated

will

be

rejected

by

laboratoryAntimicrobial

TherapyEmpiricTherapybased

on

most

probable

pathogenslocal

rates

of

resistanceacute

infection

vs

chronicreinfection

or

relapseindwelling

catheter

etcManagement

of

UTIAnatomical/Functional

Predisposition

to

UTIImpaired

bladder

emptyingDysfunctionNeuropathyVURBOODiverticulumManagement

of

UTIAnatomical/Functional

Predisposition

to

UTIObstructionAny

levelVURCalculivery

difficult

to

eradicate

if

UTI

andstonesManagement

of

UTIAnatomical/Functional

Predisposition

to

UTIIntrarenalRenal

scarsInterstitial

nephritisPapillary

necrosisMedullary

sponge

kidneyAPKDCongenital

calyceal

obstructionManagement

of

UTIAnatomical/Functional

Predisposition

to

UTIAssociated

conditionsDiabetes

mellitusPregnancyImmunosuppressionElderlyManagement

of

Female

UTIBacterial

FactorsAdherenceAdhesinsFimbriaeNon-fimbrial

AdhesinsBiofilmsImportant

in

catheter

UTISoluble

Virulence

Factor

ProductionDisrupt

bladder

protective

mucus

layerManagement

of

Female

UTIBacterial

FactorsIron

Acquisition

MechanismsSiderophores

and

HaemolysinsAllow

growthSerogroup

and

Serum

RO

ag

LPS

outer

G -vePrevent

complement

destructionCapsulesK

ag

covers

bacteria

capsuleProtects

v

phagocytosis

and

complementattackManagement

of

Female

UTIBacterial

FactorsIg

ProteasesCleave

gut

IgAUreteric

ParalysisP.

Fimbriae

and

endotoxinMotilityAscent

of

LUTUrease

ProductionHydrolyse

urea

and

increases

ammonia

whichincreases

bacterial

adherenceManagement

of

Female

UTIHost

FactorsColonisation

of

vagina,

introitus,urethraBiological

predispositionHormone

deficiency

vaginal

atrophySpermicidal

jelly

increases

vaginal

pHAntibiotics

reduce

vaginal

lactobacilliand

increase

pHAscent

to

bladderSexual

milkbackCatheterisationManagement

of

Female

UTIHost

FactorsEstablishment

of

bacteria

in

bladderUrine

composition

(extremes

inhibitbacterial

growth)Reduced

IgA

and

IgGReduced

GAG

layer

in

the

bladderLow

urine

flowIncomplete

emptyingManagement

of

Female

UTIMSSU

when

symptomaticUSS

renal

tract

with

post

voidresidualKUBTargeted

flexible

cystoscopy

(8%

yield)macroscopic

haematuriamicroscopic

haematuria

between

UTIspersistent

UTIManagement

of

Female

UTI3

days

oral

antibiotics

or

x1

high

dose

if

compliance

poor14

days

antibiotics

if

pyelonephritisAddress

any

underlying

cause

(rare)General

adviceincrease

fluid

intakecranberry

juicevoid

before

and

after

siManagement

of

Female

UTIHygienewash

without

soappat

or

air

drycotton

pants6

months

low

dose

prophylactic

antibioticsalter

gut

floramay

affect

COCPSelf-start

antibiotic

therapyManagement

of

Male

UTIMSSU

when

symptomaticUSS

renal

tract

with

flow

rate

and

post

voidresidualKUBFlexible

cystoscopymacroscopic

haematuriamicroscopic

haematuriapersistent

UTIManagement

of

Male

UTIUTI

-

7

days

oralantibioticsAddress

underlying

causeManagement

of

Childhood

UTIHistoryfevers

and

rigorsirritative

LUTSincontine