Presentation on theme: "Fungal Urinary Tract Infections Diagnosis and Management"— Presentation transcript:
1Fungal Urinary Tract Infections Diagnosis and Management Tristan T. Berry, M4Medical College of Virginia
2Objectives History Definition of the fungal UTI. Epidemiology Predisposing conditionsPresenting symptomsCommon organisms and important rare organismsDiagnosis imaging ,cytology/culture (blood and urine)TreatmentResistance to antifungals
3History1890 Schmorl reports renal involvement in patient with disseminated candidiasis.1910 Rafin recognizes candidal cystitis1931 Lundquist reports primary renal mycosis1948 Moulder reports cystoscopic findings of candidiasis in the urinary bladder1963 Twelve cases of candidal infection of the kidney reported1980 Increased reporting of fungal infection of urinary tract . Likely multifactorial.
4Epidemiology and Predisposing Factors Fungal pathogens are the cause of increasing nosocomial infections in hospital communities.
5Epidemiology and Predisposing Factors From the nosocomial fungal infectionrate for urinary tract infections had risen from9.0 to 20.5 per 10,000 hospitalized patients.
6Epidemiology and Predisposing Factors Three distinct groups of pathogens are noted for causing fungal UTIs:1) Opportunistic organisms2) Environmental3) Rare and unusual
7Opportunistic Organisms normally inhabit human flora or environment.proliferate when there is a defect in an individual's immune system. Thus causing disease.Candida species - saprophytes of the skin, oropharyx ,gasrointestinal tract and genital regions.
8Environmental Rare and unusual include Blastomyces, Histoplasmosis, Coccidoides.found primarily in soil,environment and guano. inhabit human flora or environment.Rare and unusualMucormycosis and others
12Pathogenesis Most common opportunistic fungi. Causes thrush, vaginitis, chronic mucocutaneous candidiasisWhen local or systemic host defenses are impaired, disease may result.
13Pathogenesismay disseminate to multiple organs esp. in IVDA and right sided endocarditis.kidney is the most commonly involved organ with systemic fungal infection. >85%Accounts for 6.9% of nosocomial infections
14PathogenesisCandida Spp are the most common organisms causing fungal UTI.Candida albicans accounts for 74%Glabrata 8%Parapsolosis7%Tropicalis 3%
15Predisposing Conditions 1) Diabetes (impaired phagocytic and fungacidal function of neutrophils)2) Protracted course of antibiotics
16Predisposing Conditions 4) Neoplasm5) Oral contraceptives6) Elderly Population7) Infants- due to immature T-Cell defense8) Chronic indwelling catheter
17Symptoms Frequency, dysuria and stranguria Pyuria , hematuria or pneumaturiaclassic findings of pyelonephritis, fever, flank pain and CVAThigh index of suspicion b/c fungal UTI may present like bacterial UTI.
18Diagnostic Features microscopic urine studies urine culture can be helpful for species identification and sensitivitiesUrine colony counts (significant if >105 without indwelling urinary catheter)
20Simple UTI Confined to urinary bladder and urethra. Pt may present with cystitis.(2% of UTIs)Cystoscopy may present with white patches on bladder wall.Bladder wall edema and erythema may be present.Bladder infections can lead to rupture. (rare)Microscopic: Inflammatory cells, yeast forms and pseudohyphae may be present
23TreatmentBladder irrigation with Amphotericin B 50mg/1L water x10-14 dEffective in 80-92% of patientsNystatin and Miconazole useful. -poor colloid dispersion in Nystatin-limits useSurgical intervention may be required in the form of mucosal debridementRemoval of large fungal bezoars if present.
24Complex UTI Complex infections affect the kidneys and ureters Result of either hematogenous spread or ascending from lower tract infectionsAssociated with fungal accretions that may lead to obstructive uropathy.
25Complex UTI May lead to persistent candiduria. High potential for disseminated infectionApproximately 88% present with fever and flank pain88% associated with hydronephrosis81% associated with fungemia
26Imaging U/S, Excretory urography, Retro pyelogram CT Renal ScintigraphyImaging studies typically exhibit fillingdefects of the urinary system
27TreatmentLocalizedAmphotericin B irrigation for infection of the collecting system..Systemic or multifocal infectionIV Ampho B 6mg/kg (Gold Standard) , Fluconazole 100mg BID x 10 days5-FC- 150mg/kg- high resistance
30CASEHPI:56 year old male with 4 day history of fever , N/V and diffuse abdominal pain. Anuria 24 hrs prior to admission to the hospital.PMH- Diabetes type II diagnosed 5 years prior, controlled with insulin. UTI 6 months prior tx’d with abx.
31CASE Exam- pt. was febrile & appeared acutely ill. Dry mucous membranesDiffusely tender abdomenBilateral CVATLABS:Leu =25x10^9 with 82% pmnsBUN 82, Creat 7.9 Glu 280
32CASEU/A: Numerous leukocytes per hpfMany yeast forms.Pt was initially treated with Ampicillin and Ciprofloxacin. IVF and IV insulin.Symptoms persisted.
33CASEU/S- bil. hydonephrosisCystoscopy with RPG was unsuccessful due to bilateral ureteral obstruction.Bilateral percutaneous nephrostomy tubes were placed (turbid yellow/white urine was recovered.Antegrade pyelogram- dilation of renal pelvises and ureters. Multiple filling defects.
34CASE Blood cultures on admission were negative for fungi or bacteria. Urine culture- C.Tropicalis 10^4 - 10^5Blood cultures on admission were negative for fungi or bacteria.Treatment: IV Amphotericin B, direct Ampho B through nephrostomies.Fragmentation of fungal balls by guide wire manipulation.
35CASE Therapy cont.for 3 weeks until U/C were negative. Dc’d with Creatinine of 2.1mg/dL.No evidence of hydronephrosis at 6 month follow up.
43Cryptococosis Tx: Adrenal-Amphotericin B Renal- IV Amphotericin B Prostate-Fluconazole mg/dx 4 wksPenis- Resection followed bysystemic Ampho B
44Apergillosis Organism: A. fumigatus and A.Flavus Properties: Only mold form (V shaped branches)Epidemiology: Widely distributed in nature. Grow on decaying vegetables. Linked to hospital construction and central air conditioning .Transmission: Airborne conidia.
46ApergillosisPredisposition: abraded skin, wounds, cornea, ext. ear and sinuses, immunocompromisedGU involvement: Renal- DM, malignancy or AIDS(Fever, CVAT, obstructive uropathy)Prostate and Genital-DM, Met colon ca, steroid use & AIDSDX:Isolation from urine,semen or tissue.
47Apergillosis-Treatment Systemic Amphotericin B for 3 months Kidney-Percutaneous aspiration, nephrostomy & J- stentsVery little data to support use of itraconazole
49Coccidioidomycosis Organism: Coccidioides immitus Properties:dimorphic exists as mold in soil and spherule in tissueLocation: Western U.S and Mexico. Thrives in arid desert regions.Transmission: Airborne infection of the pulmonary system
50CoccidioidomycosisClinical manifestations: mild influenza or flu like illness Valley fever.Predisposition: Age >65 and HIV+Disseminated infection: less than 1% of pulmonary infection become disseminatedMen, pregnant women, immunocompromised and non white persons more likely to have disseminated infection
51Coccidioidomycosis GU involvement: : kidney disease in 36-46% of persons with disseminated disease-microbscess & granulomasprostate in 3-6%GU manifestations: Voiding dysfunctionScrotal swellingHematuriaPneumaturia
52Histoplasmosis Organism: H. Encapsulatum Properties: dimorphic- mold in soil; yeast in tissuesEpidemiology: endemic in central and eastern states, esp Mississippi and Ohio grows in soil contaminated with bird droppings and guano.Transmission and pathogenesis: Inhaled spores are engulfed by macrophages and develop into yeast forms.
56HistoplasmosisDx- Identification of organism in urine,semen or tissue. Culture or skin test.Tx- IV Amphotericin B(>2g) total dose followed by long term Itraconazole 200mg/d x12 wksSurgical management- Surgical excision or drainage of prostate abscess.
60BlastomycesTransmission: Inhalation of mold form. Primarily affects lungs, skin, bone and CNSManifestations: flu-like illness, high fever, respiratory illness that mimics TB or CancerOften subclinical infection.GU- prostate, epididymis, tubo-ovarian abscess
61Blastomyces Dx: Fungus in urine, semen or Detection of blastomyces A antigen by immunodiffusion.Tx: Ketoconazole 400mg/d x 12mos for prostate and epididymis involvement. Amphotericin B for disseminated infxn and immunocompromised
65MucormycosisManifestations- primarily rhino cerebral, sinusitis and brain hemorrhageGU- Primarily fever and flank painDx- biopsy showing mold with nonseptate hyphaeTx-IV amphotericin B >1gram for 1 month
68Summary:The number of urinary tract infections caused by fungi is increasing. Although the majority of fungal UTIs are caused by Candida species, physicians must maintain a high index of suspicion in order to identify the rare and environmental fungi that cause disease.
69Summary:Many factors such as overuse of antibiotics, immunosuppression , antifungal resistance and disseminated fungal infections predispose individuals to developing fungal UTI.The astute physician must identify predisposing medical conditions and anatomical defects; then treat them accordingly.
70Summary:Before beginning antifungal therapy first obtain a U/A (rule out contamination).Urine and blood cultures should be obtained in order to identify the organism and sensitivities.( This helps to prevent overuse of abx and avoids contrubuting to the increasing amount of resistance antifungal agents.)
71Summary:If obstruction or structural abnormalities are suspected then imaging of the urinary system is warranted.If defects are visualized, only then should surgical management be employed.