Urinary Tract Infections, Pyelonephritis and Prostatitis2011-2012

7/29/2019 Urinary Tract Infections, Pyelonephritis and Prostatitis2011-2012

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Lower tract infections Urethritis and cystitis

Often superficial

Upper tract infections Acute pyelonephritis, prostatitis, intrarenal and

perinephric abscess

Tissue invasion


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Pathogenic microorganisms are detected Growth of > 105 organism/mm midstream

clean catch

10

2

-10

4

/ml by suprapubic aspiration,indwelling catheter or in-out catheterization


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Persistence of original infecting strain New strain

Unresolved renal or prostatic infection

Persistent vaginal or intestinal infectionleading to reinfection of the bladder


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Dysuria, frequency and urgency Unaccompanied by significant bacteriuria

Actual bladder infections


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Chronic interstitial nephritis Infectious causes


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Females 1-3% of school girls

Increasing at the onset of sexual activity

More common among younger women

Males 50 years old

Elderly Asymptomatic bacteriuria

40-50%


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E. coli* 80% Proteus*, Klebsiella*, Enterobacter, and

Pseudomonas * found in women with urethral syndrome and low

colony counts Associated with recurrent infections and urologic

manipulations

Enterococci, Staphylococcus saphrophyticus* Found in patients with renal stones and urologic

surgery/instrumentation

S. aureus bacteremic infections

Chlamydia, Neisseria and HSV in patients with (-) bacteria and who are sexually active


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Ureaplasma and Mycoplasma Unusual infections and may be seen among patients

with pyelonephritis and prostatitis

Adenovirus Acute hemorrhagic cystitis in children


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Risk factors Anatomic considerations Intercourse / sexual habits uncircumcised Use of contraceptives (spemicides) Bladder invasion by E. coli

O, K, H serogroups, fimbriae and cytotoxins

Debilitated patients / immobilization Catheter associated UTI

HIV Pregnancy Obstructions (tumors, strictures, stones or prostate) Neurologic bladder dysfunction Vesicoureteral reflux


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S/Sx Dysuria, frequency, urgency and suprapubic pain

Fever nausea and vomiting

Malodorous, cloudy urine

Bloody urine in 30% Urethral or suprapubic tenderness, CVA tenderness

Check for vaginal discharges

Pyuria, 102-104 colony counts or higher


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No mitigating circumstances Oral TMP-SMX, TMX, quinolone 3 days

Nitrofurantoin 7 days

DM, >7 days of symptoms, recent UTI, use of

diaphragm, >65 y/o, pregnant Oral TMP-SMX, quinolone 7 days


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S/Sx Rapid development of fever, chills, nausea,

vomiting, abdominal pain, diarrhea

Cystitis

(+) CVA tenderness and on deep abdominalpalpation

Pyuria, bacteriuria, pus casts, Hematuria*

*if persistent rule out TB, stone or tumor


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Mild to moderate illness, no nausea orvomiting, OPD treatment Quinolone 7-14 days

Ceftriaxone: 1 gm single dose

Gentamycin (3-5 mg/kg) IV followed by oral TMP-SMX for 14 days

Severe illness, possible urosepsis,hospitalization required Parenteral quinolone, Gentamycin (+ampicillin),

ceftriaxone, aztreonam

Oral quinolone, TMP-SMX for 14 days


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S/Sx Acute dysuria, frequency and pyuria

30% with no growth or insignificant growth r/o E. coli vs STDs

Indistinguishable from cystitis If chronic, check:

New sexual partner with hx of transmitted dse

Mucopurulent cervicitis


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Chlamydial infxn Azithromycin 1g single oral dose

Doxycycline 100mg bid x 7 days


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S/Sx Minimal symptoms

Gram (-) bacteremia

Can be prevented through proper aseptic

techniques Usually successful for those catheterized for


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Arising from catheterization, manipulation,immunosuppression, anatomic, functional,urologic, stone obstructions, renal disease ordiabetes

With mild to moderate illness, no nausea orvomiting OPD Ciprofloxacin or levofloxacin for 10-14 days

Severe illness possible urosepsis requiringhospitalization IV ampicillin and gentamicin, ceftriaxone, aztreonam,

ticarcillin/clavulanate, or imipenem cilastatin then oralquinolone or TMP-SMX for 10-21 days


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Asymptomatic Bacteriuria Antibiotic oftentimes unnecessary unless with

symptoms

Pregnancy Amoxicillin, nitofurantoin, or cephalosporin Low dose prophylaxis with nitrofurantoin for those

with recurrent infection


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Bacterial count Symptomatic patients: >105/ml

Asymptomatic patients: >105/ml in 2 consecutivespecimen with presence of a single species in both

Suprapubic aspiration or catheterizatiopn: >102/ml Microscopy

Gram stain

Pyuria

Leukocyte esterase dipstick test Cultures


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Women Usually not recommended

Relapsing infections

Childhood infections

Stones Painless hematuria

Recurrent pyelopnephritis

Males Recommended Except: AIDS, uncircumcised, recent sexual activity


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Infection of the renal pyramids Risk Factors

Diabetes, sickle cell disease, chronic alcohololism, andvascular disease

S/Sx Hematuria, flank or abdominal pain

Chills and fever Acute renal failure, oliguria and anuria Presence of ring shadow on pyelography

Tx Nephrectomy for unilateral papillary necrosis may be life

saving


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High fever, leukocytosis, renal parenchymalnecrosis and presence of fermentative gasesin kidneys and perinephric tissues seen inplain film/CT

E. coli and enterobactericeae

Surgical resection/systemic antibioticsneeded


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E. coli and gm (-) rods Related to bladder outlet obstruction/DM

Abdominal pain, dysuria, frequency andpneumaturia.

Gas with the bladder lumen and bladder wallby CT

Systemic antibiotics

Relief of obstruction Cystectomy


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Spontaneously in young men and those withindwelling urethral catheter in older men

Fever, chills, dysuria and tender, boggy prostate E. coli or Klebsiella (for non catheter related infxn)

IV flouroquinolones

3rd gen cephalosporin or an aminoglycoside

Gram (-) rods for catheter related infxn

Imipenem, aminoglycoside, flouroquinolones or a3rd gen cephalosporin

Sequelae: Abscess formation, epidymoorchitis, seminal vesiculitis,

septicemia or residual chronic bacterial prostatitis


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Infrequent, relapsing infection in a middle ageman Asymptomatic, with normal prostate on

palpation. May produce symptoms of cystitis Presence of E. coli, Klebsiella, proteus in prostatic

secretions or post massage urine TX Floroquinolones for 12 weeks Low dose antimicrobial (sulfonamide, TMP,

nitrofurantoin) Total prostatectomy/transurethral prostatectomy


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Urinary Tract Infections, Pyelonephritis and Prostatitis2011-2012