2Contents Definitions Incidence and epidemiology Pathogenesis Clinical manifestationsDiagnosisAntimicrobial therapyBladder infectionKidney infectionBactreremia, sepsis and septic shockCatheter associated UTIUTI in spinal injury Pt
3Definitions UTI : Bacteriuria : Pyuria: An inflammatory response of the urothelium to bacterial invasion that is usually associated with bacteriuria and pyuria.Bacteriuria :The presence of bacteria in the urine, which is normally free of bacteria.Pyuria:The presence of white blood cells (WBCs) in the urine,is generally indicative of infection and an inflammatoryresponse of the urothelium to the bacterium.
4Bacteriuria without pyuria →bacterial colonization Pyuria without bacteriuria → tuberculosisstonescancer
5Infections defined by their site of origin CystitisA clinical syndrome of dysuria, frequency,urgency, and occasionally suprapubic pain.Acute pyelonephritisAn acute bacterial infection of the kidney.Chronic pyelonephritisDescribes a shrunken, scarred kidney, diagnosedby morphologic, radiologic, or functional evidenceof renal disease that may be postinfectious
6An infection in a healthy patient with a structurally UTIs definition in terms of functional status of the urinary tract and the health of the host.Uncomplicated UTI :An infection in a healthy patient with a structurallyand functionally normal urinary tract.A complicated infectionAssociated with factors that increase the chance ofacquiring bacteria and decrease the efficacy oftherapy
7Functional or anatomic abnormality of urinary tract Male genderPregnancyElderlyDiabetesImmunosuppressionChildhood UTIRecent antimicrobial agent useIndwelling urinary catheterUrinary tract instrumentationSymptoms for more than 7 days at presentation
8UTIs defined by their relationship to other UTIs. : First or isolated infectionAn individual who has never had a UTI or has one remote from a previous UTI.:Unresolved infectionOne that has not responded to antimicrobial therapy.:Recurrent infectionOne that occurs after successful resolution of an antecedent infection.Reinfection :Describes a new event associated with reintroduction of bacteria into the urinary tract from outside.
10Account for:>7 million visits to physicians' offices>1 million complicate office visits1 million emergency department visit100,000 hospitalizations annually1.2% of all office visits by women0.6% of all office visits by menSurveys screening for bacteriuria in female :1% of schoolgirls have bacteriuria4% by young adulthood1% to 2% per decade of age
11The prevalence of bacteriuria in women has been estimated at 3 The prevalence of bacteriuria in women has been estimated at 3.5%, and increasing with age in a linear trend30% of 24 y women with symptomatic UTI requiring antimicrobial therapyHalf of all women will experience a UTI during their lifetime.Bacteriuria in young women is 30 times >men.with increasing age, the ratio of women to men progressively decreases.20% of women and 10% of men older than 65 years have bacteriuria
13Successful infection of the urinary tract is determined by UTIs are a result of interactions between the uropathogen and the host.Successful infection of the urinary tract is determined byThe virulence factors of the bacteria,The inoculum sizeThe host defense mechanisms.
14Routes of Infection : Ascending Route: Hematogenous Route: Uncommon Bowel reservoirAdherence to the introital and urothelial mucosaHematogenous Route:UncommonSecondarily infected in patientsLymphatic Route:Occur in unusual circumstances, such as:Severe bowel infectionRetroperitoneal abscesses..
15Urinary Pathogens community-acquired infections : E. coli accounting for 85%gram-negative Enterobacteriaceae,(Proteus and Klebsiella,)gram-positive (E. faecalis and S. saprophyticus)Nosocomial infections E. coli, accounting for 50%Klebsiella, Enterobacter, Citrobacter, Serratia, Pseudomonasaeruginosa, Providencia, E. faecalis, and S. epidermidisGardnerella vaginalis, Mycoplasma species, and Ureaplasmaurealyticum may infect patients with intermittent or indwelling catheters
16 Anaerobes in the Urinary Tract The distal urethra, perineum, and vagina are normally colonized by anaerobes.Anaerobic organisms are frequently found in suppurative infections of the genitourinary tract.Bacteroides species, including B. fragilis, Fusobacterium species, anaerobic cocci, and Clostridium perfringensMycobacterium tuberculosis and Other Non-Tuberculous MycobacteriaChlamydia
17Bacterial Virulence Factors play a role in determining the ability of an organism to invade the urinary tract and level of infection within the urinary tract.uropathogenic E. coli (UPEC), can infect the urinary tract by the expression of virulence factors that enable them to adhere to and colonize the perineum and urethra and migrate to the urinary tract where they establish an inflammatory response in the urothelium.A recent genomic analysis of a UPEC strain revealed the presence of genes for putative chaperone-usher that may function as adhesins, toxins, proteases, invasins, serum resistance factors, or motility mediators
18Early Events in UPEC Pathogenesis Bacterial AdherenceBacterial adherence is a specific interaction that plays a role in determining the organism, the host, and the site of infection.This interaction is influenced by:The adhesive characteristics of the bacteria,The receptive characteristics of the epithelial surfaceThe fluid bathing both surfaces.
19UPEC expresses a number of adhesins that allow it to attach to urinary tract tissues classified as either fimbrial or afimbrial,A typical piliated cell may contain 100 to 400 pili. The pilus is usually 5 to 10 nm in diameter, is up to 2 μm long,Pili are defined functionally by their ability to mediate hemagglutination of specific types of erythrocytes.The most well-described pili are types 1, P and S.
20Type 1 (Mannose Sensitive) Pili: Expressed on both nonpathogenic and pathogenic E. coliFacilitate bacterial colonization of the vaginal mucosa and bladder.These pili mediate hemagglutination of guinea pig erythrocytesThe reaction is inhibited by the addition of (mannoseMSHA)Consist of a helical rod composed of repeating FimA subunits joined to a 3-nm wide distal tip structure containing the adhesin FimH
21Binding of the FimH adhesin to mannosylated host receptors on the uroepithelium → colonization of E. coli in the vaginal introitus, urethra, and bladder and cause cystitisThe luminal surface of the bladder is lined by umbrella cells.appear as a quasi-crystalline array of hexagonal complexes composed of four integral membrane proteins known as uroplakinsTwo of the uroplakins, UPIa and UPIb, can specifically bind UPEC expressing type 1 pili.
22P (Mannose Resistant) Pili: Found in most pyelonephritogenic strains of UPECMediate hemagglutination of human erythrocytes that is not altered by mannose (MRHA)The adhesin PapG, at the tip of the pilus, recognizes the α-d-galactopyranosyl-(1-4)-β-d-galactopyranoside moiety present in the globoseries of glycolipids which are found on P-blood group antigens and on uroepithelium .Other Adhesins:S pili: which bind to sialic acid residues via the SfaS adhesin,It is associated with both bladder and kidney infectionF1C pili: bind to glycosphingolipids in renal epithelial cells andinduce an interleukin-8 inflammatory response
23Epithelial Cell Receptivity Vaginal Cells:E. coli strains that cause cystitis adhere more to epithelial cells from susceptible womenThe increased bacterial adherence was also characteristic of buccal epithelial cells.A small variation in both vaginal cell and buccal cell receptivity from day to daypremenopausal women susceptible at certain times during the menstrual cycle and early pregnancyUropathogens attached in larger numbers to uroepithelial cells from women > 65 years
24Blood group antigens are important part of the uroepithelial cell membrane. women with Lewis blood group Le(a−b−) and Le(a+b−) (nonsecretor) phenotypes have higher incidence of recurrent UTIs than women with Le(a−b+) phenotypeThe protective effect in women with the Le(a-b+) phenotype may be due to fucosylated structures at the vaginal cell surface or in the overlying mucus which decreases availability of putative receptors for E. coli
25Bladder Cellsthe initial step in the intricate cascade of events leading to UTIs is fimH-mediated binding to the bladder epitheliumFimH binds mannosylated residues on the uroplakin molecules covering bladder superficial epithelial cells.
26UPEC Persistence in the Bladder: After attachment to the epithelium, UPEC is quickly internalized into the bladder superficial cells → establish a new niche to protect itself from the host innate immune responseOnce intracellular, the UPEC organisms rapidly grow and divide within the cell cytosol → small clusters of bacteria(early intracellular bacterial communities IBCs )As they grow, the bacteria maintain their typical rod shape of 3 μm and form a loosely organized cluster, with microorganisms randomly oriented in the cell cytoplasm.Between 6 to 8 hours after inoculation, early IBCs show a drop in bacterial growth rate → doubling times greater than 60 minutes, a significant shortening of the bacterial morphology to of 0.7 μm,→ a biofilm-like community
27Biofilms shield bacteria from antimicrobial agents and the host immune response by: Slower growth rate of the bacteriaExpression of factors that inhibit antimicrobial activity,Inability of the antimicrobial agent to penetrate the biofilmProtects the bacteria from neutrophils because they are unableto effectively penetrate the IBC and engulf the bacteria.Bacteria on the edge of IBCs eventually detach then escape the host cell into the bladder lumen (fluxing) to readhere and reinvade superficial cells →second IBC formation.
28Natural Defenses of the Urinary Tract Periurethral and Urethral Region:The normal flora usually contain microorganisms such as lactobacilli, coagulase-negative staphylococci, corynebacteria, and streptococci that form a barrier against uropathogenic colonization.Changes in the vaginal environment related to estrogen, cervical IgA, and low vaginal pH may alter the ability of bacteria to colonize.
29Urine Bladder The most inhibitory factors : - Flow of urine and voiding #1 defense- High osmolality with a low pH inhibitory to bacterial growth- High urea and organic acid content can reduce survival ofbacteria within the urinary tract- Uromodulin (Tamm-Horsfall protein), saturating all themannose-binding sites of the type 1 pili, →blocking bacterialbinding to the uroplakin receptors of the urothelium Lactoferrin within urine: can scavenge essential iron awayfrom bacteriaBladderFactors responsible for defense :- The ability of the bladder to empty- Innate and adaptive immunity- Exfoliation of epithelial cells.
30Immune Response:mediated by a series of pathogen-associated molecular pattern receptors (PAMPs),Toll-like receptors (TLRs) :provide the link between recognition of invading organisms and development of the innate immune response. TLRs are conserved among many species of pathogens, such as (LPS) and peptidoglycan (PG),activate signaling pathways that initiate immune and inflammatory responses to kill pathogens. TLR4 expressed on Superficial bladder epithelial cells with CD14 → recognize LPS from the bacteria and → the innate immune responseTLR11 expressed on uroepithelial cells → recognizes UPEC and protects the kidneys from ascending infection cells
34Diagnosis Urine Collection: Voided and Catheterized Specimens Men: Circumcised men→no preparation.Not circumcised,→ the foreskin should be retracted and theglans penis washed with soap and then rinsed with water beforespecimen collection.Women: contamination with introital bacteria and WBCs is common,The first 10 mL of urine: urethraMidstream specimen bladderProstatic fluidFirst 10 mL after massagecatheteraizationSuprapubic Aspiration
35UrinalysisSediment from an approximately 5- to 10-mL specimen obtained by centrifugation for 5 minutes at 2000 rpm is analyzed.Bacteriuria, Pyuria, and Hematuria
36Bacteriuria:Microscopic bacteriuria →105 colony-forming units (cfu) per milliliter of urineThe bacterial count must be approximately 30,000/mL before bacteria can be found in the sediment, stained or unstained, spun or unspunFalse-negative :Early infection due to low no of bacteria and WBCsDiluted samplesFalse-positive:Contamination of the urine specimen collection.
37Pyuria :Examining the centrifuged sediment or using a hemocytometer to count the number of WBCs in the unspun urine.1 to 2 WBCs per high-power field (HPF) in sediment from a centrifuged specimen = 10 WBCs/mm3 in an unspun specimen.> 2 WBCs per HPF in a centrifuged specimen or 10 WBCs/mm3 of urine correlates well with the presence of bacteriuria and is rarely seen in nonbacteriuric patientsHematuria :Microscopic hematuria is found in 40% to 60% of cases of cystitis and is uncommon in other dysuric syndromesNitrites: formed when bacteria reduce the nitrate present in urineLeukocyte esterase : sensitivity of 75% to 96% in detecting pyuria associated with infection
38Urine Culture: Two techniques: A: Direct surface plating of urine on split-agar disposable plates.- Blood agar G+tive – G-tive bacteria- Desoxycholate or eosin–methyleneblue (EMB) G-tive 0.1 mL of urine onto each half of the plate.Overnight incubation,The number of colonies multiplied by 10 to report the number of cfu per milliliter of urine. Urine must be refrigerated immediately on collection and should be cultured within 24 hours of refrigeration.
39B: The dip slidesSoy agar (a general nutrient agar to grow all bacteria) on one side and EMB or MacConkey’s agar on other. A slide is dipped into urine, the excess is allowed to drain off, and the slide is replaced in its plastic bottle and incubated.The volume of urine that attaches to the slide is between 1/100 mL and 1/200 mL.the colony count is 100 to 200 times the number of colonies that become visible with incubation.
40IMAGING TECHNIQUES Plain Film of the Abdomen Radiopaque calculiGas patternsAbsent psoas or abnormal renal contour, perirenal or renal abscessPlain Film Renal TomogramsSmall or poorly calcified stones despite overlying gasStruvite and uric acid stones that contain small amounts of calcium may be seen
41Voiding Cystourethrogram Excretory UrogramUseful to determine the exact site and extent of urinary tract obstructionNot the best screening test for hydronephrosis, pyonephrosis, or renal abscessUnnecessary for routine evaluationVoiding CystourethrogramNeuropathic bladdersFemale patient who has a urethral diverticulum causing her persistent infectionsVUR
42Ultrasonography CT and MRI Useful in r/o hydronephrosis associated with UTI, pyonephrosis, and perirenal abscessesNo radiation or contrast agent riskCT and MRIBest antomic detailMore sensitive than IVP or U/S for acute focal bacterial nephritis and renal and perirenal abscessesMR: advantages in delineating extrarenal extension of inflammation
43Radionuclide Studies Gallium-67 used to distinguish some upper tract from lower tract infectionspossible mechanisms:concentration within labeled PMNsleakage of protein-bound gallium through capillariesincreased vascularity of the lesioncan see focal bacterial nephritis and infected renal cystsIndium-111Indium 111–labeled WBC accumulate only in sites of inflammation and not in normal kidneys or tumors- highly specific for inflammation
45Efficacy of the antimicrobial therapy is critically dependent on: - The antimicrobial levels in the urine- The duration that this level remains above the minimalinhibitory concentration of the infecting organismResolution of infection is closely associated with the susceptibility of the bacteria to the concentration of the antimicrobial agent achieved in the urineThe concentration of the antimicrobial agent achieved in blood is not important in treatment of uncomplicated UTIs.
46In renal insufficiency, dosage modifications are necessary for agents that are cleared primarily by the kidneysIn renal failure, the kidneys may not be able to concentrate an antimicrobial agent in the urine; →difficulty in eradicating bacteria may occur.A decision regarding the antimicrobial selection and the duration of therapy must consider:- The spectrum of activity of the drug against the pathogen- Uncomplicated or complicated,- Potential adverse effect- Cost.
47Bacterial Resistance Inherited chromosomal resistance Exists in a bacterial species because of the absence of the proper mechanism on which the antimicrobial agent can act.Proteus and Pseudomonas species are always resistant to nitrofurantoin .
48Acquired chromosomal resistance Selection of resistant mutants within the urinary tract during therapyResistant organism (clone) was present before, but only in one per 105 to 1010 organismsThe remainder of the bacteria, which are susceptible to the administered antimicrobial agent, will be eradicated by therapy, but within 24 to 48 hours a repeat urine culture will show high bacterial counts of the resistant mutant.This phenomenon is most likely to occur when the antimicrobial level in the urine is close to or below the minimal inhibitory concentration of the drug
49Extrachromosomal-mediated resistance Acquired and transferable via plasmids, which contain the genetic material for the resistance, called R-factor resistanceMuch more commonProduces multiply resistant strains, making therapy more difficultOccurs only in the fecal flora, never within the urinary tractPatients previously exposed to β-lactams, aminoglycosides, sulfonamides, TMP, and tetracycline will often have R-factor resistance to both the antimicrobial agent to which the bacteriawere exposed and also to other antimicrobial agents.
50Production of β-lactamase- Mechanisms of Drug ResistanceMechanism of ActionDrug or Drug ClassProduction of β-lactamase-- Alteration in binding site of penicillin-binding protein- Changes in cell wall porin size (decrease penetration)Inhibition of bacterial cell wall synthesisβ-Lactams penicillins, cephalosporins, aztreonam- Mutation in DNA gyrase binding siteActive effluxInhibition of bacterial DNA gyraseQuinolones- Downregulation of drug uptake into bacteria- Bacterial production of aminoglycoside-modifying enzymesInhibition of ribosomal protein synthesisAminoglycosides- Not fully elucidated-develops slowly with prolonged exposureInhibition of several bacterial enzyme systemsNitrofurantoinDraws folate from environment (enterococci)Antagonism of bacterial folate metabolismTrimethoprim-sulfamethoxazoleEnzymatic alteration of peptidoglycan targetInhibition of bacterial cell wall synthesis (at different point than β-lactams)Vancomycin
51Antimicrobial Formulary Reliable Coverage of Antimicrobials Used in the Treatment of UTIs of Commonly Encountered Pathogens :Gram-Negative PathogensGram-Positive PathogensAntimicrobial Agent or ClassEscherichia coliProteus mirabilisStreptococcusEnterococciAmoxicillin or ampicillinP. mirabilisHaemophilus influenzae, Klebsiella speciesStaphylococcus (not MRSAEnterococci)Amoxicillin with clavulanateE. ColiP. MirabilisKlebsiella speciesStaphylococcus (not MRSA)First-generation cephalosporinsE. coli, P. mirabilisSecond-generation cephalosporins (cefamandole, cefuroxime , cefaclor )Most, excluding P. aeruginosaThird-generation cephalosporins (ceftriaxone)Most, including P. aeruginosaThird-generation cephalosporins (ceftazidime )
52Gram-Negative Pathogens Gram-Positive Pathogens Antimicrobial Agent or ClassMost, including P. aeruginosaStaphylococcus (urine)AminoglycosidesStreptococcus*FluoroquinolonesMany Enterobacteriaceae (not Providencia, Serratia, Acinetobacter)Klebsiella speciesStaphylococcus (not MRSA)EnterococciNitrofurantoinMost Enterobacteriaceae (not P. aeruginosa)StreptococcusStaphylococcusTrimethoprim-sulfamethoxazoleNoneAll, including MRSAVancomycin
55ANTIMICROBIAL PROPHYLAXIS FOR COMMON UROLOGIC PROCEDURES
56Host Factors That Increase the Risk of Infection Advanced ageAnatomic anomaliesPoor nutritional statusSmokingChronic corticosteroid useImmunodeficiencyChronic indwelling hardwareInfected endogenous/exogenous materialDistant coexistent infectionProlonged hospitalization
57Urethral Catheterization and Removal The risk of infection after one-time urethral catheterization is 1% to 2% in healthy domiciliary womenProlonged use of an indwelling urethral catheter in hospitalized patients ↑ risk of bacterial colonization- 3% to 10% incidence of bacteriuria per catheter day- 100% incidence of bacteriuria with long-term (>30 days)Prophylactic administration of antimicrobial agents during catheterization is not generally recommended because ofbacterial resistance
61Special Considerations Patients with Risk of EndocarditisThe urinary tract is the second most common site of entry of organisms that cause endocarditis.The risk of endocarditis after urologic procedures is lowEnterococcus faecalis (enterococci) is the most common organism causing endocarditis after urologic proceduresProphylaxis is recommended for both high- and moderate-risk patients.
62Prophylaxis should be initiated for urologic procedures, including - obstructed urinary tract- prostatic surgery- urinary reconstruction with intestine- percutaneous renal surgery- cystoscopy, and urethral dilation
63Moderate-risk patients include other congenital malformations
67Uncomplicated Cystitis Risk Factors for UTIsurethral stricture, foreign body (calculus)Reduced Urine FlowNeurogenic bladderOutflow obstruction, prostatic hyperplasia, prostatic carcinoma,Promote ColonizationInadequate fluid uptake (dehydration)Spermicide-increased bindingSexual activity-increased inoculationAntimicrobial agents-decreased indigenous floraEstrogen depletion-increased bindingFacilitate AscentCatheterizationResidual urine with ischemia of bladder wallUrinary and Fecal incontinence
68Clinical Presentation Dysuria, frequency or urgency, and suprapubic pain Hematuria or foul-smelling urine may develop.Fever, chills, and other signs of dissemination are not present. (superficial infection of bladder mucosa),suprapubic tendernesscausative organism :75% to 90% E. coli10% to 20% S. saprophyticus,
69Laboratory Diagnosis pyuria : sensitivity 95% and specificity 70%. pyuria : sensitivity 95% and specificity 70%.bacturia : sensitivity 40-70% and specificity %,Dipsticks: nitrite or leukocyte esteraseUrine culture -/+
701 double-strength tablet (160-800 mg) ManagementAntimicrobial SelectionDuration (days)Frequency per doseDosage (mg)DrugRouteCircumstancesWomen3BIDQD500 mg1 double-strength tablet ( mg)400 mgCiprofloxacinLevofl oxacinTMP-SMXNorfloxacinOralHealthy7As aboveTMP-SMX or FluoroquinoloneSymptoms for >7 days, recent UTI, age >65 yr, diabetes, diaphragm useTIDQID250 mgAmoxicillinCephalexinNitrofurantoin macrocrystalsTMP-SMX*PregnancyMenFluoroquinoloneHealthy and age <50 yr
72 young asymptomatic → no Follow-up. older women or men → urinalysis, and urine culture
73Asymptomatic Bacteriuria Women : Two consecutive voided urine specimens with isolation of the same bacterial strain in quantitative counts of 105 cfu/mLMen: A single clean-catch voided specimen with similar counts is adequate.Catheter : A single catheterized urine specimen with a solitary isolate with a quantitative count of 102 cfu/mL identifies bacteriuria in women or men
74Prevalence of Asymptomatic Bacteriuria in Selected Populations Elderly persons in a long-term care facility25-50 Women14-50 MenPatients with spinal cord injuries23-89 Intermittent catheter use57Sphincterotomy and condom catheter in placePatients with indwelling catheter use9-23 Short-term100 Long-termPrevalence, %PopulationHealthy, premenopausal womenPregnant womenPostmenopausal women aged yearsDiabetic patients9.0-27 Women0.7-11 MenElderly persons in the community3.6-19 28Patients undergoing hemodialysis
75Screening for and Treatment of Asymptomatic Bacteriuria Management :ObservationScreening for and Treatment of Asymptomatic BacteriuriaNot recommendedPremenopausal nonpregnant womenRecommendedPregnant womenDiabetic womenOlder persons residing in the communityElderly institutionalized subjectsSubjects with spinal cord injuriesPatients with indwelling urethral cathetersUrologic interventionsImmunocompromised patients and transplant patients
76Complicating Host Factors Complicated Cystitisinfection in a compromised urinary tract or caused very resistant pathogen .Complicating Host FactorsFunctional/structural abnormalities of urinary tractRecent urinary tract instrumentationRecent antimicrobial agent useDiabetes mellitusImmunosuppressionPregnancyHospital-acquired infection
77Recommended Empirical Treatment Mitigating Circumstances Treatment of Complicated UTIsRecommended Empirical TreatmentMitigating CircumstancesCommon PathogensOral* norfloxacin , ciprofloxacin, or ofloxacin for daysMild-to-moderate illness, no nausea or vomiting-outpatient therapyE. coli, Proteus species, Klebsiella species, Pseudomonas species, Serratia species, enterococci, staphylococciParenteral† ampicillin and gentamicin, ciprofloxacin, levofloxacin , ceftriaxone, aztreonam , ticarcillin-clavulanate or imipenem-cilastin until fever gone; then oral* trimethoprim-sulfamethoxazole, norfloxacin , ciprofloxacin, or levofloxacin for daysSevere illness or possible urosepsis- hospitalization required
78Unresolved UTIsBody_ID: HC008102inadequate initial therapy eliminate symptoms and/or bacterial growth in the urinary tract.Causes of Unresolved Bacteriuria, in Descending Order of ImportanceBacterial resistance to the drug selected for treatmentDevelopment of resistance from initially susceptible bacteriaBacteriuria caused by two different bacterial species with mutually exclusive susceptibilitiesRapid reinfection with a new, resistant species during initial therapy for the original susceptible organismAzotemiaPapillary necrosis from analgesic abuseGiant staghorn calculi in which the "critical mass" of susceptible bacteria is too great for antimicrobial inhibitionSelf-inflicted infections or deception in taking antimicrobial drugs (a variant of Munchausen's syndrome)Initial empirical antimicrobial agent different from the original agent Fluoroquinolones for 7 days.
79Recurrent UTIs Bacterial persistence : Reemergence of bacteria from a site within the urinary tract (bacterial persistence) or new infections from bacteria outside the urinary tract (reinfection).Bacterial persistence :Caused by the same organismClose intervalsCured by identification, removal or correction of the focus
80Correctable Urologic Abnormalities That Cause Bacterial Persistence Unilateral medullary sponge kidneysInfection stonesNonrefluxing, normal-appearing, infected ureteral stumps after nephrectomyChronic bacterial prostatitisInfected urachal cystsUnilateral infected atrophic kidneysInfected communicating cysts of the renal calycesUreteral duplication and ectopic uretersPapillary necrosisForeign bodiesPerivesical abscess with fistula to bladderUrethral diverticula and infected periurethral glands
81Reinfections : Caused by different species. Long intervals No an alterable urologic abnormality → medical management.women and girls : ascending from the bowel flora.Men: associated with a urinary tract abnormality.Risk factorsFistula,Evidence of upper tract infectionsAnalgesic abuseHistory of unexplained hematuria,Severe diseaseObstructive symptoms,Diaphragm-spermicideNeurogenic bladder dysfunction,Postmenopausal women,Renal calculi,
82Antimicrobial management : Indicated in women ≥ 2 UTIs over 6-month or ≥ 3 UTIs within a 12-month involves:Low-dose continuous prophylaxis,Self-start intermittent therapyPostintercourse prophylaxis.
83Low-Dose Continuous Prophylaxis: Oral antimicrobial agents with minimal adverse effects on the bowel and vaginal flora and do not cause bacterial resistance(1) Nitrofurantoin, 50 to 100 mg half-strength (HS)(2) TMP-SMX, 40 to 200 mg(3) TMP, 50 mg(4) Keflex, 250 mgMonitoring for infections every 1 to 3 months, even in asymptomatic patients.Breakthrough infections usually respond to full-dose therapy with the drug used for prophylaxis
84Self-Start Intermittent Therapy The patient is given a dip slide device to culture the urine and is instructed to perform a urine culture when symptoms of UTI occurA broad spectrum antibiotics with minimal or no side effects on the bowel flora.Fluoroquinolones are idealPost-intercourse ProphylaxisNitrofurantoin, Cephalexin, TMP-SMX, or a fluoroquinolone taken as a single dose, will effectively reduce the incidence of reinfection
87Acute Pyelonephritis Clinical Presentation: Laboratory Diagnosis: Abrupt onset of chills, fever (100° F or greater)unilateral or bilateral flankAccompanied by dysuria, increased urinary frequency, and urgency.Laboratory Diagnosis:Blood tests:leukocytosis with a predominance of neutrophils,↑ESR↑ C-reactive protein levelselevated creatininecreatinine clearance may be decreased.Blood cultures may be positive.( 25% uncomplicated )
88- Gram-positive bacteria rarely cause pyelonephritis. Urinalysis usually :The presence of large amounts of granular or leukocyte casts in the urinary sediment is suggestive of acute pyelonephritis.Bacteriology:- E. coli 80% of cases.- Proteus, Klebsiella, Pseudomonas, Serratia, Enterobacter, or Citrobacter should be suspected in patients with recurrent UTIs, are hospitalized, or have indwelling catheters, as well as in those who required recent urinary tract instrumentation- Gram-positive bacteria rarely cause pyelonephritis.Brightfield micrograph of a mixed bacterial leukocyte cast from patient with acute pyelonephritis. Only the bacteria and the nucleus of a leukocyte stain strongly. Many bacteria are clearly demonstrated by through-focusing (toluidine blue O stain, magnification ×640). (From Lindner LE, Jones RN, Haber MH: A specific urinary cast in acute pyelonephritis. Am J Clin Pathol 1980;73: )
89Radiologic Findings: Excretory Urogram: Renal enlargement, (most common)An overall length of 15 cm or a length 1.5 cm greater than the unaffected side has been established as a criterion for the diagnosis of renal enlargement in acute pyelonephritisThe calyces have an attenuated or spidery appearance.Calyceal and ureteral dilation (the bacte-rial endotoxins that impair ureteral peristalsis).A, Excretory urogram. Ten-minute film demonstrates enlarged right kidney with minimum function. Findings are consistent with edema. B, Ultrasound of the right kidney demonstrates renal enlargement, hypoechoic parenchyma, and compressed central collecting complex (arrows). (From Schaeffer AJ: Urinary tract infections. In Gillenwater JY, et al [eds]: Adult and Pediatric Urology. Philadelphia, Lippincott William & Wilkins, 2002, pp )
90Renal Ultrasonography and Computed Tomography: used :Complicated UTIsNot respond after 72 hours of therapyRenal enlargement,Hypoechoic or attenuated parenchyma and a compressed collecting system.
91Pathology :The parenchyma shows a focal, patchy infiltrate of neutrophils.Bacteria are often in the infiltrate.Early: limited to the interstitiumLater: linear bands extend from the papillae to the cortexAbscesses may cause tubular destruction;The glomeruli are usually spared.
92Management: Initial Management. Subdivided into : (1) Uncomplicated infection : Not warrant hospitalization(2) Uncomplicated infection : Ill patient with normal urinary tractswarrant hospitalization(3) Complicated infection : Associated with hospitalization,catheterization, urologic surgery,or urinary tract abnormalities
93Risk factors associated with increased risk of death or hospitalization: Advanced age,Septic shock,Bedridden status,Immunosuppression,Recent antibiotic use,Diabetes mellitus,Long-term urinary catheterizationA change in initial antimicrobial therapy
95Duration (days) Frequency per Dose Dosage Drug Route Circumstances 10-14BID160 to 800 mgTMP-SMXOralOutpatient-moderately ill, no nausea or vomiting 7500 mgCiprofloxacinQDLevofloxacin400 mgNorfloxacin14ParenteralInpatient-severely ill, possible sepsisTID1 g1.5 mg/kgAmpicillin and gentamicin1 to 2 gCeftriaxoneTake until afebrile, then take oral TMP-SMX or fluoroquinolonePregnantAztreonamTID-QIDTake until afebrile, then take:Cephalexin
96Acute Focal or Multifocal Bacterial Nephritis An uncommon, severe form of acute renal infection in which a heavy leukocyte infiltrate is confined to a single renal lobe (focal) or multiple lobes (multifocal).Clinical Presentation:Similar but more severe.50% of the patients are bacteremic
97Radiologic Findings: IVP : Poorly marginated mass The mass has slightly less nephrographic density than the surrounding normal renal parenchyma.Ultrasonography :poorly marginated sonolucent with low-amplitude echoes that disrupt the cortical medullary junctionCT contrast :Wedge-shaped areas of decreased enhancementAcute focal bacterial nephritis. A, Excretory urogram. Five-minute tomogram demonstrates normally functioning upper and lower poles and a poorly marginated midrenal mass with poor function and absent collecting system visualization. B, Ultrasound; longitudinal view of the left kidney demonstrates spleen (S) and left kidney (arrows). Note irregular midpole mass (M) of slightly higher echo texture than surrounding normal renal parenchyma. C, Contrast medium-enhanced CT scan demonstrates a wedge-shaped area of low density (arrows) in the middle portion of the left kidney. The findings resolved after antimicrobial therapy.
98Management:Hydration and IV antimicrobial agents for at least 7 days, followed by 7 days of oral antimicrobial therapy.Follow-up studies will show resolution of the wedge-shaped zones of diminished attenuation.Failure to respond to antimicrobial therapy :Rule out obstructive uropathy,Renal or perirenal abscess,Renal carcinomaAcute renal vein thrombosis.
99Emphysematous Pyelonephritis An acute necrotizing parenchymal and perirenal infection caused by gas-forming uropathogens.Considered a complication of severe pyelonephritis rather than a distinct entity.Pathogenesis:Usually occurs in diabetic patients,High tissue glucose levels provide the substrate for microorganisms such as E. coli, which are able to produce carbon dioxide by the fermentation of sugar.Impaired host response caused by local factors, such as obstruction, or a systemic condition, such as diabetes, allows organisms producing carbon dioxide to use necrotic tissue to generate gas
100Clinical Presentation: Severe, acute pyelonephritisA chronic infection precedes the acute attack. Some timeClassic triad:FeverVomitingFlank painPneumaturia is absent unless the infection involves the collecting system.
101The diagnosis is established radiographically. Radiologic Findings:The diagnosis is established radiographically.KUB:A crescentic collection of gas over the upper pole of the kidneyGas extends to the perinephric space and retroperitoneum. (progression)Emphysematous pyelitis Vs pyelonephritisAir is in the collecting systemSecondary to a gas-forming bacterial UTI,Nondiabetic patientsplain film. Extensive perinephric (long arrows) and intraparenchymal (short arrows) gas secondary to acute bacterial pyelonephritis. (From Schaeffer AJ: Urinary tract infections
102Not recommended (abnormal renal function) Excretory urographyNot recommended (abnormal renal function)UltrasonographyFocal echoes suggesting the presence of intraparenchymal gasCT scan:Define the extent of the emphysematous process and guiding managementA nuclear renal scanAssess the degree of renal function impairmentA, CT scan of the right kidney shows complete destruction with gas (arrowheads) extending beyond the renal fascia. B, CT scan with a modified lung window display shows the characteristic streaky gas in the completely destroyed kidney. The patient died on arrival in the emergency department.
103Management : Emphysematous pyelonephritis is a surgical emergency. Most patients are septicFluid resuscitation and broad-spectrum antimicrobial therapyFunctioning kidney:Medical therapy can be considered.Nephrectomy if not improve after a few days of therapyNonfunctioning kidney:Not obstructed → nephrectomy.Obstructed → catheter drainageIf improved → nephrectomy may be deferred
104Renal Abscess Clinical Presentation A collection of purulent material confined to the renal parenchyma.Hematogenous gram-positive abscess (past)Gram-negative organisms (majority)Ascending infection associated with tubular obstruction from prior infections or calculi appears to be the primary pathwaypredisposing factors:Complicated UTIs associated with stasis, calculi, pregnancy, neurogenic bladder, and diabetes mellitusClinical Presentation fever, chills, abdominal or flank pain,and occasionally weight loss and malaise.
105Radiologic Findings : Ultrasonography : low-echodensity space-occupying lesion with increased transmissionAcute renal abscess. Transverse ultrasonographic scan of the right kidney demonstrates a poorly marginated rounded focal hypoechoic mass (arrows) in the anterior portion of the kidney
106- Renal enlargement and focal, rounded areas of decreased attenuation CT contrast scan:Initially :- Renal enlargement and focal, rounded areas of decreased attenuationLater :- A thick fibrotic wall begins to form around the abscess.Acute renal abscess. Nonenhanced CT scan through the mid pole of the right kidney demonstrates right renal enlargement and an area of decreased attenuation (arrows). After antimicrobial therapy, a follow-up scan showed complete regression of these findings.
107- Obliteration of adjacent tissue planes Chronic:- Obliteration of adjacent tissue planes- Thickening of Gerota's fascia- A round or oval parenchymal mass of low attenuation- The ring sign is caused by the increased vascularity of the abscess wallChronic renal abscess. A, Enhanced CT scan shows an irregular septated low-density mass (M) extensively involving the left kidney. Note thickening of perinephric fascia (arrowheads) and extensive compression of the renal collecting system. Findings are typical of renal abscess. B, Ultrasound longitudinal scan demonstrates a septated hypoechoic mass (M) occupying much of the renal parenchymal volume
108Management :The classic treatment for an abscess has been percutaneous or open incision and drainage (>5 cm)Evidence that the intravenous use of antimicrobial agents and careful observation of a small abscess less than 3 cm in diameterCT- guided needle aspiration may be necessary to differentiate an abscess from a hypervascular tumor.Empirical antimicrobial therapy
109Hematogenous:penicillin , cephalosporin or vancomycin.Gram-negativeThird-generation cephalosporins, antipseudomonal penicillins, or aminoglycosides≥5 cm in immunocompromised hosts or those that do not respond to antimicrobial therapy should be drained percutaneously
110Infected Hydronephrosis and Pyonephrosis Infected hydronephosis :Bacterial infection in a hydronephrotic kidney.pyonephrosis :Infected hydronephrosis associated with suppurative destruction of the parenchyma of the kidney with loss of renal functionClinical Presentation : Very ill ppatient,High fever, chills, flank pain, and tenderness.History of urinary tract calculi, infection, or surgery is common.Pyonephrosis-gross specimen. The kidney shows marked thinning of the renal cortex and medulla, suppurative destruction of the parenchyma (arrows), and distention of the pelvis and calyces. Previous incision released a large quantity of purulent material. The ureter showed obstruction distal to the point of section
111Radiologic Findings U/S : Infected hydronephrosis: U/S :Infected hydronephrosis:internal echoes within the dependent portion of a dilated pyelocalyceal system.pyonephrosis :Focal areas of decreased echogenicity are seen within the hydronephrotic parenchyma.Pyonephrosis. A, Longitudinal ultrasound scan of the right kidney demonstrates echogenic central collecting complex (C) with radiating echogenic septa (arrows) and thinned hypoechoic parenchyma. Multiple dilated calyces (o) with diffuse low-level echoes are seen.
112Management : Antimicrobial drugs and drainage of the infected pelvis. A ureteral catheter to drain the kidneyPercutaneous nephrostomy tube insertion.
113Perinephric Abscess Route : Rupture of an acute cortical abscess into the perinephric spaceHematogenous seeding from sites of infection.Bowel perforation,Crohn's diseaseSpread of osteomyelitis from thethoracolumbar spineE. coli, Proteus, and S. aureus account for most infections
114paranephric abscess:A perinephric infection ruptures through Gerota's fascia into the pararenal spaceLeft, Normal anatomic relationships of structures surrounding the kidney. Right, Anatomic differences seen in subcapsular (A) and perirenal (B) processes. In perirenal abscesses, the abscess fluid extends outside the renal capsule, thus causing the capsular artery and renal fascia to deviate away from the kidney. These findings may be seen in radiologic studies.
115Clinical Presentation : Similar to that of pyelonephritisOne third of patients may be afebrile.An abdominal or flank mass.Should be suspected in a patient with UTI and abdominal or flank mass or persistent fever after 4 days of antimicrobial therapy.Laboratory features :Leukocytosis,↑creatinine,.Urine culturesBlood culture
116Radiologic Findings :Nonenhanced CT scan through the lower pole of the right kidney (previous left nephrectomy) shows extensive perinephric abscess. Extensive abscess (A) distorts and enlarges the renal contour, infiltrates perinephric fat (straight arrows), and also extends into the psoas muscle (asterisk) and the soft tissues of the flank (curved arrow). Also note that normal renal collecting system fat has been obliterated by the process.Perinephric abscess involving the right adrenal gland. CT scan shows large right pararenal mass (arrows) with multiple low-density areas within. At surgery, a large pararenal abscess with extensive involvement of the right adrenal was found.
117Management :The primary treatment for perinephric abscess is drainage Vs nephrectomyPercutaneous drainage contraindicated in large abscess cavities filled with thick, purulent fluid.Antimicrobial therapy.An aminoglycoside together with an antistaphylococcal agent
118Chronic Pyelonephritis Clinical Presentation : No symptoms until →renal insufficiency,Symptoms of chronic renal failure.History of recurrent of acute pyelonephritis,Intermittent symptoms of fever, flank pain, and dysuria may beelicited.
119Radiologic Findings : pyelographic findings Asymmetry and irregularity of the kidney outlines,Blunting and dilation of calycesCortical scarsIn advanced pyelonephritis,Calyceal distortion and irregularity together with cortical scars complete the picture.Chronic pyelonephritis. Ten-minute excretory urogram demonstrates irregular renal outline with upper pole parenchymal atrophy. Note significant loss of renal cortical thickness over blunted and dilated calyces. Lower pole mass (M) is a simple cyst. (From Schaeffer AJ: Urinary tract infections.
120Pathology : Gross:kidney is often diffusely contracted, Y-shaped scar, and pitted.The parenchyma is thin, and the corticomedullary demarcation is lost.Histology:An interstitial infiltrate of lymphocytes, plasma cells, and occasional polymorphonuclear cells. Portions of the parenchyma replaced by fibrosis,Periglomerular fibrosisAtrophied tubules with Leukocyte and hyaline casts
121Management :Treating infection, if present; ( prolonged AB)Preventing future infections; andMonitoring and preserving renal function.Antimicrobial prolongedUnderlying renalNephrologic and urologic evaluation
122Xanthogranulomatous Pyelonephritis A rare, severe, chronic renal infection typically resulting in diffuse renal destruction.Unilateral nonfunctioning, enlarged kidney associated with obstructive uropathy secondary to nephrolithiasis.Characterized by accumulation of lipid-laden foamy macrophagesIt begins within the pelvis and calyces and subsequently extends into and destroys renal parenchymal and adjacent tissues.It has been known to imitate virtually every other inflammatory disease of the kidney, as well as renal cell carcinoma, on radiographic examination
123Pathogenesis :Nephrolithiasis(1ry factor) → obstruction + infection → tissue destruction and collections of lipid material by macrophages .These macrophages (xanthoma cells) are distributed in sheets around parenchymal abscesses and calyces and are intermixed with lymphocytes, giant cells, and plasma cells.Other possible interrelated factors include:Venous occlusion and hemorrhage,Abnormal lipid metabolism,Lymphatic blockage,Failure of antimicrobial therapy in UTI,Altered immunologic competence,Renal ischemia
124Histology :The parenchyma contains dark sheets of lipid-laden macrophages (foamy histiocytes with small, dark nuclei and clear cytoplasm) intermixed with lymphocytes, giant cells, and plasma cellsXanthogranulomatous pyelonephritis. A, Gross specimen. Kidney is massively enlarged, measuring 23 × 12 cm; the normal architecture is replaced by a shaggy yellow upper pole mass corresponding to xanthogranulomatous inflammation and numerous distorted and dilated calyces. B, Microscopically, the shaggy yellow tissue is composed primarily of lipid-laden histiocytes mixed with other inflammatory cells. (From Schaeffer AJ: Urinary tract infections.
125Clinical Presentation : Flank pain (69%),Fever and chills (69%),Persistent bacteriuria (46%)Flank mass (62%) Classic triad :Unilateral renal enlargementPoor functionA large calculus in the renal pelvis Bacteriology and Laboratory DiagnosisProteus is the most common organismAzotemia or frank renal failure is uncommon
126Radiologic Findings : CT scan: (most useful) A large, reniform mass with the renal pelvis tightly surrounding a central calcification but without pelvic dilatation99mTc-DMSA :confirm and quantify the differential lack of function in the involved kidney Xanthogranulomatous pyelonephritis. Enhanced CT scan shows collecting system and parenchymal calculi (straight arrows) with lower pole pyonephrosis (curved arrow) and an irregular, predominantly low-density perinephric abscess (A) extending into the soft tissues of the flank
127Management :Primary obstacle to treatment of XGP is incorrect diagnosisXGP + hydronephrosis looks just like pyonephrosisUsually post-operative diagnosisRCC is usual pre-op diagnosis, so nephrectomy performed- If localized, may be amenable to partial nephrectomy.Xanthoma cells resemble clear cell adenocarcinoma difficult to distinguish on frozen sectionDo nephrectomy if can't exclude malignancy
128Antibiotics may be necessary to stabilize the patient preop If diffuse and extensive disease goes to retroperitoneum, must remove of the kidney and perinephric fat- Dissection of granulomatous tissue from the diaphragm, great vessels, and bowel- Remove entire mass, as tissue infected in ¾ of ptsif I&D alone, illness may persist, or develop reno-cutaneous fistula
130 Bacteremia: The presence of viable bacteria in the blood. Systemic inflammatory response syndrome (SIRS):Extremes of body temperature, heart rate, ventilation, and immune response.SIRS can occur in response to multiple insults including systemic infection, trauma, thermal injury or a sterile inflammation.
131Sepsis:A clinical syndrome characterized by extremes of body temperature, heart rate, respiratory rate, and WBC count that occurs in response to an infection.Sepsis occurs when a local infectious process becomes an uncontrolled systemic bloodborne inflammatory response resulting in damage to tissues or organs remote from the initial site of infection or injury Septic shock:An extreme form of sepsis complicated by organ dysfunction and persistent circulatory failure despite fluid and pharmacologic resuscitation.
132Pathophysiology: Bacterial Cell Wall Components in Septic Shock The exotoxins (P. aeruginosa)Bacterial cell wall components → innate immunologic pathways (macrophages, neutrophils, and dendritic cells and the complement system).The endotoxin (G – tive) :An LPS component → the coagulation, complement, and fibrinolytic systems→ release of small molecules that cause vasodilation and ↑ endothelial permeability
133Cytokine Network :Monocytic cells have a role in mediation of the biologic effects of SIRS and septic shock.Monocytes can remove and detoxify LPS However, LPS-stimulated monocytes produce cytokines such as tumor necrosis factor (TNF) and interleukin (IL)-1.The intravascular activation of inflammatory systems involved in septic shock is mainly the consequence of an overproduction of these and other cytokines.
134Clinical Presentation and Diagnosis: Early signs of the sirs include:- Temperature extremes (>38° C [100.4° F] or <36° C [96.8 ° F]),- Tachycardia (heart rate > 90 beats per minute),- Tachypnea- Altered mental status.
135Characteristics of Sepsis Fever (core temperature >38.3° C)Hypothermia ( core temperature <36)Heart rate > 90, 1or 2 SD above the normal value for age.TachypneaAltered mental stateSignificant edema or positive fluid balance (20mg\kg over 24h)Hyperglycemia plasma sugar >120mg\dl or 7.7 mol\l in absence of diabetesGeneralLeukocytosis (WBC count >12,000/μL)Leukopenia ( WBC count < 4000/µL)Normal WBC count with >10% immature formsinflammatoryArterial hypoxemia (PaO2/FIO2 >300)Acute oligouria (urine output 0.5 Ml\kg in 1hr for at least 2 hrs)Creatinine increase 0.5mg\dlCoagulation abnormalities ( INR 1.5 or aptt >60 sec)Illus absent bowel soundThrombocytopenia ( platelets <100,000µL)Hyperbilirubinemia ( plasma bilirubin >4mgdl or 70 mmol/L)Organ dysfunctionHyperlactatemia (>1 mmol/L)Decreased capillary refill or mottlingTissue perfusion
136Bacteriology : The classic findings of septic shock : - Peripheral vasodilation, and ↓ SVR- A warm patient,- Brisk capillary refill- A bounding pulse- Hypotension, oliguria, or ileus- ↓↑WBC, hyperbilirubinemia, hyperlactatemia, hyperglycemia,coagulation abnormalities, and elevated C reactive protein andrespiratory alkalosis due to hyperventilation.Bacteriology :Gram-negative 30% to 80% of cases mainly E.coliGram-positive 5% to 24% of cases
137Management : Resuscitation, vasoactive(phenylephrine) Supportive care, monitoring,Administration of broad-spectrum antimicrobial agents (aminoglycoside+/-)Antimicrobial treatment should be continued until the patient has been afebrile for 3 to 4 days and is clinically stable. Human activated protein C (Drotrecogin alfa)It reduces mortality in sepsisAn inhibitor of multiple inflammatory and coagulation pathway components:The inhibition of the coagulation factors Va and VIIIa,Inhibition of macrophage production of TNF,limitation of thrombin-induced inflammationinhibition of plasminogen activator inhibitor
139The most common hospital-acquired infection Accounting for up to 40% and ≥1 million per yearThe incidence of bacteriuria :10% per day of indwelling catheterization.1% in healthy individuals and 15% in elderly hospitalizedpatients for Intermittent catheterization
140risk factors : Duration of catheterization, Female gender, Absence of systemic antimicrobial agents,Catheter-care violations
141Clinical Presentation : A symptomatic.Symptomatic.Suprapubic discomfort ,fever, chills, or flank pain Laboratory Diagnosis Significant bacteriuria if >100 cfu/mL
142Management :Careful aseptic insertion of the catheter and maintenance of a closed dependent drainage system are essential to minimize development of bacteriuria.The catheter-meatal junction should be cleaned daily with waterIncorporation of silver oxide or silver alloy into the catheter and hydrogen peroxide into the drainage bag has been reported to decrease the incidence of bacteriuria in some studies but not in other populations.
143Patients with indwelling catheters should only be treated if they become symptomatic (e.g., febrile).Urine cultures should be performed before initiating antimicrobial therapy.Empirical antimicrobial therapy such as TMP-SMX or a fluoroquinolone before de-catheterization for 2 days. A post-therapyCulture should be obtained 7 to 10 days later to confirm the eradication of the bacteriuria.
144MANAGEMENT OF UTI IN PATIENTS WITH SPINAL CORD INJURY
145Epidemiology :UTIs are among the most common urologic complications of spinal cord injury.33% of spinal cord-injured patients have bacteriuria at any time.patients on CIC or condom catheterization:18 episodes of bacteriuria per person per year1.8 per person per year of febrile UTIs
146risk factors impaired voiding, overdistention of the bladder, elevated intravesical pressure,increased risk of urinary obstruction,vesicoureteral reflux,instrumentationincreased incidence of stones.decreased fluid intakepoor hygiene,perineal colonization,local tissue traumareduced host defense associated with chronic illness
147Clinical Presentation : The majority of patients are asymptomaticUTI is the most common cause of fever in spinal cord-injuredFlank, back, or abdominal discomfort, leakage between catheterizations, increased spasticity, malaise, lethargy, and/or cloudy, malodorous urine.Bacteriology and Laboratory Diagnosis Urinalysis : bacteriuria and pyuria. E. coli is isolated in approximately 20% of patients.Enterococci, P. mirabilis, and Pseudomonas are more common among spinal cord-injured patients than patients with intact spinal cords.Other common organisms are Klebsiella species, Serratia species, Staphylococcus, and Candida species.
148Management :urine culture must be obtained before initiating empirical therapy. (diverse flora + resistance)
149No clinical improvement UTI in Pt with spinal cor injuryFebrile UTIadmitted and treated with a parenteral aminoglycoside and a penicillin or a third-generation cephalosporin for24-48 hNo clinical improvement- reculture and adjustment of antimicrobial therapy imaging urodynamicclinical improvementAfebrile UTI- oral fluoroquinolone β-Lactams, TMP-SMX, and nitrofurantoin are not recommended because of bacterial resistanceAn indwelling catheter should be change