Urinary Tract Infection
2nd Affiliated Hospital
ZJ University
Yu Gong
Epidemiology of UTI by Age Group and Sex
Balance
Host
Pathogen
Host defenses:
miscellaneous
• Multi-layer transitional cells
• Urinary immunoglobulins :
Tamm-Horsfall protein
• Spontaneous exfoliation of uroepithelial
cells with bacterial detachment
• Mechanical flushing of micturition
Come with a rush, go with a flush!
Pathogens
Bacteria of UTI
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Bacterial Species Outpatients (%)
Escherichia coli
89.2
Proteus mirabilis
3.2
Klebsiella pneumoniae
2.4
Enterococci
2.0
Enterobacter aerogenes
0.8
Pseudomonas aeruginosa 0.4
Proteus species
0.4
Serratia marcescens
0.0
Staphylococcus epidermidis 1.6
Staphylococcus aureus
0.0
Inpatients (%)
52.7
12.7
9.3
7.3
4.0
6.0
3.3
3.3
0.7
0.7
Opportunistic pathogens
Fungal Pathogens
Most such infection occurs in patients :
• with long indwelling Foley catheters
• receiving broad-spectrum antibacterial
therapy
• diabetes mellitus
• on corticosteroids
Other Pathogens
• C. Trachomatis
• U. Urealyticum
Chronic Urethritis
Chronic Prostatitis
Urinary Tract Infection (UTI)
• Upper UTI－pyelonephritis
(renal abscess, perinephric abscess, Surgical
kidney)
• Lower UTI －cystitis
(urethritis)
Surgical kidney
Pyelonephritis
Pyelonephritis —— inflammation of
the kidney and its pelvis
PATHOGENESIS
How bacteria reach the urinary tract in
general and the kidney in particular?
Pathogenesis
Two potential routes :
(1) hematogenous infection
bacteremia → kidney
(Descending)
(2) retrograde infection
urethra→bladder→ ureter →kidney
(ascending)
Hematogenous Infection
Because the kidneys receive 20% to 25% of
the cardiac output, any microorganism that
reaches the bloodstream can be delivered to
the kidneys.
Hematogenous Infection
Existing infection (skin, respiratory tract)
blood circulation
small abscess
renal papillary
kidney(cortex)
renal tubular
renal pelvis
PATHOGENESIS
Factors predisposing to pyelonephritis
• Urinary Tract Obstruction
• Vesicoureteral Reflux
• Instrumentation of the Urinary Tract
• Pregnancy
• Diabetes Mellitus
How long will there be possibility of UTI
after urethral catheterization?
Diabetes Mellitus
• 3-4 times UTIs in DM than in non-diabetes
• Diabetic neuropathy and vascular injury
affects bladder emptying(paralytic bladder)
• hyperglycemia impact host immuno system
Clinical Presentation
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fever
back pain
colicky abdominal pain
nausea and vomiting
Sepsis, septic shock
Clinical Presentation
Cystitis
• Suprapubic region pain
• frequency, urgent urination, odynuria and dysuria
Complications
• Sepsis
• Peri-renal abscess
• Renal papillary necrosis/Acute renal failure
Laboratory findings
• Urine dipstick
pyuria on microscopic examination
urine WBC
> 3 WBC/high-power field
• Middle stream urine culture
bacterial account > 105cfu/ml
(cfu:clony-forming units)
• blood culture
Treatment
• Rest
• Drinking large amount of water
• Antibiotics: 2 weeks / until symptom free
• Treat related diseases: diabetes, renal stones, etc
Antibiotic therapy
• Objective
- prevention of sepsis
- eradication of organism
- prevention if recurrences
• Medications
- trimethoprim-sulfamethoxazole(SMZ)
- fluoroquinolones
- ampicillin
Catheter-associated UTI
• Over 1 million catheter-associated UTIs occur
in the US each year
• Risk factors:
duration of catheterization: mostly at 72 hours
after catheterization (Bacteria film)
Remove catheter as early as possible
Change catheter
Any abnormalities of structural,
or functional causes should be
excluded when UTI was diagnosed
and treated.
Take radical measures, insted of
providing temporary solutions
治标，更要治本
Genitourinary
Tuberculosis
Epidemiology
• 8~10 million new active cases of TB each
year(WHO)
• TB is the most common opportunistic infection in
AIDS patients(WHO)
Transmission and Development
• Genitourinary TB is caused by metastatic spread
of the organism through bloodstream during initial
infection (hematogenous).
• Kidney is usually the primary organ infected in
urinary disease
• Primary site for infection of genital system is often
the epididymis in men and the fallopian tubes in
women
Pathological renal TB
Parenchyma to Collecting system
Clinical renal TB
Clinical Features
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Most patients are aged 20~40 years
Some cases with Pulmonary tuberculosis
Bladder is always the spokesman for renal TB
Urologist should always consider the diagnosis
of genitourinary TB in a patient presenting with
vague, long-standing urinary symptoms for
which there is no obvious cause
Diagnosis
• Urine examination (Sterile pyuria, pH<7,
WBC, RBC, Pro)
• Urine : Acid-fast bacilli (AFB)
• Blood: TB-Antibody
• Imageology (Ultrasonography, Plain film,
IVU, RGP, CU, CTU, )
• Cystoscopy and Biopsy
Acutely inflamed ureteric orifice
Tuberculosis bullous granulations
Hyperemia and tuberculosis ulcer
1. Severe calyceal and parenchymal destruction
Multiple stricture of ureter
Moth-eaten sign
2. Contracted bladder
RGP
Autonephrectomy
Lateral renal tuberculosis, Contralateral hydronephrosis
Calcification, parenchymal scarring, hydrocalycosis,
thickening of the walls of renal pelvis
Painting petal
Extensive tuberculosis of kidney
Antituberculous drugs
Isoniazid(INH), Rifampicin(RFP),
Streptomycin(SM), Pyrazinamide(PZA),
Ethambutol(EMB), PAS
Surgery
1. Excision of diseased tissue
(Partial )Nephrectomy, Abscess Drainage,
Epididymectomy
2. Reconstructive Surgery
Ureteral stricture, Augmentation cystoplasty,
Urinary conduit diversion(Bricker’s procedure,
ileum conduit), orthotopic Neobladder
Thank You