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Urinary tract infections

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Urinary tract infections

  1. 1. EVALUATION SEMINAR ON PRESENTED TO Dr. Santhrani Thaakur P.Bindu M.Pharmacy 1st year
  2. 2. Contents Introduction Terminology Classification of UTI Epidemiology Etiology Pathogenesis Risk factors Clinical presentation Diagnosis Treatment Conclusion References
  3. 3. Introduction• Symptomatic presence of micro organisms within the urinary tract i.e., kidney, ureters, bladder and urethra.• Associated with inflammation of urinary tract.
  4. 4. • Significant bacteriuria: presence of at least 105 bacteria/ml of urine.• Asymptomatic bacteriuria : bacteriuria with no symptoms.• Urethritis: infection of anterior urethral tract *dysuria, urgency and frequency of urination.• Cystitis: infection to urinary bladder *dysuria, frequency and urgency, pyuria and
  5. 5. • Acute pyelonephritis: infection of one/both kidneys; sometimes lower tract also. *pyuria, fever, painful micturition• Chronic pyelonephritis: particular type of pathology of kidney; may/may not be due to infection.
  6. 6. UTI - Terminology• Uncomplicated: UTI without underlying renal or neurologic disease.• Complicated: UTI with underlying structural, medical or neurologic disease.• Recurrent : > 3 symptomatic UTIs within 12 months following clinical therapy.• Reinfection: recurrent UTI caused by a different pathogen at any time• Relapse: recurrent UTI caused by same species causing original UTI within 2 wks after therapy.
  7. 7. UTI Upper Lower •Acute pyleonephritis •Cystitis •Chronic pyleonephriitis •Prostatitis •Interstitial pyleonephritis •Urethritis •Renal abscess •Perirenal abscess•Both upper & lower UTI are further divided intocomplicated and uncomplicated.
  8. 8. Epidemiology Seen in all age groups Infants up to 6 months – 2/1000 More common in boys than girls Women – at greater risk than men; prevalence 40-50% in women and 0.04% in men. 10% women have recurrent UTI in their life 7 million new cases of lower UTI / year 1 million hospitalizations / year Incidence of UTI increases in old age; 10% of men and 20% of women are infected.
  9. 9. Etiology• Acute uncomplicated UTI:• Escherichia coli – cause about 80% of UTI• 20% of UTI caused by- Gram negative enteric bacteria – Klebsiella, Proteus Gram positive cocci – Streptococcus faecalis Staphylococcus saprophyticus• S.saprophyticus – restricted to infections in young sexually active women.
  10. 10. Complicated UTI: Pseudomonas aeruginosa, Enterobacter & Serratia Isolated in hospital acquired infections and catheter associated UTI. Viruses - Rubella, Mumps and HIV Fungi - Candida, Histoplasma capsulatum Protozoa - T. vaginalis, S. haematobium
  11. 11. Pathogenesis• 4 routes of bacterial entry to urinary tract. 1) Ascending infection 2) Blood borne spread 3) Lymphatogenous spread 4) Direct extension from other organs
  12. 12. • Ascending Infection:  most common route.  organisms ascend through urethra into bladder. organism Colonize in perineal and periurethral areas Ascend to bladder, kidneys UTI
  13. 13. • Hematogenous spread: Blood borne spread to kidneys. Occurs in bacteraemia mostly S.aureus.
  14. 14. • Lymphatogenous spread:  Men- through rectal and colonic lymphatic vessels to prostrate and bladder.  Women- through periuterine lymphatics to urinary tract.• Direct extension from other organs:  Pelvic inflammatory diseases  Genito-urinary tract fistulas
  15. 15. • The organism:  E.coli – many strains present but only few cause infection.  Virulence factors: 1. fimbriae 2. resistance to serum bactericidal activity ; increased amounts of capsular K antigen activity 3. toxin production 4. production of urease enzyme (proteus sps)
  16. 16. Vesiculourethral reflux
  17. 17. UTI – RISK FACTORS1. Aging: diabetes mellitus urine retention impaired immune system2. Females: shorter urethra sexual intercourse contraceptives incomplete bladder emptying with age3. Males: prostatic hypertrophy bacterial prostatis age
  18. 18. UTI-CLINICAL PRESENTATION• Clinical manifestations depending on site of infection• Clinical manifestations depending on age of patient
  19. 19. Clinical manifestations depending on site of infection• Urethritis:  Discomfort in voiding  Dysuria  Urgency  frequency
  20. 20. • Cystitis:  dysuria, urgency and frequent urination  Pelvic discomfort  Abdominal pain  Pyuria• Hemorrhagic cystitis:  Visible blood in urine.  Irritating voiding symptoms
  21. 21. • Pyleonephritis:  Invasive nature  Suprapubic tenderness  Fever and chills  White blood cell casts in urine  Back pain  Nausea and vomitingComplications include sepsis, septic shockand death.
  22. 22. Clinical manifestations depending on age• Babies and infants:  Failure to thrive  Fever  Apathy  Diarrhoea• Children:  Dysuria, urgency, frequency  Haematuria  Acute abdominal pain  Vomiting
  23. 23. • Adults:  Lower UTI- frequency, urgency, dysuria, haematuria  Upper UTI- fever, rigor and lion pain and symptoms of lower UTI.• Elderly patients:  Mostly asymptomatic  Not diagnostic as the symptoms are common with age.
  24. 24. UTI- DIAGNOSIS• Microscopic examination of urine• Urinalysis• Urine culture• Imaging techniques – CT scan and MRI
  25. 25. Laboratory examination• Uncontaminated, midstream urine sample used.• Methods for urine collection: 1. stick on bags 2. catheterization 3. suprapubic aspiration(SPA) – gold standard for urine collection
  26. 26. Laboratory findings Normal Findings Abnormal findings• pH - 4.6 – 8.0• Appearance- clear •pH – Alkaline ( increases)• Color – pale to amber • Appearance – cloudy yellow • Color - deep amber• Odor – aromatic• Blood – none • Odor – foul smelling• Leukocyte esterase – •Blood – maybe present none •Leukocyte esterase -• WBC- absent present •WBC- present• Bacteria- absent •Bacteria- present
  27. 27. Urinalysis :• Presence of pus, white blood cells, red blood cells• Bacterial count > 105 /ml – significant bacteriuria• Leukocyte esterase dipstick test – WBC in urine• Nitrite dipstick test- pink colour
  28. 28. Urine culture : For pyelonephritis Not a rapid diagnostic tool >105 bacteria /ml Differential leukocyte count- Urine culture increased neutrophils
  29. 29. Diagnostic tests for adults with recurrent UTI• Intravenous pyelography / excretory urography
  30. 30. • Voiding cystourethrography• Cystoscopy• Manual pelvic and prostrate examination
  31. 31. UTI urinalysis Urine microscopy and culture Further investigation pyelonephritiAdult female Male s Children Lower UTI Any UTI Complicated Any UTITreat without Blood further Ultrasound cultures cystourethroinvestigation cystoscopy CT scan graphy Check renal
  32. 32. UTI - management• Symptomatic UTI- antibiotic therapy• Asymptomatic UTI- no treatment required except in special situations.• Non- specific therapy: • more water intake. • Maintaining acidity of urine by fluids like canberry juice.
  33. 33. Anti-microbial therapy• Goals of therapy:  Elimination of infection  Relief of acute symptoms  Prevention of recurrence and long term complications• Decision to hospitalize ??• Treatment considerations ??
  34. 34. • Ideal antibiotic for UTI :  Adequate coverage over E.coli  Concentration in urine  Duration of therapy  Low resistance  Cost  Low adverse effect profile
  35. 35. Principles of anti microbial therapy• Levels of antibiotic in urine but not in blood• Blood levels of antibiotic – important in pyleonephritis• Penicillins and cephalosporins – drugs of choice for UTI with renal failure.
  36. 36. treatment duration• Single dose therapy• 3 day course• 7 day course• 10 – 14 day course
  37. 37. Single dose therapya. Trimethoprim- sulfamethaxole bactrim–DS : TMP–160mg + SMZ–800mg co-trimoxazole-DS :TMP-160mg + SMZ-800mgb. Amoxicillin- clavulnate 500mg aceclav tab acmox- AG tabc. Amoxcillin 3gmd. Ciprofloxacin 500mg – alquin tabe. Norfloxacin 400mg – Actiflox-400 tab
  38. 38. • for uncomplicated UTI• Not for patients with 1. past history of complicated UTI 2. history of antibiotic resistance 3. history of relapse with single dose• advantages: compliance, cost, less side effects, less resistance• Disadvantages: increased recurrence or relapse
  39. 39. 3 day therapy• Efficacy same as 7 day therapy with less adverse effects• Drugs used include 1. quinolines 2. TMP-SMZ 3. betalactam antibiotics• Extended release ciprofloxacin 500mg for uncomplicated UTI 1000mg for complicated UTI
  40. 40. 7 day therapy• Used less for uncomplicated UTI• Useful in 1. recurrent cases 2. pregnancy 3. UTI with other risk factors 14 day therapy• For complicated UTI• High risk of mortality and morbidity
  41. 41. Pathogen specific treatment Pathogen Treatment optionsEscherichia coli Ceftriaxone 50mg/kg i.v /I.M Qday Pseudomonas Gentamycin 6-7.5mg /kg aeroginosa i.v Q8hr / Qday Klebsiella spsEnterobacter sps Ceftadizine 100- Proteus sps 150mg/kg/day i.v Q8hrEnterococcus sps Ampicillin 100- 200mg/kg/day Q6hr
  42. 42. Infection specific treatment Lower UTI 3day therapy preferred *Trimethoprim Cephalaxin *Nitrofurantion *ciprofloxacin Amoxicillin *Co-amoxiclav Norfloxacin
  43. 43. Antibiotic Dose Side effects contraindicationsCo-amoxiclav 375mg nausea, diarrhea, Penicillin every rashes, hepatitis hypersensitivity 8hrTrimethoprim 200mg Nausea, vomiting, Severe renal every pruritis, rashes failure, neonates 12hrCiprofloxacin 250mg Nausea, vomiting, CNS disorders every dizziness, Pregnancy 12hr convulsions, Children hallucinations, G6PD deficiency hepatitis, blood disorders, photosensitivityNitrofurantoin 100mg Nausea, vomiting, Renal failure every peripheral Neonates 12hr neuropathy, Porphyria pulmonary G6PD deficiency reactions
  44. 44. Acute pyelonephritis• Paranteral antibiotics• Cefuroxime – 750mg i.v. Q8h Gentamycin - 80-120g i.v. Q12h Ciprofloxacin – 200mg i.v. Q12h• 10-14 days treatment• Ceftazimide, imipenam, ciprofloxacin – for hospital acquired pyelonephritis
  45. 45. Asymptomatic bacteriuria• Children – treatment same as symptomatic bacteriuria• Adults – treatment required in cases of a. pregnancy b. patient with obstructive structural abnormalities
  46. 46. Bacteriuria in pregnancy• To prevent risk of pyelonephritis• 7 day course with following antibiotics  Cephalaxin  Nitrofurantoin  Amoxicillin• Therapy continued at regular intervals of pregnancy.
  47. 47. Relapsing UTI• 7-10 day course• If fails – 2week course / 6week course• Structural abnormalities corrected by surgery• 6week course – a. children b. adults with continuous symptoms c. high risk of renal damage
  48. 48. Prophylaxis for UTI• Single dose of trimethoprim 100mg / nitrofurantion 50mg• Long term low dose prophylaxis beneficial• Women- single dose of antibiotic after sexual intercourse.
  49. 49. Catheter associated UTI• Asymptomatic UTI develop in catheterized patients after 10-14 days.• Antibiotic treatment - eradicate organism but high chance of relapse.• Catheter removal before treatment is beneficial.
  50. 50. Antibiotics used in treatment
  51. 51. Sulfamethoxazole-trimethoprim Adverse effects: Mechanism of actiono Steven Johnsons syndromeo Dermatitiso Angiodemao GI disturbanceso Agranulocytosis Contraindicated ino Hypersensitivity to sulfa drugso Infantso Megaloblastic anaemia
  52. 52. nitrofurantoin Damages bacterial DNA. Reduced to reactive forms by bacterial nitroreductase- damage DNA, ribosomes Adverse effects:o Hypersensitivity pneumonitis,GI disturbances, haemolytic anaemia Contraindications:o Renal failure, neonates, pregnancy
  53. 53. Cefixime 3rd generation cephalosporin Disrupts synthesis of peptidoglycan of bacterial cell wall Adverse effects:o Rash, utricariao Diarrheao Thrombocytopeniao leucopenia
  54. 54. Amoxicillin Penicillin class antibiotic Inhibits cross linking of peptidoglycan polymer chains which is the major component of bacterial cell wall. Adverse effects:o Rasho GI disturbances, renal dysfunctiono Antibiotic associated colitis, lethergy Contraindications: penicillin hypersensitivity
  55. 55. Ciprofloxacin Fluoroquinoline antibiotic Inhibits DNA gyrase and topisomerase 1V, the enzymes necessary for separation of bacterial DNA – inhibit cell division Adverse effects:o Peripheral neuropathyo Rhabdomyolysiso Steven Johnsons syndromeo Hemolytic anaemia
  56. 56. Surgical treatmenta) Surgical removal of renal calculi, bladder calculib) Ureteroplastyc) Reimplatation of ureters if VUR present
  57. 57. Conclusion Urinary tract infections are the 2nd most common bacterial infections. Women are the most infected subjects in the population. Development of resistance to antibiotics by the bacteria result in problems during the treatment and lead to relapse or recurrence. Recent advances such as development of immunologicals like intranasal vaccines may result in life time cure of the infection
  58. 58. References• Clinical pharmacy and therapeutics by Roger Walker, Clive Edwards; 3rd edition; page 503 – 511.• Applied therapeutics the clinical use of drugs by Mary Anne konda- kimble; 8th edition; page456 – 465.