1. Renal Case based-Interactive Review Dr. P. K. Rajesh 07 May 2013 The aim of education is to teach “how to think” rather than “what to think”!

2. Name 6 organisms causing UTI. Escherichia coli Klebsiella pneumoniae Proteus mirabilis/vulgaris Pseudomonas aeruginosa Serratia spp Staphylococcus aureus/saprophyticus

3. 6. A sexually-active woman develops a urinary tract infection which ascends to the kidneys (pyelonephritis). Macconkey culture yields a lactose fermenting Gram-negative rod. In this situation, which of the pathogen below is most common? 6. A. Salmonella enteritidis B. Pseudomonas aeruginosa. C. Serratia marcescens D. Escherichia coli

4. Nosocomial urinary tract infections are MOST commonly associated with Proteus mirabilis Klebsiella pneumoniae Enterobacter species Pseudomonas aeruginosa

5. What are the ways by which the urine sample can be collected? Clean catch mid stream specimen Collection bags (children) Suprapubic aspiration Indwelling catheters

6. Should the urine of all patients with a suspected UTI be cultured? Urine Culture is indicated when…… WBC is increased (Gram smear of urine) leukocyte esterase test is positive nitrate test is positive presence of bacteria is observed in urine

7. 10 5 colonies/ml of urine (Kass criteria)

8. In children Suprapubic aspiration Patients on diuretics Patients on antibiotic therapy Pregnancy- think of risks to the neonate Staphylococcus aureus

9. Patient’s name: F: M: THANKAM SHANKAR X Specimen details: Urine culture Hospital No: F24452 Ward: FOPDate of collection: 08/08/04 Date of Birth: 04/01/1948Specimen no: U396543 Test required: Microscopy, culture and antibiotic susceptibility Clinical details: PUO for evaluation-urine routine shows-acidic urine and bacteria Gram stain- Plenty of epithelial cells, many gram positive bacilli Specimen not fit for culture-culture deferred. The microscopy result was telephonically informed by Dr Rajesh to Dr.Chandrasekar on 08/08/04 Decided to defer urine culture, if necessary to later date. Suggest-Repeat blood widal (last one negative) and Blood culture, as patient gives two weeks history of fever Specimen number: FINALAuthorised by: P.K.Rajesh Contact- 98410 32583 Date: 08/08/04

10. Patient’s name : F: M MOHAMMED JALALUDDIN X Specimen details: Mid-stream urine Hospital No: M23465 Ward: MOP /M4 Date of collection: 09/05/04 Date of Birth: 20.3.1968Specimen number: U22222 Test required: Microscopy, culture and sensitivity Clinical details: burning micturition Urine microscopy: White blood cells: +++, Epithelial cells: 0, Red blood cells: 0 Urine culture: Pure growth of Escherichia coli > 10^5 colonies/mL Sensitive to: Co-amoxiclav, nitrofurantoin, ciprofloxacin, gentamicin Resistant to: Amoxicillin, cefalexin Report status: FINALAuthorised by:Date: 10/05/04

11. Case 001-bloody pis! 28-year old Mrs. JB who appears toxic got admitted to the hospital with giddiness and a two day history of fever, burning sensation on urination, pain in the loin and suprapubic area Mrs. JB gave the past history of similar complaints 3 years ago during her second pregnancy and also of getting treatment for renal calculi. Her last menstrual period was 8 days ago.

12. More on the case Mrs. JB gave the family history of her mother, father and elder sister suffering from diabetes mellitus. The clean-catch, midstream specimen of urine is collected and sent for microbiological examination. Rajesh insisted and the blood sample was sent for culture and sensitivity.

13. More on the case Urine analysis report: Color and appearance: light yellow and turbid Specific gravity: 1.010 pH: 6 Glucose: NIL Ketone bodies: NIL Protein: NIL Uribilinogen: NIL Bilirubin: NIL Leucocyte esterase: POSITIVE Occult blood: NIL Nitrates: NEGATIVE WBC casts: PRESENT

14. Urine culture-Mac Conkey

15. Urine culture-MHA

16. The plot thickens Blood culture grew the same organism with a similar sensitivity pattern?

17. Leave no stone unturned A 21-year old female student was admitted to a hospital with a fever and loin pain. After obtaining diagnostic cultures, the house officer ordered empirical antibiotics and ordered her to drink 3 liters of water in the next 24 hours. Shortly after this, the student experienced severe pain radiating into the groin. An X-ray was hurriedly arranged for.

18. More on the case Urine analysis report: Color and appearance: yellow and turbid Specific gravity: 1.010 pH: 7.6 Glucose: NIL Ketone bodies: NIL Protein: NIL Uribilinogen: NIL Bilirubin: NIL Leucocyte esterase: POSITIVE Occult blood: POSITIVE Nitrates: POSITIVE WBC casts: PRESENT

20. Rajesh UTI/GNB formula Organism Motility E.coli Motile Klebsiella Nonmotile Proteus Motile Pseudomonas Motile Mac conkey Lactose fermenting Non lactose fermenting Non fermenting/ Pigmented-green Serratia MotileNon fermenting/ Pigmented-Magenta E.coli is citrate negative Kleb is +ve Proteus swarms Pseudo is oxidase +ve

21. A 70 year old female diabetic who reveals a history of recurrent UTI and habitual self treatment with antibiotics, presents with burning micturition. Gram staining revealed…….

22. A 24-year old hotel receptionist has a 2-day history of increased frequency of urine, dysuria and haematuria. She also complained of suprapubic pain but there is no vaginal discharge. The doctor obtains a midstream urine specimen (MSU), which appears cloudy and requests for microbiology and microscopy report.

23. Plenty of white blood cells mm; few red cells /mm; moderate number of epithelial cells seen. Moderate number of Gram positive cocci and few Gram positive bacilli

24. Culture of the urine grew a pure culture of >10 3 /ml of Staphylococcus saprophyticus, and sensitive to trimethoprim. The patient’s symptoms completely disappeared after 2-3 days of a 5-day course of trimethoprim, and a follow up urine sample taken after the course was sterile.

25. What is the interpretation of the above microscopic report? Could the isolation of Staphylococcus saprophyticus here not represent skin contamination as indicated by microscopy? Does the patient require further investigation?

26. Will you wait for culture results or start antibiotics in a case of acute UTI?

27. Urinalysis of a 40 year old middle eastern man shows many red blood cells, few white blood cells and an oval-shaped parasitic egg with terminal spines. What organism is likely to cause his haematuria? A.Schistosoma haematobium B.Trichomonas vaginalis C.Enterobius vermicularis D.Entamoeba histolytica