Urological Infections

Urological Infections
Miss Rashmi Singh
June 2012
Overview
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UTI
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Simple
Complicated
High risk groups
Recurrent
Pyelonephritis
Epididymo-orchitis
Prostatitis
Rarities
UTI’s
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15% of all community prescribed abs
100,000 hospital admissions
40% of hospital acquired infections
Distressing for patients
Impact on quality of life
Can be significant cause of morbidity
in the elderly
Acute Uncomplicated Cystitis
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Acute cystitis in otherwise healthy individual
Usually women with no underlying urinary tract
abnormality
 70-80% E coli
 10-20% other coliforms (serratia, enterobacter, klebsiella,
morganella)
 6-7% Enterococci
 1% pseudomonas- suspect urological abnormality
 1-2% others- group B Strep, staph aureus, staph saprophyticus,
Coag negative staph, Candida
Diagnosis
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Symptoms
 Exclude vaginal discharge/irritation
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Urine dipstick can be sufficient
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Urine cultures if:
 Suspect acute pyelonephritis
 Atypical symptoms
 Symptoms persist or recur 2-4 weeks
after treatment
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>103 colony count microbiologically
diagnostic
Urine dipstick
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Leucocytes- 75-95% sensitive
 False negative –concentrated urine,
glycosuria, ascorbic acid, urobilinogen
 False positive- contamination
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Nitrites- low sensitivity 35-85%
 False negative- very common if low
bacterial count
 False positive- contamination.
 Use in conjunction with urine appearance
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MSU sensitivity affected by collection
technique, time taken to reach lab,
bacterial count etc
Antibiotic Therapy
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Clinical success significantly more likely with antibiotics
compared to placebo
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Local resistance patterns
Efficacy
Tolerability
Adverse effects
Compliance
Cost
Availability.
Local sensitivity patterns
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“simple” Ecoli
 Trimethoprim 60-70%
 Amoxicillin 50-60%
 Co-amoxiclav/cephalexin 70-80%- beware C. diff in >65yr
 Nitrofurantoin 90%- only for simple UTI. Poor renal
penetration
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Enterococci- most sensitive to amoxicillin. Resistant to
cephalosporins
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Pseudomonas- cipro only oral option- risk of C.diff
Others- d/w microbiology
Resistance patterns
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Increasing problem locally with multi resistant Ecoli and
coliforms (ESBL producer and AMP-C producer)
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15-20% incidence
Always resistant to amox, ceph and co-amoxiclav
80-90% resistance to trimethoprim and cipro
Can be sensitive to nitrofurantoin if simple UTI
Usually need parenteral antibiotics to eradicate
Follow up
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No need for routine urinalysis/MSU
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Re-treat with alternative antibiotic for 7/7
MSU for culture If symptoms do not resolve or resolve
and recur within 2 weeks
Acute pyelonephritis
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Rigors, fever > 38 degrees, flank pain, N&V
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Refer if vomiting, signs of sepsis or suspect complicating
factors.
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1-3 days parenteral antibiotics
Absent cystitis symptoms
Uss and KUB xray recommended to rule out obstruction
or calculi
14 days antibiotic treatment recommended
Who to Investigate?
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Recurrent episodes
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Persisting sterile pyuria
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Hx of urological disease/surgery
Atypical symptoms
Haematuria with equivocal symptoms/msu
results
Failure to respond to appropriate
antibiotics
Terminology
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Isolated UTI- first UTI or one separated by 6 months from a
previous infection
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Unresolved bacteriuria- urinary tract not sterilised
 Resistant to selected antibiotic
 Rapid development of resistant organism from previously
susceptible population
 Patient compliance problem
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Bacterial persistence-urine sterilised but repeat infection
with same organism
 Implies a persistent source of infection: stone, fistula
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Re-infection- new infection with new organism after a
previous infection eradicated
Recurrent UTIs
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At least 3 UTI’s within 12/12 or 2 UTI’s within 6/12 confirmed
by culture.
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Usually due to re-infection. Minority bacterial persistence
Usually young healthy women
Not necessary to routinely investigate
Antibiotics- reduce recurrences by 90% cf placebo
 Post coital
 Self diagnosis and self start
 Continuous low dose 3-6/12
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Trimethoprim, nitrofurantoin, cephalexin
Other measures
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Lifestyle measures
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Avoid spermicides
Fluids
Regular bladder emptyng
Local hygiene/avoidance of artificial products
Oral pro-biotics- lactobacillus strain
Topical yoghurt!
Cranberry juice
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small number of weak clinical studies.
No pharmacological data
Useful in reducing the recurrence rate of cystitis
36mg/day proanthocyainidin A
UTI’s and pregnancy
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Common
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All should be screened in first trimester and
treated if positive
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Regular urine cultures
Asymptomatic bacteriuria before pregnancy
20-40% will get acute pyelonephritis
Asssociated with increased risk of pre-term
labour and LBW
Consider low dose prophylaxis if history of
recurrent UTI’s
UTI’s in post menopausal women
Risk Factors
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Catheters
Institutionalised
Atrophic vaginitis
Incontinence/prolapse
Post void residual urine
History of premenopausal UTI’s
Treatment
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As for pre-menopausal
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Topical oestrogens to re-colonize with lactobacilli
Asymptomatic bacteriuria common- should not be
treated
Rule out obstruction/neurogenic bladder/malignancy
Catheter associated UTI’s
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Commonest non-socomial infection
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Beware bladder cancer
Risk increases with longer catheter time (>30 days)
Use closed systems. Change promptly
Keep drainage bag below bladder level
Hand hygiene/sterile gloves/aseptic technique
Routine ab prophylaxis not recommended
Do not treat asymptomatic bacteriuria
Consider alternatives e.gsuprapubic, conveen,
CISC
UTI and Diabetes
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Females prone to asymptomatic bacteriuria
More likely to progress to acute pyelonephritis
Abscess formation
Emphysematous pyelonephritis
Interstitial nephropathy
Papillary necrosis
Autonomic neuropathy- voiding dyfunction
Complicated UTI
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Infection associated with underlying condition or
structural/functional abnormality of urinary tract
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Altered host defence mechanisms
Increased susceptibility to infection
Increased chance of therapy failure
Broader range of pathogens
More virulent/resistant e.g ESBL, pseudomonas, proteus
Usually require hospitalisation
Need to treat underlying condition
Factors suggesting complicated
UTI
UTI’s in males
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Uncommon in men aged 15-50
7 days minimum treatment
If febrile, usually concomitant prostate infection
 Need 2/52 quinolone
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Do not check PSA- elevated for up to 3/12
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Investigate if
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Febrile UTI
Pyelonephritis
Recurrent infections
Suspect complicating factors
Epididymo-Orchitis
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Post Mumps- 30% post pubertal boys .
 Haematogenous spread
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<35 associated with STD organisms
Older men- common urinary pathogens. BPH
TB causes chronic epididymitis
Complications
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Abscess formation
Chronic epididymitis in 15%
Testicular atrophy/infarction
Infertility
Clinical picture
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Acute onset over few days
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Swollen tender cord
Usually unilateral
Pain and swelling in tail and body of
epididymis +/- testis
Can mimic acute torsion
 Consider age
 Onset
 Hx of urethritis/STD
Investigation and management
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Urethral swab
MSU
Uss with doppler
Urology opinion if ? Torsion
<35 usually chlamydia- ofloxacin/doxycycline. Treat partner
>35 as for UTI- ciprofloxacin
NSAIDS/Scrotal support
Beware abscess in Diabetics, Hx scrotal surgery
Pain settles but up to 6-8 weeks for swelling to fully resolve
Classification of Prostatitis
Acute Bacterial Prostatitis
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Serious condition
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DRE- swollen boggy tender prostate
1% after TRUS biopsy
Fevers/rigors
Pain in perineum,testes, penis,lower back,
painful LUTS
May require hospitalisation
Usually E coli
Prostate abscesses need surgical drainage
PSA elevated for up to 3/12
Chronic AbacterialProstatitis
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Multifactorial/unclear origin
Negative cultures
2 weeks antibiotics (up to 6 weeks if response)
Alpha blockers/ 5 alpha reductase inhibitors
NSAIDS/tricyclics
Muscle relaxants
Prostatic massage 2-3x week
Transurethral microwave heat therapy
Holistic approach- physio/pain team/psychologists
30% resolution of symptoms within 1 year
Fourniers Gangrene
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Aggressive necrotising fasciitis of perineum and genitalia
Rare. Can be fatal
Diabetics
Immunosuppressed
malnourished
Elderly males
Nursing home
Indwelling catheters
Recent instrumentation/ perineal surgery
Presentation
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Severe sepsis
Painful, swollen, erythematous skin
Bullae/necrotic skin
Crepitus
Offensive smell
Urgent debridement and parenteral
antibiotics
Urogenital TB
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Common site of extra pulmonary TB
Kidney- calyceal deformities, scarring, auto nephrectomy
Ureters- strictures and obstruction
Bladder- ulceration and fibrosis. “thimble” bladder
Prostate- calcification. hard woody prostate
Epididymis- beaded cord. Abscesses. Infertility.
6/12 Anti TB therapy/surgery
Schistosomiasis (Bilharzia)
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Second commonest parasite
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Chronic renal failure/bladder
contraction/ carcinoma
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2 doses praziquantel
Parasite- schistosomahaematobium
Africa/Egypt. Swimming in Nile
Life cycle complex.
Flu like illness
Haematuria, frequency, terminal
dysuria