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  1. INFECTIONS OF THE URINARY TRACT NOVEMBER 6, 2014 Ank Nijhawan, MD, MPH Division of Infectious Diseases 2. Case 1  A 23 yo woman presents to clinic reporting lower…
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  • 1. INFECTIONS OF THE URINARY TRACT NOVEMBER 6, 2014 Ank Nijhawan, MD, MPH Division of Infectious Diseases
  • 2. Case 1  A 23 yo woman presents to clinic reporting lower abdominal pain and dysuria for 3 days.  On exam she is afebrile but has suprapubic discomfort.  A urinalysis is sent and shows positive leukocyte esterase, positive nitrite, 30 WBCs, no epis  Urine culture pending  What other questions do you want to ask?  Vaginal discharge? Sexually active? Back pain? Fever? N/V? History of PID?  Other exam findings?  CVA tenderness? Pelvic exam?  Other testing?  Consider pregnancy test, urine GC/CT, trichomonas testing, candida,Bacterial vaginosis, other STIs  Treatment? For how long?
  • 3. Infections of the urinary tract  Urethritis  Prostatitis  Cystitis  Pyelonephritis female male
  • 4. Outline  Asymptomatic bacteruria  Urethritis  Cystitis/Pyelonephrit is  Uncomplicated  Complicated  Epidemiology  Pathogenesis  Clinical presentation  Microbiology  Diagnosis  Differential diagnosis  Treatment
  • 5. What is Asymptomatic Bacteruria?  Isolation of bacteria >= 100,000 CFU/mL  On 2 separate specimens in women, 1 in men  Appropriately collected urine sample  Absence of signs or symptoms of UTI  May or may not have pyuria
  • 6. Prevalence of Asymptomatic Bacteruria Nicholle et al, CID 2005, IDSA Guidelines
  • 7. Who to screen and treat for Asymptomatic Bacteruria:  Pregnant women (at least once early on)  Prior to Trans-Urethral Resection of the Prostate (TURP)  If positive, start treatment just prior to procedure  Stop after procedure unless catheter to remain in place  Prior to urologic procedures where mucosal bleeding is anticipated  Consider in women with catheter-associated bacteruria, if bacteruria persists after catheter removed
  • 8. Who NOT to screen/treat for Asymptomatic Bacteruria  Premenopausal nonpregnant women  Diabetic women  Older persons living in community  Elderly institutionalized subjects  Persons with spinal cord injury  Catheterized patients where catheter remains in situ  *Pyuria with asymptomatic bacteruria is not a reason to treat
  • 9. What about Funguria?  Common diagnosis in inpatients, candida  Usually a benign process  May be difficult to distinguish infection from colonization, pyuria and colony counts not helpful  Rarely develops into disseminated infection  If catheter in place, consider removal and repeat U/A and culture  If symptomatic, start antifungal treatment, fluconazole preferred if susceptible  Amphotericin bladder washes no longer recommended
  • 10. Cystitis, Pyelonephritis in Women  Epidemiology  Pathogenesis  Clinical presentation  Microbiology  Diagnosis  Differential diagnosis  Treatment
  • 11. Epidemiology  UTIs are a common occurrence in otherwise healthy women  Risk factors:  History of UTI  Sexual activity  Spermicide use
  • 12. Pathogenesis  Colonization of vagina with fecal flora  Cystitis: ascend urethra into bladder  Pyelonephritis: pathogens ascend to kidneys via ureters
  • 13. Microbiology  75%-95% E. coli  Enterobacteriaceae:  Proteus  Klebsiella  Staph saprophyticus  Frequent contaminants:*  Coag negative staph (other than S. saprophyticus)  Group B strep  Enterococci  Lactobacilli
  • 14. Clinical presentation of uncomplicated UTI in women Cystitis Pyelonephritis  Dysuria  Urinary frequency  Urgency  Suprapubic pain  Fevers  Chills  Flank pain  CVA tenderness  Nausea, vomiting Why are symptoms important? 50% of women with 1 or more UTI symptoms will have a UTI 90% of women with dysuria/frequency but without vaginal irritation or discharge have a UTI Bent, JAMA, 2002
  • 15. Urinalysis  WBCs: >10 WBCs/microL in urine= pyuria  WBC casts: indicate upper tract infection  RBCs: Hematuria is common in UTI, not vaginitis  Leukocyte esterase: used to detect >10WBCs/hpf  Nitrite: indicate >105 Enterobacteriaceae infection (which convert urinary nitrate to nitrite); can get false positives with pyridium or eating beets
  • 16. Differential Diagnosis for cysitis/pyelonephritis  Vaginitis  Urethritis  Structural Urethral abnormalities (stricture)  Painful bladder syndrome/interstitial cystitis  Pelvic inflammatory disease  Nephrolithiasis
  • 17. IDSA Treatment algorithm for cystitis Woman with acute uncomplicated cystitis Absence of fever, flank pain? Able to take oral medications? Consider Pyelonephritis or complicated UTI YES NO Nitrofurantoin 100mg bid x 5 d OR Bactrim DS po bid x 3 d OR Fosfomycin 3gm single dose OR Pivmecillinam •If none of these treatments are an option due to allergy, compliance, tolerability, may consider •Fluoroquinolones •Select Betalactams
  • 18. Antibiogram at UTSW/St. Paul  E. coli, urine  Ampicillin 45%  Amp/sulbactam 49%  Pip/Tazo 96%  Cefuroxime 88%  Cefotaxime 95%  Ceftriaxone 95%  Ceftazidime 95%  Cefepime 95%  Ertapenem 99%  Meropenem 100%  Gentamicin 88%  Amikacin 99%  Tobramycin 87%  Ciprofloxacin 68%  Levofloxacin 69%  TMP/SMX 65%  Nitrofurantoin 96%
  • 19. Treatment for Pyelonephritis  Indication to get a urine culture  Only Fluoroquinolones are approved as oral therapy for this  Consider possibility of resistance (e.g. ESBL)  If >10% resistance locally, consider broad spectrum antibiotics  May require admission/IV antibiotics
  • 20. Recurrent UTIs in Women  25% of women will have a recurrent UTI within 6 months  Defined as >=2 infections in 6 mo or >=3 infections/1 year  Reinfection v. Relapse  Risk factors:  Genetic: nonsecretor uroepithelial cell; decreased IL-8 receptor/CXCR-1  Behavioral: spermicide, diaphragm, history of UTI  Pelvic anatomy: shorter distance between anus and urethra  Post-menopausal women, incontinence  Prophylaxis:  Post-coital voiding, discontinue spermicide/diaphragm  Cranberry juice (?)  Probiotics (suppository better)  Antibiotics  Estrogen cream
  • 21. Interactions between mucosal surfaces and pathogens and commensals during symptomatic UTI or asymptomatic bacterial carriageIBC= intracellular bacterial community Ragnarsdottir, Nature Reviews Urology, 2011
  • 22. Considerations in Men  Men are less likely to get UTIs due to longer urethra, drier peri-urethral area and antibacterial secretions from prostate  Some consider all UTIs in men to be complicated  Differential includes  prostatitis,  epididymitis,  urethritis
  • 23. Acute v. Chronic Bacterial Prostatitis Acute Chronic Micro Similar to UTIs, urethritis Same Clinical presentation Fevers, chills, dysuria, pelvic, perineal pain, cloudy urine, obstructive symptoms, dribbling of urine Milder symptoms Exam Tender prostate, do not do vigorous prostatic massage BPH, edema, may have nontender prostate Diagnosis Urine culture Urine and prostate secretion culture Treatment FQ, Bactrim FQ Special considerations More common in HIV patients If presentation consistent, but cultures negative, consider Chlamydia
  • 24. Complicated Cystitis/Pyelonephritis Clinical Anatomic  Male gender (?)  Diabetes  Pregnancy  Acute Pyelo in past year  Symptoms for >7 d PTA  Hospital Acquired Infection  Multiple drug resistance  Renal failure  Renal transplantation  Immunosuppression  Catheter, stent, nephrostomy  Recent urinary instrumentation  Obstruction  Anatomic abnormality  Urologic dysfunction
  • 25. Catheter-associated UTI  Most common health care associated infection worldwide Definition:  Signs and symptoms of UTI in patient with indwelling catheter:  new onset or worsening of fever, rigors,  altered mental status, malaise, or lethargy with no other identified cause;  flank pain; costovertebral angle tenderness;  acute hematuria; pelvic discomfort;  >= 103 CFU of a single bacteria isolated from urine
  • 26. Limiting Unnecessary Catheterization  Incontinence, convenience not an indication  Remove catheters as soon as they are no longer needed  Automatic discontinuation orders, Reminders  Use condom catheters in men when possible  Use a closed catheter system
  • 27. Catheter awareness survey  469 patients, 117 had a catheter  Providers were unaware of catheter 28% of time  21% students  22% interns  27% residents  37% attendings  Catheter use was inappropriate 31% of patients  Catheter more likely to be appropriate if team aware of it (OR 3.7) Saint, AM J Med, 20000
  • 28. Microbiology of complicated UTI  E. coli, Proteus, Klebsiella, Staph saprophyticus  Pseudomonas, Serratia, and Providencia species,  Enterococci  Staphylococci  Fungi  More likely to have resistant organisms
  • 29. Clinical presentation of complicated Pyelonephritis  Fever (>38ºC), chills, flank pain, costovertebral angle tenderness, and nausea/vomiting  Sepsis, multiple system organ dysfunction  Shock, acute renal failure  May develop emphysematous UTI- cystitis, pyelitis, pyelonephritis or Perinephric abscess
  • 30. Diagnosis  Pyuria, WBC casts  If no pyuira, consider alternate diagnosis or obstruction  Urine culture  CT scan, Ultrasound if renal dysfunction
  • 31. Treatment of complicated UTI  Cystitis:  Fluroquinolones, not moxifloxacin  Do not use Bactrim, fosfomycin, nitrofurantoin unless known to be susceptible  May need IV treatment, Ceftriaxone, carbapenems, aminoglycosides  For enterococci, use Ampicillin
  • 32. Treatment of complicated UTI  Pyelonephritis  Initial treatment should be inpatient  If Mild-moderate:  Ceftriaxone, Cefepime, Fluoroquinolones, Aztreonam  If Severe:  Carbapenem, Betalactam/betalactamase inhibitor such as Ampicillin/Sulbactam and Pipercillin/Tazobactam
  • 33. What do you do if you see this?
  • 34. Emphysematous UTI  Cystitis, Pyelitis, Pyelonephritis  Over 80% are in Diabetics; often women in 60s  Abdominal pain (rather than dysuria), most common presenting sign  Diagnosis made on imaging/CT scan
  • 35. Emphysematous UTI, management  Classification  Class 1- Pyelitis without obstruction or abscess– IV anbx  Class 2- with disease limited to renal parenchyma- IV anbx with percutaneous drainage  Class 3- extension of gas into perinephric space  If AKI, thrombocytopenia, Shock, Altered mental status- nephrectomy and IV anbx  If only 1 or less of the above, can consider percutaneous drainage and IV anbx, nephrectomy if not improving  Class 4- bilateral disease or in solitary kidney  Percutaneous drainage and IV anbx, relief of obstruction
  • 36. Renal and Perinephric Abscess  Ascending infection (renal abscess) or hematogenous spread (perinephric abscess)  Treat with IV Antibiotics, consider staph coverage if hematogenous spread  Renal abscess need percutaneous drainage if > 5 cm  Perinephric abscesses require drainage
  • 37. What if you see this on CT?
  • 38. Xanthogranulomatous Pyelonephritis  Unusual variant of chronic pyelonephritis  Destruction of the kidney from lipid laden macrophages (defect in microbial processing)  Most common in middle-aged women with recurrent UTIs  Micro: Escherichia coli, Proteus mirabilis, Pseudomonas aeruginosa, Enterococcus faecalis, and Klebsiella species  Treatment: IV Anbx, Partial or total nephrectomy  Consider Renal Cell CA
  • 39. Case #2  18 yo man from Mexico  4 months of urinary urgency, incomplete emptying  3 months ago dysuria, hematuria  Also with cough, fever, night sweats  CT scan show asymmetric bladder wall thickening, hydronephrosis
  • 40. Results  CXR with cavitary lesion  HIV negative  Urine AFB (collected at morning void, 20- 30cc):  Mycobacterium Tuberculosis
  • 41. Summary  Urinary Tract Infections encompass infections of urethra, bladder, prostate, ureters and kidneys  Wide range of severity and clinical presentations from asymptomatic bacteriuria to complicated pyelonephritis  Consider urethritis, vaginitis, PID in women; prostatitis, epididymitis in men  Clinical presentation should guide management  Do not treat a urinalysis, treat the patient  Prudent use of fluoroquinolones  Get Urology involved early in complicated infections
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