4Urinary Tract Infection definition Pathogenic microorganisms in urine, urethra, bladder, kidney, prostateUsually growth > 105 organisms per milliliter
5Urinary Tract Infection LowerurethritiscystitisprostatitisUpperpyelonephritisintrarenal and perinephric abscess
6categorized in to Non-catheter associated (commum. acquired) Catheter associated (hosp. acquired)ORComplicated UTIUncomplicated UTI
7categorization Uncomplicated UTI Complicated UTI Young women without underlying U.T or systemic diseaseComplicated UTIMales,children,chronicly catheterized ,women with recurrent infection, urologic abnormality ,underlying disease:More resistant to A.B
11UTI Etiology Majority of UTI are due to a single pathogen The Enterobacteriaceae responsible for 90% of all UTI - gram negative bacilli - facultatively anaerobic - common intestinal floraEscherichia coli most commonly isolated pathogen ~80% of all UTI
12Pathogenesis and route of transmission Organisms usually enter the urinary tract by;Direct or ascending route; via the urethra to the urinary bladder and the kidney where they multiply and produce toxins,.
13Pathogenesis and route of transmission 2.Blood(hematogenous) from septic focus causing bacteremia and UTI.Staph.aureus bacteremia or endocarditisrarely Gr - bacilli
14:Outpatint,Acute infection Escherichia coliE. coli (serotypes: 02, O4, O6) which are fimbrinated strains adhering to uro-epithelial cells, leading to colonization and infection is the commonest cause of urinary tract infections.
16:Outpatint,Acute infectio Stoph.saprophiticus Coagulase (-) staph. , novobiocin resistanceAmong Coagulase (-) staphs it is a true UT pathogen causing both upper and lower UTIThe second most common cause of UTI representing 11-32% of UTI in female patient.
17Inpatient,recurrent UTI,structural abnormality Pseudomonas,Proteus,Klebsiella,Serratiainfections often follow catheterization and gynecological surgery (nosocomial pathogen).Infection with proteus may be complicated by phosphate stone formation as its urease leads to alkaline pH.
18Inpatient,recurrent UTI,structural abnormality Enterococci Occasionally in acute uncomplicated Cystitis
19Inpatient,recurrent UTI, structural abnormality Corynebacterium urealiticum Urea splitting bacillusImportant nosocomial path.(renal transplant,immunosupressed)Resistant to A.BSensitive to Vancomycin
20Inpatient,recurrent UTI, structural abnormality Staph.aureus Hematogenous route:intrarenal or perinephric abcesses
21Inpatient,recurrent UTI, structural abnormality Staph. Epidermidis Coagulase (-) staph. , novobiocin sensitiveUsually catheter associated and occurs in elderly patients with UT instrumentation or surgery, renal transplantation,urolithiasi and UT abnormality
22Sexually transmitted Mycoplasma hominis, M Sexually transmitted Mycoplasma hominis, M.genitalium,ureaplasma urealiticumMycoplasma hominis and ureaplasma urealiticum colonize genitourinary track of male and female from 0% to 77%, depending on age, sex, race, sexual experience and socioeconomic state.They are sexually transmitted germsThey have roles in p.p endometrit, L.B.W, prematurity and infertility.
23Sexually transmitted Mycoplasma hominis, M Sexually transmitted Mycoplasma hominis, M.genitalium,ureaplasma urealiticumUreaplasma urealyticum has frequently been isolated from the urethra and urine of patients with acute dysuria and frequency but is also found in specimens from many patients without urinary symptoms.Ureaplasmas probably account for some cases of urethritis and cystitis. U. urealyticum and Mycoplasma hominis have been isolated from prostatic and renal tissues of patients with acute prostatitis and pyelonephritis, respectively, and are probably responsible for some of these infections as well.
26Miscellaneous organisms Candida or other fungal species : commonly assoc. with cath. or DMMycobacteriaAdenoviruses :Hemoragic cystitis in children and in some young adults, often in epidemics. Although other viruses can be isolated from urine (e.g., cytomegalovirus), they are thought not to cause acute UTI.
27Predisposing conditions to UTI FemaleShort urethra, proximity to anus, termination beneath labiaSexual activityPregnancy2-3% have UTI in Pregnancy, 20-30% with asymptomatic bacteriuria may lead to pyelonephritisIncreased risk of pyelonephritis : decreased ureteral tone, decreased ureteral peristalsis, incompetence of vesicoureteral valves
28Predisposing conditions Neurogenic bladder dysfunction or bladder diverticulum (incomplete emptying)Age - Postmenopausal women with uterine or bladder prolapse (incomplete emptying), lack of estrogen, decreased normal flora, concomitant medical conditionsVesicoureteral refluxInstrumentation and surgeryChange in urine nutrients, DM, goutBacterial virulenceGenetics
30Community-Acquired UTI E.coliS.epi &gm - entericsEnterococcusProteusS.saprophyticusK.pneumoniae
31Nosocomial UTI catheter associated Short TermLong TermE.coliEnterobacterE.coliProteusEnterococcusCandidaPseudomonasEnterococcusProteusS.aureusProvidenciaS.aureusPseudomonasMorganella
32Host parasite interaction: organism Virulence factors:ClonizationInvasionUsing urine as growth medium:Synthesis of guanine arginine glutaminepathogenicity islands: multigen, duplicated gensUropathogenic Ecoli clones have certain O,K,H serotypes:O1,O2,O4,O6,O7,O8,O75,O150,O180
33Virulence factors Clonisation Clonisation =adhesive properties:Selection of bacteriainfluence severity ,anatomic and U.T level of UTI:pyelonephritis or cystitisThe attachment of bacteria to uroepithelial cells initiates a number of important events in the mucosal epithelial cell, including secretion of interleukin (IL) 6 and IL-8 (with subsequent chemotaxis of leukocytes to the bladder mucosa) and induction of apoptosis and epithelial cell desquamation.
34Virulence factors Clonisation Pilli =fimberia : filamentous surface organeles.In Ecoli:1) P.fimbriae(MR): binding to globoserries glicosphingolipid(a component of the glycocalix that surrounds epithelial cells =P blood group on RBC & E.c in U.T particularly kidney
35Virulence factors Clonisation In Ecoli:2) type 1 fimbriae(MS) : binding to mannose containing glicoproteins3) G, 1C, S fimbriae4) Dr hemagglutinin family
36Virulence factors Clonisation Other species :Proteus Mirabilis & klebseilla : similar adherence factorsS.saprophiticus adhers better to U.T than do S.aureus or S.epidermidis (uncommon cystitis & pyelonephritis)
37Virulence factors invasion Invasion factors:motilityHemolysin productionHigher quantity of K Ag (K1,K2,k3) in capsulesEndotoxinsProduction of urease (proteus)Aerobactin(iron scavenging protein)
38Comment:in presence of underlying structural abnormalities organisms lack virulence factors
39Host parasite interaction: genetics A maternal history of UTI is more often found among women who have experienced recurrent UTIs than among controls.The number and type of receptors on uroepithelial cells to which bacteria may attach are at least in part genetically determined.Many of these structures are components of blood group antigens and are present on both erythrocytes and uroepithelial cells..,
40Host parasite interaction: genetics For example, P fimbriae mediate attachment of E. coli to P-positiveb erythrocytes and are found on nearly all strains causing acute uncomplicated pyelonephritis. Conversely, P blood group–negative individuals, who lack these receptors, have a decreased likelihood of pyelonephritis.nonsecretors of blood group antigens are at increased risk of recurrent UTI; may relate to a different profile of genetically determined glycolipids on uroepithelial cells.Mutations in host genes integral to the immune response (interferon receptors and others) may also affect susceptibility to UTI
42Urethritis ? Acute dysuria, frequency Often need to suspect sexually transmitted pathogens esp. if symptoms last more than 2 days, gradual, no hematuria, no suprapubic pain, new sexual partner, cervicitis
43UrethritisApproximately 30% of women with acute dysuria, frequency, and pyuria have midstream urine cultures that show either no growth or insignificant bacterial growth. Clinically, these women cannot always be distinguished from those with cystitis.In this situation, a distinction should be made between women infected with sexually transmitted pathogens, such as C. trachomatis, N. gonorrhoeae, mycoplasma spp., or herpes simplex virus, and those with low-count E. coli or staphylococcal infection of the urethra and bladder.
44Cystitis Symptoms: frequency, dysuria, urgency, suprapubic pain Cloudy, malodorous urine (nonspec.)Leukocyte esterase positive = pyuriaNitrite positive (but not always)WBC (2-5 with Symptoms) and bacteria on urine microscopy
45PyelonephritisFeverchills, N/V, diarrhea, tachycardia, muscle tendernessCVAT or tenderness with deep abdominal tendernessPossibly signs of Gram neg. sepsis
46Pyelonephritis Leukocytosis Pyuria with leukocyte casts, and bacteria and hematuria on microscopyComplications: sepsis, papillary necrosis, ureteral obstruction, abscess, decreased renal function if scarring from chronic infection, in pregnancy – may increase incidence of preterm labor
47Catheter-Associated Urinary Tract Infections 10-15% of hosp. patients with indwelling catheter develop bacteriuriaRisk of infection is 3-5% per day of catheterizationUTI after one-time bladder cath approx. 2%Gram neg. bacteremia most significant complication of cath-induced UTIGreater antimicrobial resistance
50Diagnosis of UTI History Physical exam Lab Urinalysis with microscopic exam.Urine cultureSensitivities of culture for tailored antibiotic therapyMay diagnose acute uncomplicated cystitis based on history and Physical exam and UA alone, no need for culture to treat
51Specimen collectionSamples should be collected before the start of antibiotics.Transport within 2 h. if delay is suspected then refrigeration at 4C or boric acid.
52Specimen collection Contamination : Bacteria from vagina Perineum Indigenous flora in urethra
53Contamination Commensals Urinary tract is normally sterile, except of urethra which may contain a few commensals such as acinetobacter species, and diptheriods. Yeast may also be found in the female urethra.Contamination of the urine with skin commensals including staphylococci, dipththeroids, and mycobacterium smegmatis may occur as a specimen is being collected.In female patients, the urine may become contaminated with organisms from the vagina (epithelial cells)
55Specimen collectionClean catch mid stream specimens - most frequently used method - urethra cleaned prior to collection - first void urine allowed to pass to clear urethra - mid-stream collected in sterile containerCollection bags (children) - used in young children lacking bladder control - often contaminated - most meaningful result is a negative culture
56Specimen collectionSuprapubic aspiration / straight catheters - invasive - specimen obtained directly from bladder(full bladder)- neonates and small childrenIndwelling catheters - urine obtained by inserting needle into catheter- preferable to obtain specimen from new catheter, rather than old catheter
58Specimen collectionFor urethritis : initial portion of voided urine or a swab inserted in to distal urethra (neisseria gonorreae & clamydia )For prostatitis : prostatic secretions before & after prostatic massage.
59Specimen transportSent to and processed by lab as quickly as possible - Require: method of collection time of collection patient’s antibioticsSpecimens not received by lab in 1-2 hours MUST be refrigeratedUrines not received within 24 hours or not refrigerated will be rejected by laboratory
60U/A Microscopic examUrine sediment with or without gram stain or uncetrifuged urineCentrifuge for 5 m. at 2000 rmpExamine under high powerPyuria : 5 WBC is upper limit of normal and nonspecificBacteria : 1 in h.p.f in centrifuged stained smire = 10*5 per ml urineWBC cast : pyelonephritisHematuria : UTI, calculi, tumor, vasculitis, glumeronephritis, T.B
62Urine culture Media : combination of 5% blood agar & MacConkey agar In ambulatory patients: EMB agar
63Urine culture Semiquantitive colony counts Streaking technique Non ferrous (nichrome or platinum) inoculating loops, calibrated in to an either 0.01 or ml of fluid are immersed in to an uncentrifuged urine sample
64Urine culture Streaking technique After 18 to 24 h. of incubation :counting number of colonies on the agarnumber of colony * 100 (for 0.01 ml)number of colony * 1000 (for ml)
66Urine culture in symptomatic patient In symptomatic patient one titer of 10*5 org/ml or more, carries a 95% probability of UTI.In suprapubic or catheterized urine : low colony count (10*2) and multiple org. is important.in lower colony counts with symptomatic patient : acute urethral syndrome.
67Urine culture in symptomatic patient The Infectious Disease Society of America consensus definition :10*3 cfu of uropathogens :cystitis10*4 cfu of uropathogens :pyelonephritis
68Urine culture In urethral syndrome About one-third of women with dysuria and frequency have either an insignificant number of bacteria in midstream urine cultures or completely sterile cultures and have been previously defined as having the urethral syndrome.About three-quarters of these women have pyuria,while one-quarter have no pyuria and little objective evidence of infection.In the women with pyuria, two groups of pathogens accountfor most infections.
69Urine culture In urethral syndrome 1. Low counts (102 to 104/mL) of typical bacterial uropathogens such as E. coli, S. saprophyticus, Klebsiella, or Proteus are found in midstream urine specimens from most of these women.These bacteria are probably the causative agents in these infections because they can usually be isolated from a suprapubic aspirate, are associated with pyuria, and respond to appropriate antimicrobial therapy.
70Urine culture In urethral syndrome 2. In other women with acute urinary symptoms, pyuria, and urine that is sterile (even when obtained by suprapubic aspiration), sexually transmitted urethritis-producing agents such as Chlamydia trachomatis, Neisseria gonorrhoeae, mycoplasma, ureoplasma and herpes simplex virus are etiologically important.- These agents are found most frequently in young, sexuallyactive women with new sexual partners.
71Urine culture in asymptomatic patient More than 10*5 org/ml of enterobacteriaceae in two clean-catch specimens confirms infection : asymptomatic bacteriuria10*4 to 10*5 of enterobacteriaceae represents contamination10*4 to 10*5 of gram(+) organisms (staph. Saprophiticus), fungi, and fastidious org. represents infectionLess than 10*4 org/ml often :saprophytic skin org.In males 10*3 org/ml is suggestive of infection.
72Diagnosis6. Diagnostic Tests for adults who have recurrent infections or persistent bacteriuriaa. Intravenous pyelography (IVP) or excretory urography1. Evaluates structure and excretory function of kidneys, ureters, bladder2. Kidneys clear an intravenously injected contrast medium that outlines kidneys, ureters, bladder, and vesicoureteral reflux
73Diagnosisb. Voiding cystourethrography: instill contrast medium into bladder and use xray to assess bladder and urethra when filled and during voidingc. Cystoscopy1. Direct visualization of urethra and bladder through cystoscope2. Used for diagnostic, tissue biopsy, interventionsd. Manual pelvic or prostate examinations to assess structural changes of genitourinary tract, such as prostatic enlargement, cystocele, rectocele
75Treatment Medications a. Short-course therapy: 3 day course of antibiotics for uncomplicated lower urinary tract infection; (single dose associated with recurrent infection)b. 7 – 10 days course of treatment: for pyelonephritis, urinary tract abnormalities or stones, or history of previous infection with antibiotic-resistant infections; clients with severe illness may need hospitalization and intravenous antibiotics
76Treatmentc. Antibiotics commonly used for short and longer course therapy include trimethoprim-sulfamethoxazole (TMP-SMZ), or quinolone antibiotic such as ciprofloxacin (Cipro)d. Intravenous antibiotics used include ciprofloxacin, gentamycin, ceftriaxone (Rocephin), ampicillin
77TreatmentPossible outcomes of treatment for UTI, determined by follow-up urinalysis and culture1. Cure: no pathogens in urine2. Unresolved bacteriuria: pathogens remain3. Persistent bacteriuria or relapse: persistent source of infection causes repeated infection after initial cure4. Reinfection: development of new infection with different pathogen
78Treatmentf. Prophylactic antibiotic therapy with TMP-SMZ, TMP alone or nitrofurantoin (Furadantin, Nitrofan) may be used with clients who experience frequent symptomatic UTIsg. Catheter-associated UTI: removal of indwelling catheter followed by 10 – 14 day course of antibiotic therapy
79Treatment Asymptomatic Bacteriuria Empiric treatment of all asymptomatic bacteriuria (ASB) in pregnancy. Screening at first visit.ASB if untreated increases preterm labor and LBW, 20-30% develop pyelonephritisDo U/A in 2 weeks and each trimester.Screen Sickle cell trait each trimester. Twofold increase risk of ASB
80Treatment Asymptomatic Bacteriuria Treatment failures: repeat treatment based on sensitivities for 1 week, then prophylactic therapy for remainder of pregnancyProphylaxis: Nitrofurantoin, Ampicillin, TMP/SMX
81TreatmentSurgerySurgical removal of large calculus from renal pelvis or cystoscopic removal of bladder calculi which serve as irritant and source of bacterial colonization; may also use percutaneous ultrasonic pyelolithotomy or extracorporeal shock wave lithotripsy (ESWL
82TreatmentSurgeryb. Ureteroplasty: surgical repair of ureter for stricture or structural abnormality; reimplantation if vesicoureteral reflux; clients usually return from surgery with catheter and ureteral stent in place for 3 –5 days
83Treatment Nursing Care: Health promotion to prevent UTI a. Fluid intake 2 – 2.5 L daily, more if hot weather or strenuous activity is involvedb. Empty bladder every 3 – 4 hours
84Treatment Nursing Care: Health promotion to prevent UTI c. Females 1.Cleanse perineal area from front to back2.Void before and after sexual intercourse3.Maintain integrity of perineal tissuesa. Avoid use of commercial feminine hygiene products or douchesb. Wear cotton underweard. Maintain acidity of urine (use of cranberry juice, take Vitamin C, avoid excess milk and milk products, sodium bicarbonate