Management of uti
Post on 31-May-2015
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Javed IqbalFCPS, FRCS,
Professor Of Surgery
Quaid-e-Azam Medical College, &
Iqbal Minimal Invasive Surgery Center Bahawalpur
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Introduction
Most common type of bacterial infections
Although the urinary tract, unlike the respiratory tract or the gastrointestinal tract, is not exposed to the outside world, and is normally sterile.
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Urinary tract infection is diagnosed when bacteria and pus cells are recovered from the urine with or
without symptoms.
Definition
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UTI
Women during the reproductive years
Old age
Post-operative period
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“complicated” UTI Long-term foreign bodies such as indwelling
urinary catheters and stents. Urinary tract stones. Congenital or anatomic anomalies. Obstructive uropathy Vesicoureteric reflux, or structural urologic
abnormalities, including surgically created structural changes, such as ileal loops;
Neurogenic bladder disorder Renal transplantation.
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Why is the Concept of 'Complicated' Urinary
Tract Infections Useful in Practice?
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Complicated UTI
More chances of infection with bacteria that are resistant to first-line antibiotics
Less likely to respond to a short course (<7 days) of antibiotics; and
More likely to require microbiologic laboratory testing, follow-up assessment, and consideration of imaging procedures
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Premenopausal Women Nosocomial pathogens --recent hospitalization Diabetes mellitus Pregnancy Recent instrumentation or surgery Uremia from renal causes Anatomic abnormalities of the urinary tract Urinary tract stones Urinary stents or other foreign bodies Immunocompromised or immunosuppressed,
including from the use of immunosuppressive drugs; and a history of renal transplantation.
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Why are Women so Prone to Urinary Tract
Infections?
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Short urethra. Close proximity to the anus, vulva and
perineal area. In adults the UTIs have been shown to be
strongly and independently associated with recent sexual activity
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In infants below the age of three months
hematogenous spread
After this ageThe route of entry of pathogens is by ascending through the urethra, as in
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The organism most commonly associated with
UTI in children, as in adults, is E. coli
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Diagnosis is not always as straightforward as in adults, especially in neonates and very young children;
The risk of recurrence is relatively high The risk of complications, or long-term
sequela is relatively high, a risk that can be significantly reduced with timely diagnosis and prompt treatment.
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More extensive diagnostic investigations Greater emphasis on prompt and
appropriate treatment Longer follow-up after apparent cure
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What is Required for the Diagnosis of a Pediatric Urinary Tract Infection?
Urine Culture is must
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Again, women outnumber men as far as incidence is
concerned
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Urinary Tract Infections in the Elderly should always
be Considered 'Complicated'
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Non-specific, vague, or atypical clinical presentation
Decline in mental status
1
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The sensitivity of standard urinalysis for leukocyte esterase as a marker of infection is low.
Urine cultures
2
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Non-first-line antibiotics
short-course antibiotic therapy is much less likely to be effective.
3
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Wide variety of both Gram-negative and Gram-positive bacteria, and polymicrobial
infection is relatively common.
E. coli accounts for less than 50% of bacterial isolates in the elderly
4
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Treatment failures and recurrences, despite what would be considered appropriate and
adequate therapy, are common in
the elderly
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Why elderly are more prone to UTI
Oestrogen Anatomical changes due to
gyaenacological surgery Some degree of BOO in male Debilitating diseases resulting in
decreased immunity
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More than 100,000 colony-forming units (CFU)/mL of voided urine in a person
with no symptoms of UTI
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Asymptomatic Bacteriuria in elderly
The current view is that it should not be treated
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Pregnant Patients
1. asymptomatic bacteriuria
2. symptomatic lower UTIs
3. pyelonephritis
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Asymptomatic bacteriuria
It should be treated E-coli is the common bug First line treatment is the choice Duration should be short Recurrence should be monitored
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Patients with Anatomic Abnormalities of the
Urinary Tract
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Patients with congenital developmental or anatomic anomalies;
Patients with surgically created anatomic changes in the urinary tract;
Patients with any kind of obstructive uropathy; Patients with urinary tract stones; and Patients with long-term foreign bodies in the
urinary tract, such as stents or indwelling catheters
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Infected with a wider range of bacteria They sustain renal damage and scarring
as a result of infection They have a high risk of poor response to
antibiotic therapy.
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Catheter-related Urinary Tract Infection
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Risk Factors
longer duration of catheterization female sex poor catheter care inadequate use of antibiotics
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Can Urinary Tract Infection be Prevented in Catheterized Patients?
Minimal duration Close system Intermittent cathetrization Supra-pubic cystostomy
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Should Asymptomatic Bacteriuria in
Catheterized Patients be Treated?
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Chronic (Bacterial) Prostatitis
Chronic Pelvic Pain Syndrome
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UTI was first treated with sulfonamides during the
Second World War in 1939 by the Nobel Prize Winner
Gerhard Domagk
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Non specific therapies
Hydration and increased fluid intake; E. coli do not grow in a low osmolar
(dilute) urine. Alkalinization of the urine: dissolves urate
and oxalates crystals and less growth of E.coli
Urination after intercourse. Analgesia.
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General Considerations
Concentration in the urine Concentration in vaginal secretions Spectrum of activity against infecting
organisms Half-life Safety and adverse effect profile Cost
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Traditional First-line Agents for Uncomplicated Urinary Tract
Infections Amoxicillin Ampicillin Trimethoprim Trimethoprim–sulfamethoxazole
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First-line Agents
No role in Complicated UTI Very little role when the isolate is E-Coli
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Classification of Fluoroquinolones
What is the Anti-bacterial Activity of the Fluoroquinolones?
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Which Fluoroquinolones are Suitable as First-line Agents for Treatment of
Complicated Urinary Tract Infections?
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