1. GENITOURINARY TRACT INFECTION Anacta, Klarizza Andal, Charlotte Ann Ang, Jessy Edgardo Ang Joanne Marie Ang, Kevin Francis

2. Urinary Tract Infection a term applied to a variety of clinical conditions in the urinary tract ranging from the asymptomatic presence of bacteria in urine to severe infection of the kidney accurate diagnosis and treatment is essential to limit morbidity & mortality a term applied to a variety of clinical conditions in the urinary tract ranging from the asymptomatic presence of bacteria in urine to severe infection of the kidney accurate diagnosis and treatment is essential to limit morbidity & mortality

3. Epidemiology Smith’s Urology, 17 th ed.

4. Pathogenesis need to understand: –bacterial entry –host susceptibility factors –bacterial pathogenic factor need to understand: –bacterial entry –host susceptibility factors –bacterial pathogenic factor

5. Bacterial Entry Modes of entry: 1. periurethral bacterial ascend - most common cause 2. hematogenous spread - immunocompromised & neontes ( S. aureus, Candida sp. & M. tuberculosis) 3. lymphatogenous spread 4. adjacent organs - intraperitoneal abscesses or fistulas Modes of entry: 1. periurethral bacterial ascend - most common cause 2. hematogenous spread - immunocompromised & neontes ( S. aureus, Candida sp. & M. tuberculosis) 3. lymphatogenous spread 4. adjacent organs - intraperitoneal abscesses or fistulas

6. Host Defense Factors: 1.unobstructed urinary flow 2.urine itself - Tamm-Horsfall glycoprotein 3.anatomic functional abnormality -obstructive condition, neurologic disease, diabetes or pregnancy 4.presence of foreign bodies-stones, catheters and stents 5.aging (men: increase in obstructive uropathy; women: alteration in vaginal and periurethral flora) Factors: 1.unobstructed urinary flow 2.urine itself - Tamm-Horsfall glycoprotein 3.anatomic functional abnormality -obstructive condition, neurologic disease, diabetes or pregnancy 4.presence of foreign bodies-stones, catheters and stents 5.aging (men: increase in obstructive uropathy; women: alteration in vaginal and periurethral flora)

7. Host Defense Defenses –Inflammatory mediators –Blood group antigens –Periurethral normal flora (in women: lactobacillus) –Prostate secretion (in men: fluid containing zinc) –Vesicoureteral reflux (in children) Defenses –Inflammatory mediators –Blood group antigens –Periurethral normal flora (in women: lactobacillus) –Prostate secretion (in men: fluid containing zinc) –Vesicoureteral reflux (in children) Defenses –Inflammatory mediators –Blood group antigens –Periurethral normal flora (in women: lactobacillus) –Prostate secretion (in men: fluid containing zinc) –Vesicoureteral reflux (in children)

8. Bacterial Pathogenic Factor Escherichia coli (common) – increased adherence to uroepithelial cells –resistance to bactericidal activity –production of hemolysin –increased expression of K capsular antigen Recurring infection –bacteria matured in biofilms and create pod-like bulges on urothelial surface

9. Causative Pathogens Common(80%): E.coli (O serogroups) Less Common: Klebsiella, Proteus and Enterobacter spp., and enterococci Hospital setting: pseudomonas and staphylococcus sp. Children: Klabsiella and Enterobacter spp. more common Pregnant: Group B beta – hemolytic streptococci Normal flora: Anaerobic bacteria, lactobacilli, corynebacteria, streptococci & S. epidermidis Common(80%): E.coli (O serogroups) Less Common: Klebsiella, Proteus and Enterobacter spp., and enterococci Hospital setting: pseudomonas and staphylococcus sp. Children: Klabsiella and Enterobacter spp. more common Pregnant: Group B beta – hemolytic streptococci Normal flora: Anaerobic bacteria, lactobacilli, corynebacteria, streptococci & S. epidermidis Common(80%): E.coli (O serogroups) Less Common: Klebsiella, Proteus and Enterobacter spp., and enterococci Hospital setting: pseudomonas and staphylococcus sp. Children: Klabsiella and Enterobacter spp. more common Pregnant: Group B beta – hemolytic streptococci Normal flora: Anaerobic bacteria, lactobacilli, corynebacteria, streptococci & S. epidermidis

10. Diagnosis Urinalysis Urine Culture – gold standard for identification of UTI Localization studies Ultrasound, MRI or CT Scan Urinalysis Urine Culture – gold standard for identification of UTI Localization studies Ultrasound, MRI or CT Scan

11. Antibiotic Treatment Goal: to eradicate the infection by selecting the appropriate antibiotic that would target specific bacterial susceptibility Consider the following in choosing: –Infecting pathogen –The patient –Site of infection Goal: to eradicate the infection by selecting the appropriate antibiotic that would target specific bacterial susceptibility Consider the following in choosing: –Infecting pathogen –The patient –Site of infection

12. Antibiotic Treatment DrugsFeatures Trimethoprim – Sulfamethoxazole For most UTI except Enterococcus and Pseudomonas spp. Fluoroquinolones Best vs gram – negatives, Staphylococcus sp. not Streptococci Nitrofurantoin Good bs gram – negative bacteria. Straphylococci and enterococci spp., except Pseudomonas and Proteus spp. Aminoglycosides For complicated UTI; vs gram – negative + ampicillin – vs enterococci Cephalosporins Most uropathogens Aminopenicillins Good vs Enterocicci, Staphylococci, E.coli and Proteus mirabilis + clavulanic acid – vs gram - negative DrugsFeatures Trimethoprim – Sulfamethoxazole For most UTI except Enterococcus and Pseudomonas spp. Fluoroquinolones Best vs gram – negatives, Staphylococcus sp. not Streptococci Nitrofurantoin Good bs gram – negative bacteria. Straphylococci and enterococci spp., except Pseudomonas and Proteus spp. Aminoglycosides For complicated UTI; vs gram – negative + ampicillin – vs enterococci Cephalosporins Most uropathogens Aminopenicillins Good vs Enterocicci, Staphylococci, E.coli and Proteus mirabilis + clavulanic acid – vs gram - negative

13. Acute Cystitis urinary infection of the lower urinary tract, principally the bladder women > men Mode of infection: ascending from periurethral/vaginal and fecal flora urinary infection of the lower urinary tract, principally the bladder women > men Mode of infection: ascending from periurethral/vaginal and fecal flora

14. Acute Cystitis Presentation –Irritative voiding (dysuria, frequency & urgency) –Low back and suprapubic pain –Hematuria –Cloudy / foul – smelling urine Work – up –Urinalysis: WBCs in urine with hematuria –Urine culture: confirm diagnosis and identify causative orgnanism Management –Short course of oral antibiotic (TMP – SMX & nitrofurantoin) –Treatment of 3 – 5 days Presentation –Irritative voiding (dysuria, frequency & urgency) –Low back and suprapubic pain –Hematuria –Cloudy / foul – smelling urine Work – up –Urinalysis: WBCs in urine with hematuria –Urine culture: confirm diagnosis and identify causative orgnanism Management –Short course of oral antibiotic (TMP – SMX & nitrofurantoin) –Treatment of 3 – 5 days Presentation –Irritative voiding (dysuria, frequency & urgency) –Low back and suprapubic pain –Hematuria –Cloudy / foul – smelling urine Work – up –Urinalysis: WBCs in urine with hematuria –Urine culture: confirm diagnosis and identify causative orgnanism Management –Short course of oral antibiotic (TMP – SMX & nitrofurantoin) –Treatment of 3 – 5 days

15. Recurrent Cystits Presentation: –Bacterial persistence or reinfection with another organism Work – up: –Urine culture: to identify for management of bacterial persistence –Ultrasonography: screening evaluation of the GUT –Pyelogram, Cystoscopy and CT Scan Management: –Surgical removal of source –Prophylactic antibiotic Presentation: –Bacterial persistence or reinfection with another organism Work – up: –Urine culture: to identify for management of bacterial persistence –Ultrasonography: screening evaluation of the GUT –Pyelogram, Cystoscopy and CT Scan Management: –Surgical removal of source –Prophylactic antibiotic Presentation: –Bacterial persistence or reinfection with another organism Work – up: –Urine culture: to identify for management of bacterial persistence –Ultrasonography: screening evaluation of the GUT –Pyelogram, Cystoscopy and CT Scan Management: –Surgical removal of source –Prophylactic antibiotic

16. Recurrent Cystits Management: –Intermittent self – start antibiotic – treat recurrent antibiotic –Sexual activity: frequent bladder emptying and single does of antibiotic taken after sexual intercourse reduces incidence –Alternatives: Intravaginal estriol Lactobacillus vaginal suppositories Cranberry juice taken orally Management: –Intermittent self – start antibiotic – treat recurrent antibiotic –Sexual activity: frequent bladder emptying and single does of antibiotic taken after sexual intercourse reduces incidence –Alternatives: Intravaginal estriol Lactobacillus vaginal suppositories Cranberry juice taken orally Management: –Intermittent self – start antibiotic – treat recurrent antibiotic –Sexual activity: frequent bladder emptying and single does of antibiotic taken after sexual intercourse reduces incidence –Alternatives: Intravaginal estriol Lactobacillus vaginal suppositories Cranberry juice taken orally