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Urinary Tract Infections

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MID 11Urinary Tract Infections Magdalena Sobieszczyk, MD MPHDivision of Infectious DiseasesColumbia UniversityClinical Scenario #1• 23 y.o woman presents to her doctor complaining of 1 day of increased urinary frequency, dysuriaand sensation of incomplete voiding• She is otherwise healthy, takes no medications,and is sexually active, using spermicide-coated condoms forcontraception. She says she does not have fever, chills, vaginaldischarge, or flank pain • Sexually active with one partner, no hx/o sexually transmitted diseasesClinical Scenario #1• She looks a little uncomfortable but is afebrile, with a normal blood pressure• Her abdominal exam is notable for mild suprapubic tenderness, no RUQ tenderness, no costovertebral tenderness• Pelvic exam is deferredClinical Scenario #1 : Labs• Urinalysis: pyuria (WBC too numerous to count), RBC and bacteria present• Urine dipstick: positive leukocyte esterase and nitrite• Urine culture: not done• Patient receives 3 days of TMP/SMX for UTIGram stain of urine shows numerous Gram-negative rods. E.coli grew from this urine specimenUrinary Tract Infections• Definitions• Clinical Symptoms and Diagnosis• Microbiology and Epidemiology• Pathogenesis– Host Factors– Bacterial Factors• Clinical Scenario• Treatment and PreventionMID 11UTI: Definitions• Lower UTI: cystitis, urethritis, prostatitis• Upper UTI: pyelonephritis, intra-renal abscess, perinephric abscess (usually late complications of pyelonephritis)• Uncomplicated UTI – Infection in a structurally and neurologically normal urinary tract. Simple cystitis of short (1-5 day) duration• Complicated UTI – Infection in a urinary tract with functional or structural abnormalities (ex. indwelling catheters and renal calculi). Cystitis of long duration or hemorrhagic cystitis.UTI Clinical Symptoms and Presentation in Adults• Lower tract: Cystitis– Dysuria, urinary urgency and frequency, bladder fullness/discomfort– Hemorrhagic cystitis (bloody urine) reported in as many as 10% of cases of UTI in otherwise healthy women• Upper tract: Pyelonephritis– Fever, sweating– Nausea, vomiting, flank pain, dysuria– Signs and symptoms of dehydration, hypotension• A history of vaginal discharge suggests that vaginitis, cervicitis, or pelvic inflammatory disease is responsible for symptoms of dysuria (pelvic examination)– Important additional information includes a history of prior sexually transmitted disease (STD) and multiple current sexual partners.UTI in children– Younger than 2 years - enuresis, fever, poor weight gain– Older than 3 years - dysuria, lower abdominal painDiagnosis of UTI• U/A microscopic examination– WBC, RBC– Presence of bacteria • Urine dipstick test: rapid screening test– leukocyte esterase test– Nitrate → nitrite test (+ in only 25%)• Indications for urine culture– Pyelonephritis– Children, pregnant women– Patients with structural abnormalities of the urinary tractIndications for Evaluating the Urinary Tract• Children– ultrasound, IVP, CT scan• Bacteremic pyelonephritis not responding to therapy– ultrasound, IVP, CT scan• Nephrolithiasis or Neurogenic Bladder– Ultrasound, CT, or IVP with post-voiding films• Men with 1stor 2ndinfection– Careful prostate examination– Ultrasound or IVP with post-voiding filmsUrinary Tract Infections• Definitions• Clinical Symptoms and Diagnosis• Microbiology and Epidemiology• Pathogenesis– Host Factors– Bacterial Factors• Clinical Scenario• Treatment and PreventionMID 11Etiology of Uncomplicated UTI in Sexually Active Women E. coli 79%S. saprophyticus11%Klebsiella 3%Mixed 3%Proteus 2%Enterococcus 2%Other 2%Microbial Species Most Often Associated with Specific Types of UTI’s8%15%0%0%S. epidermidis28%1%0%0%Candida spp.10%5%2%0%Other*11%10%5%3%Mixed9%20%0%0%Ps. aeruginosa7%22%0%2%Enterococcus spp.8%5%4%3%Klebsiella spp.6%4%4%2%P. mirabilis0%1%0%11%S. saprophyticus24%32%89%79%E.coliCatheter-associated UTIComplicated UTIAcute uncomplicated pyelonephritisAcute uncomplicated cystitisOrganism*Serratia, Providencia, Enterobacter, Acinetobacter, CitrobacterUTI: Epidemiology and Risk Factors by Age GroupAll of the above; urinary catheters (35%)Estrogen deficiency and loss of lactobacilli (40%)>65Prostate hypertrophy, obstruction, catherization(20%)Gynecologic surgery, bladder prolapse(35%)36-65Anatomic, insertive anal intercourse (0.5%) Sexual intercourse, spermicideuse, previous UTI (20%)16-35Vesicoureteral reflux (0.5%)Vesicoureteral reflux (4.5%)6-15Congenital abnormalities, uncircumcised penis (0.5%)Congenital abnormalities, Vesicoureteral reflux (4.5%)1-5Anatomic/functional abnormalities (1%)Anatomic/functional abnormalities (1%)< 1Males(% Prevalence)Females (% Prevalence)Age in yearsUrinary Tract Infections• Definitions• Clinical Symptoms and Diagnosis• Microbiology and Epidemiology• Pathogenesis– Host Factors– Bacterial Factors• Clinical Scenario• Treatment and PreventionPathogenesis of UTI• Hematogenous Route• Ascending Route– Colonization of the vaginal introitus– Colonization of the urethra– Entry into the bladder– InfectionIntroitalColonizationGut FloraCystitis (Urethritis)PyelonephritisBladder inoculationUrethralColonizationSexual ActivityMID 11UTI in Women: Factors Predisposing to Infection• Short urethra• Sexual intercourse & lack of post coital voiding• Diaphragm, spermicide use• Estrogen deficiency•P1blood group - upper UTIHost Factors Predisposing to Infection • Extra-renal obstruction– Posterior urethral valves– Urethral strictures• Renal calculi• Incomplete bladder emptying• Neurogenic bladder• Immunocompromised individuals (e.g. DM, transplant recipients) Bacterial Virulence Factors-I• Enhanced adherence to receptors on uroepithelial cells– Type 1 fimbriae: mediate binding to uroplakins, mannosylatedglycoproteins on the surface of bladder uroepithelial cells– P fimbriae: bind to galactose disaccharide on the surface of uroepithelial cells and to P1 blood group antigen ( D-galactose-D-galactose residue) on RBCs• 97% of women with recurrent pyelo are P1 blood group (+)• Higher prevalence of P-fimbriated E.coli in cystitis-causing strains than in strains from asymptomatic persons (60% vs. 10%)• Phase variation:– Type 1 fimbriae increase susceptibility to phagocytosis, P-fimbriaeblock phagocytosis– In strains that cause upper-tract infections: Type 1


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