1. Urinary tract infection Dr. Mai Banakhar

2. UTI inflammatory response of urothelium to bacterial invasion.

3. Bacteriuria : bacteria in urine Asymptomatic or symptomatic Bacteriuria + pyuria= infection Bacteriuria NO pyuria = colonization

4. Pyuria : WBCs in urine. Infection T.B Bladder stone.

5. Complicated VS uncomplicated Un complicated UTI: UTI structurally & functionally normal urinary tract. Female. Respond to short course of antibiotic Complicated UTI: Anatomical or funtional abnormality. Male. Longer time to respond to ttt

6. Isolated UTI: 6 months between infections.

7. Recurrent UTI:>2 infections in 6 months 3 UTI in 12 months. Reinfection by different bacteria. Persistence : same organism from focus within the urinary tract. Struvate stone. Bacterial prostatitis. Fistula Urethral diverticulum. atrophic infected kidney.

8. Unresolved infection: in adequate therapy, bacterial resistance to ttt.

9. Risk factors to bacteriuria Female Age Low estrogen ( menopause) Pregnancy. D.M Previous UTI. FC Stone GU malignancy. Obstruction. Voiding dysfunction. Institutionalized elderly

10. Microbiology Faecal-drived bacteria Uncomplicated UTI E.Coli, G-ve baccillus, (85%- 50%) Staph saprophyticus Enterococ faecalis Proteus Klebsiella. Complicated UTI E.coli 505 Enterococ faecalis. Staph aureus Staph epidermidis Pseudomonas aeruginosa

11. Route of infection Ascending Short urethra Reflux Impair urteric peristalisis. Pregnancy Obstruction G-ve, Edotoxins Organism P pili

12. Route of infection Haematogenous: Uncommon. Staph aureus. Candida fungemia. T.B Lymphatics: Rarely in inflammatory bowel disease, reteroperitoneal abscess

13. Increase UTI risk Increase bacterial virulence Protect against UTI Host defences

14. Factors increasing bacterial virulence Adhesion factors Toxins Enzyme production. Avoidance of host defense mechanisms

15. Factors increasing bacterial virulence Adhesion factors G-ve bacteria, Pili Attachment to host urothelial cells. Single type or different types e.x E.coli Defined functionally be mediating hemagglutination (HA) of specific erythrocytes Mannose –sensitive (type 1) Produced by all strains E.coli Certain pathogenic types of E.coli mannose resistant pili ( pyelonephritis)

16. Factors increasing bacterial virulence Avoidance of host defense mechanisms E.coli Extracellular capsule Immunogenisity phagocytosis M.Tuberculosis reisit phagocytosis by preventing phagolysosome fusion Toxins: E.coli cytokines, pathogenic effect on host tissues Enzyme production: Proteus ureases Ammonia struvite stone formation

17. Host defences Protective Mechanical (flushing of urine) antegrade flow of urine Tamm-Horsfall protein (mucopolysaccharide coating bladder prevent bacterial attachment) chemical : Low Urine PH & high osmolality Urinary Immunoglobulin I gA inhibit adherence

18. Lower UTI Cystitis: infection& inflammation of the bladder Frequency, samll volumes, dysuria, urgency, offensive urine SP pain, haematuria, fever & incontinence.

19. Investigation Dipstick of MSU WBC ( pyuria ) 75 -95% sensitivity infection False –ve False +ve Other causes of pyuria Nitrite testing: Bacteriuria. Specificity >90% Sensitivity 35- 85% + test ------- infection - --------infection

20. Investigation Microscopy : Bacteria : False –ve low bacterial count False +ve contamination (lactobacilli & corynebacteria ) epithelial cells RBCs & pyuria

21. Investigation Indications for further investigations in LUTI. Symptoms of Upper UTI. Recurrent UTI. Pregnancy Unusal infecting organism ( proteus suggest infection stone) KUB Ultrasound IVU cystoscopy

22. DD Non-infective cystitis: radiation cystitis Drud cystitis ( cyclophosphamide ) Haemorrhagic cystitis Urethritis

23. Treatment Aim : Eliminate bacterial growth from urine. Empirical ttt before culture & sensitivity for the most likely organism. Adgusted according to the culture & sensitivity. Resistance : Intrinsic (proteus) Genetically transferred between bacteria by R plasmids.

24. Recurrent UTI >2 in 6 months or 3 within 12 months Reinfection Bacterial persistence

25. Recurrent UTI Reinfection ( different bacteria) After prolonged interval with adifferent organism Reinfection in females No anatomical nor functional pathology In males BOO, urethral stricture Bacterial persistance ( same organism from a focus within tract) within short interval Functional or anatomical problem. The underlying problem should be treated

26. Management Reinfection UTI Females KUB, Ultrasound, cystoscopy Simple Reinfection TTT Avoid spermicides Estrogen replacement therapy dose antibiotic prophylaxis Low dose antibiotic prophylaxis

27. Female recurrent reinfection Prophylactic antibiotic: Reduce infection 90% at bed time 6-12 months Symptomatic reinfection Trimethoprim Nitrofurantoin Cephalexin Fluoroquinolones

28. Female recurrent reinfection Natural youghart Post-intercourse antibiotic prophylactic Self-started therapy

29. Management of bacteria persistance Investigations: Kub, renal ultrasound. C.T, IVU Cystoscopy Treatment : For the functional or anatomical anomaly

30. Antibiotics Empirical therapy. Definitive therapy. Bacterial resistance to drug therapy.

31. Acute pyelonephritis Clinical Dx: Flank pain Fever. Elevated WBCs DD: acute cholecystitis. Pancreatitis.

32. Acute pyelonephritis Risk factors: VUR UTO Spinal cord injury D.M Malformation pregnancy FC

33. Acute pyelonephritis Pathogenisis : Initially patchy Inflammatory bands from renal papilla to cortex. 80% E.coli, others klebsiella, proteus& pseudomonas.

34. Acute pyelonephritis Urine analysis & culture. CBC, U&E KUB & ultrasoundif no response with I.V antibiotic for 3 days go for CTU

35. Perinephric abscess Pathogenesis. Suspected?? C.T, ultrasound PC drainage. Open surgical

36. Pyonephrosis Infected hydronephrosis. Pus accumulation Causes Ultrasound. C.T Management: PCN, I.V antibiotic, I.V fluids.

37. Emphysematous pyelonephritis Severe form of acute pyelonephritis Gas forming organism Fever, abdominal pain with radiographic evidence of gas within the kidney. D.M Urinary obstruction. High glucose level-------fermentation,CO2 production

38. Emphysematous pyelonephritis Presentation: sever acute pyelonephritis High fever & systemic upset E.coli, commonly, Klebsiella & proteus less frequent

39. Management KUB Ultrasound, C.T Patients are unwell Mortality is high

40. Management Conservative ? I.V antibiotic, IVF PC drainage Control D.M Sepsis is poorly controlled Nephrectomy

41. Xanthogranulomatous pyelonephritis Severe renal infection Renal calculi & obstruction. Result in non-functioning kidney E.coli & proteus common. Macrophage full of fat deposit around the abscess Kidney, perinephric fat

42. Xanthogranulomatous pyelonephritis Acute flank pain Fever & tender flank mass C.T, Ultrasound Stone, mass ?? RCC

43. Xanthogranulomatous pyelonephritis IV antibiotic, Nephrectomy