Urinary tract infection Dr.Nariman Fahmi

Objectives Define Urinary Tract Infection (UTI) Diagnosis of UTI treatment for UTI

Relationship of the Kidneys to Vertebra and Ribs Figure 23.1b They are retroperitoneal and are located in the abdominal cavity. They are at the level of T12 to L3, so they are at the costal margin, and the ribs protect them a little. Even though they are protected by thoracic ribs, they are NOT in the thoracic cavity because they are below the diaphragm. 4

Case history A 9 year old girl with a 2 days history of loin pain,fever and vomiting, clinically she appears ill. a full blood count shows a Hb 12 mg/dl, WBC of 14x10( cells/L You send of a midstream urine sample for culture. prescribed paracetol and ask the patient came next day. The next day you find that she has been reported urine culture of more than colonies of E-Coli.

What is the most probable diagnosis ?? Which part of renal tract is most likely infected and why?? What choice of antibiotics?? investigations that are needed

Urinary Tract Infections Yes, it is a bacteriuria

Female Male

A UTI can happen anywhere along the urinary tract. UTI have different names, depending on what part of the urinary tract is infected.  Bladder -- an infection in the bladder is also called cystitis or a bladder infection  Kidneys -- an infection of one or both kidneys is called pyelonephritis or a kidney infection Definition of UTI

 Bacteriuria Presence of bacteria in the urine  Dysuria Pain or difficulty in urinating  Pyuria Presence of/increased numbers of white blood cells in the urine Terminology

Most UTIs are from ascending bacteria – E. coli (60-80%), Proteus, Klebsiella, Enterococcus, and coag. neg. staph.

forms of UTI are 1-pyelonephritis 2-Cystitis 3- urithritis 4- prostitis

Cystitis (bladder involvement ) clinical fatures dysuria, urgency, frequency, suprapubic pain, incontinence, malodorous urine. Cystitis does not cause fever and does not result in renal injury s

General urine exam

Microscopical exam Pus cells in urine

DIAGNOSIS urine culture

Imaging of the Renal tract * Renal U/S * KUB * DMSA * IVU * Cystogram VCUG/RNC The goal of imaging studies in UTI is to identify Anatomic abnormalities that predispose to infection and identify scarring

Reflux Seen on Voiding Cystourethrogram (VCUG) using transurethral contrast

Urinary Tract Infection Upper urinary tract Infections: – Pyelonephritis Lower urinary tract infections – Cystitis (“traditional” UTI) – Urethritis (often sexually-transmitted) – Prostatitis

Symptoms of pyelonephritis Hematuria Fever Nausea/Vomiting (pyelonephritis) Flank pain (pyelonephritis)

Findings on Exam in UTI Physical Exam: – Costo Vertebral Angle tenderness (pyelonephritis) – Urethral discharge (urethritis) – Tender prostate on PRE (prostatitis) – Suprapubic tenderness (cystitis) Labs: Urinalysis  Positive + WBCs  Positive + RBCs

Culture in UTI Positive Urine Culture = >10 5 CFU/mL Most common pathogen for cystitis, prostatitis, pyelonephritis: – Escherichia coli – Staphylococcus saprophyticus – Proteus mirabilis – Klebsiella – Enterococcus Most common pathogen for urethritis Chlamydia trachomatis Neisseria Gonorrhea

Pyelonephritis Infection of the kidney Associated with constitutional symptoms – fever, nausea, vomiting, headache Diagnosis: Urinalysis, urine culture, CBC, Chemistry Treatment: 2-weeks of Trimethroprim/sulfamethoxazole or fluoroquinolone,cephalosporins Hospitalization and Intravenous antibiotics if patient unable to take orally.

Question A 24-year old woman presents with fever, chills, nausea, vomiting, flank pain and tenderness. Her temperature is 40°C, pulse rate is 120/min., and blood pressure is 100/60 mm Hg.

Question What further studies do you want in this patient? How would you treat this patient? What might you do if she does not improve after 3-4 days?