URINARY SYSTEM INFECTIONS Dr. Murat UĞRAŞ Dept. of Urology

1. URINARY SYSTEM INFECTIONS Dr. Murat UĞRAŞ Dept. of Urology

2. Most common bacterial infections of the hospital environment, • A serious cause of morbidity and mortality, • Wide symptom diversity: • Asyptomatic bacteriuria • Septic shock • Economical issues.

3. Definition: With signs of infections; >105 same kind of bacteria. In two consecutive urine samplings in females, In any urine sampling in males is called a urinary infection.

4. Incidence increases with age: (100% in <80 yrs ) Positive urine culture (without any symptoms and signs) in elderly does not mean UTI.

5. Positive urine culture is important in two situations: • Before urinary surgery (if the urinary mucosa will be deteriorated); • In pregnancy (due to the increased risk of mortality and “small for gestational age biths”)

6. Uncomplicated acute cystitis of women • Bacterial infection of the bladder and urethra. • Without a known predisposing factor or recurrent UTI. • Most common in pregnants.

7. SYMPTOMS: • Disuria • Frequency • Urgency • Suprapubic discomfort

8. DIFFERENTIAL DIAGNOSIS: • Urethritis (C.trochomatis, N.gonorrhoeae, HSV) • Vaginitis (Candida and Trochomanas) Vaginal discharge and irritation leads to the examination for vaginitis. MICROBIOLOGICAL DIAGNOSIS: • Bacteria or fungus in midstream cleancatch urine samples • Baseline value in culture: 10 cfu/ml • Not always necesary

9. Leuccocyte estherase dipstick test is sufficient in most cases. Less sensitive than microscopy. • If a symptomatic patient reveals negative in leucocyte estherase test, miroscopy should be performed. • Continuing strong suggestion of UTI despite negative leucocyte estherase and microscopy, a urine culture should be performed. • Positive leucocyte estherase or positive microscopy indicated an empirical treatment.

10. ANTIMICROBIAL THERAPY • Usually empiric for uncomplicated UTI: • TRP-SMX • Fluorokinolons (ciprofloxacyn, ofloxacyn, norfloxacyn ) • Women with uncomplicated UTI are treated empirically for 3 days.

11. Complicated UTI: • Acute urinary infection in a predisposing era and/or recurrent UTI. • Difficult to diagnose and to treat. • Underlying disease must be established for complete recovery.

12. Predisposing era for complicated UTI Anatomic / functional Obstruction Other diseases • DM • CRF Solitary kidney Polycystic kidney Nephrostomy tube Ureteral stents Vesicoureteral reflux Renal transplantation BPH Stone disease Nörogenic bladder

13. PATHOGENS: • E.coli (%75-95) • Staf.saprophyticus (%5-15) • Others (Entereococci, Klebsiella, Proteus) RISC FACTORS: • Sexual intercourse • Spermicids for contraception • Delayed postcoital micturation • Recent UTI

14. RECURRENT UNCOMPLICATED UTI Occurs in the first 6 months of a recent UTI ( %27-%40). May be due to new reinfection from an external source of infection; or, a completely new microorganism. Vaginal or fecal microflora may be the fountain.

15. Anatomic and/or functional abnormalities of the urinary system may be missed in initial diagnosis. • Some risc factors: • Spermicids and diaphrams for contraception. • Vaginal intercourse • UTI before 15 yrs of age • Maternal UTI history

16. Microbiology;: • S.saprophyticus • Entercocci • Non-E.coli Gr- bacilli

17. Empirical therapy in recurrent UTI: • Nitrofurantoin • Fluorokinolons • Phosphomycime • Amoxicilline-clavulonate

18. ACUTE PYELONEPHRITIS • Infection of renal pelvis and parenchyma. • Diagnosed clinically in patients with overt laboratory diagnosis of UTI. • Hallmark signs: • Fever, • Flank pain, • Tenderness, • Nausea and vomitting, dysuria, abdominal pain, septic shock

19. Causative microorganism is E.coli (80%) A urine culture is mandatory due to the necessity of definitive treatment.

20. Positive blood culture is seen in 15 to 20% of patients. Pyuria is usually present in urine. Positive staining for Gram stain indicates wide spctrum antibiotic treatment for S.aureus.

21. Radiology is not mandatory for the diagnosis of pyelonephritis. • Only patients with the suspicion of renal abscess or urinoma needs computed tomography.

22. TREATMENT OF PYELONEPHRITIS: Patients should be hospitalised. Supportive treatment including liquid replacement, antiemetics and antipyretics are necessary. Definitive treatment is based on the culture results. Broad spctrum antibiotics should be given initially.

23. TMP-SMX, phosphamycin and nitrofurantoin are not used in treatment. Cephtriaxon, ciprofloxacin or ampicillin combined with gentamycin are alternatives for empirical therapy.

24. Treatment of acute pyelonephritis should continue for 14 days. Signs and symptoms should vanish in 48 to 72 hours. Culture results should be negative at the end of 7 days. Otherwise, tomography or ultrasonography should be performed for renal abscess, emphysematous pyelonephritis or urinoma.

25. UTI in PREGNANCY • Serious problem for both the mother and the fetus. • May cause stillbirths, “SGA” babies or maternal septic shock. • Rapid diagnosis and treatment is necessary for healthy pregnancy. • Routine scanning of pregnants is performed at 16th week of gestation.

26. Symptoms and Signs • Fever, • Flank pain, • Dysuria, • Nausea and vomitting, • Positive fetal stress test

27. Microorganisms: E.Coli,S.Saphrophyticus,group B streptococci and Klebsiella • Treatment: pennicilin, cephalosporins nitrofurantoin • Pyelonephritis is most common in the last trimester.