Transcript Urinary Tract Infection

Urinary tract infection
Piroon Mootsikapun M.D.
Infectious Dis Unit
Department of Medicine, KKU
Urinary Tract Infection
• Acute uncomplicated cystitis in women
• Acute uncomplicated pyelonephritis
• Acute complicated UTI
• Recurrent UTI
• Asymptomatic bacteriuria
• Prostatitic syndrome
Urinary Tract Infection
Acute uncomplicated cystitis in women
• Common 40-50% of adult women had at least 1
UTI in lifetime
Microbial cause
• E. coli
• S. saprophyticus
80%
5-20%
• Other: Klebsiella, Proteus, Enterococci
Urinary Tract Infection
Acute uncomplicated cystitis in women
• Clinical
• Dysuria, urgency, frequency, suprapubic
pain
• No urinary symptoms within 4 weeks before
• Laboratory
• > 10 WBC/mm3
• > 103 cfu/mm3
Urinary Tract Infection
Acute uncomplicated cystitis in women
Differential Dx
• acute urethritis
• acute vaginitis
Acute uncomplicated cystitis
Treatment
• Single dose therapy effective < 3 day
regimen but = longer duration
• TMP/SMX is standard ATB
• Quinolones =TMP/SMX efficacy as 3 dayRx
Ampicillin less effective than TMP/SMX
• Expected eradication of bacteriuria > 90%
Acute uncomplicated cystitis
Treatment
Drug
Dose
Days
Eradication rate
2-wk
> 2-wk
• Norfloxacin
400 BID x3d
95%
87%
• Ofloxacin
100 BID x3d
89%
-
• Ciprofloxacin
100 BID x3d
92%
83%
• TMP/SMX
480BID x3d
94%
84%
x3d
82%
75%
• B-lactam
Acute uncomplicated cystitis
Treatment
Drug
Dose
Days
Eradication rate
2-wk
> 2-wk
• Norfloxacin
800 mg
80%
76%
• Ofloxacin
400 mg
93%
-
• Ciprofloxacin
500 mg
89%
81%
• TMP/SMX
480 mg
89%
81%
66%
72%
• B-lactam
Recurrent cystitis
Treatment
• Urine culture
• Longer course of Rx with quinolones if
not used initially
• Prophylatic ATB
Recurrent cystitis
• Prophylactic ATB
•
•
•
•
•
•
•
•
•
Long term low dose
TMP/SMX
½ tab (80/400) OD
Norfloxacin
200 mg x3/wk
Ciprofloxacin
250 mg x3/wk
Post intercouse
TMP/SMX
½ tab (80/400)
Norfloxacin
200 mg
Ciprofloxacin
250 mg
Ofloxacin
200 mg
Urinary Tract Infection
Acute uncomplicated pyelonephritis
• Almost all cases occur in women
Pathogenesis
• ascending
• dissemination
Microbial cause
• E. coli
• GNR
• S. saprophyticus, Enterococci
Urinary Tract Infection
Acute uncomplicated pyelonephritis
• Clinical
• Fever, chill, flank pain
• No urological abnormality by clinical, Xray, ultrasound
• Laboratory
• > 10 WBC/mm3
• > 104 cfu/mm3
Urinary Tract Infection
Acute uncomplicated pyelonephritis
• Treatment
• as soon as possible to prevent renal
parenchymal damage and scarring
• In-patients – IV antibiotic
• Out-patient – oral ATB
Urinary Tract Infection
Acute uncomplicated pyelonephritis
• In-patient treatment
• Inability to maintain oral hydration
• Uncertain compliance
• Uncertain diagnosis
• Severe symptoms/toxicities
• Unable to return for follow up
• Pregnant
Acute uncomplicated pyelonephritis
GNR found only
• Ceftriaxone
1-2 gm
iv q 24 hr
• Gentamicin
3-5 mg/kg
iv q 24 hr
• Cefepime
1 gm
iv q 12 hr
• Gatifloxacin 400 mg
iv q 24 hr
• Levofloxacin 500 mg
iv q 24 hr
• Ciprofloxacin 200-400 mg
iv q 12 hr
Acute uncomplicated pyelonephritis
GPC also found -> enterococci?
• Add Ampicillin
1 gm iv q 6 hr
• Or Ampicillin/Sulbactam 1.5 gm iv q 6 hr
Urinary Tract Infection
Quinolones
Dose
Total 24 hr
Cmax
urine excretion
urine
Levofloxacin
500
70.7%
579
Gatifloxacin
400
69.7%
400
Moxifloxacin
400
16.9%
55
Ciprofloxacin
500
40.8%
585
Acute uncomplicated pyelonephritis
Transitional therapy (IV to oral ATB)
• When
• Significant clinical improvement (S&S)
• No fever at least 24 hour
• Stable vital sign (BP, PR,RR) at least 48 hr
• CBC - WBC return to normal
Acute uncomplicated pyelonephritis
Transitional therapy (IV to oral ATB)
• Switch therapy
• Step down therapy
Acute uncomplicated pyelonephritis
• Oral antibiotic (GNR only)
• Ofloxacin
200 mg
po q 12 hr
• Levofloxacin 300 mg
po q 24 hr
• Ciprofloxacin 500 mg
po q 12 hr
• Gatifloxacin
400 mg
po q 24 hr
• Cefipime
200 mg
po q 12 hr (alternative)
• Cefdinir
200 mg
po q 12 hr (alternative)
• Cefpodoxime 200 mg
po q 12 hr (alternative)
Acute uncomplicated pyelonephritis
• Oral antibiotic (enterococci)
• Amoxycillin 500 mg po q 8 hr
• Amoxycillin/clavulanate 1 gm po q 12 hr
• Cotrimoxazole
80/400 mg po q 12 hr
Urinary Tract Infection
Duration of treatment
• Conventional Rx – 10 -14
• Short course Rx -
7
days
days
• Mild to moderate case, rapid response
• Longer course Rx
3-4
weeks
• Severe case, slow response
• Prolonged treatment
• Focal abcess
Persistent febrile UTI
Possible cause
• ATB resistant pathogen, before or after
• Multiple pathogens
• Azotemia -> indequate drug delivery
• Papillary necrosis,
• Abscess – intrarenal, perirenal
• Obstruction – intraluminal, extraluminal
• Underlying dis that Impaired host defense
Recurrent acute pyelonephritis
Treatment
• Within 2 weeks
• Urine culture
• Ultrasound KUB
• Rx with another new class ATB
• > 2 weeks after previous episode
• Rx with ATB as previous episode
Complicated UTI
Complicated factor
• Catheter use
• > 100 cc residual urine – spinal cord ds
• Obstructive uropathy
• Vesicoureteral reflux
• azotemia due to intrinsic renal dis
• renal transplantation
Complicated UTI
Complicated factor
•
•
•
•
•
Men
Children
Nosocomial MDR infection
Pregnancy
Comorbid – diabetes, analgesic use
Complicated UTI
• Clinical
• Persistent febrile UTI after 3 days
• Recurrence UTI
• Renal colic
• Gross hematuria
• Infection with urea splitting pathogen
(Proteus)
Complicated UTI
• Approach
• Repeat urine culture
• Ultrasound KUB
• (Men) – prostatic massage urine C/S
Acute UTI with stone obstruction
and hydronephrosis
• Management other than ATB
• Consult urosurgeon
• Cystoscope –> ureteral stent ->
infection cleared -> stone removal
• If stent placement not possible ->
percutaneous nephrostomy tube (PNT)
UTI in patients with spinal cord injury
• Often without classic symptoms
• May present with back pain, abdominal
pain, lethargy, malodorous urine
• Usually polymicrobial with rapid and
constant change
• Pyuria – unclear significance
UTI in patients with spinal cord injury
Management
• Asymptomatic bacteriuria – not Rx
• Except
• Immunocompromised
• Before urinary instrumentation
• Proteus spp. infection
UTI in patients with spinal cord injury
Management of symptomatic UTI
• UA, Urine C/S
• Remove long indwelling cath and insert the
new one to eliminate colonization
• Start broad spectrum ATB cover NI
• Rx duration 7-14 days, episodic Rx only
• Follow up urine culture to determine cure
Recurrent UTI in women
• Clinical
• > 3 episodes of acute UTI in a year
• No urinary tract abnormalities
• Laboratory
• < 103 cfu/mm3 of uropathogen
Asymptomatic bacteriuria
• Clinical
• No urinary symptoms
• Laboratory
• > 10 WBC/mm3
• > 105 cfu/mm3 of same organism in 2
consecutive urine MSU cultures > 24 hours
apart
Asymptomatic bacteriuria
Sceening and treatment benefit only in
• Pregnancy
• Undergoing urological instrumentation
• Renal transplantation - unclear
Prostatitis syndrome
NIH/NIDDK system classification
Category
Description
• I
Acute bacterial prostatitis
• II
Chronic bacterial prostatitis
• III
Chronic pelvic pain syndrome
• III A
Inflammatory
• III B
Non-inflammatory
• IV
Asymptomatic inflammatory
prostatitis
Acute bacterial Prostatitis
Clinical
• Flu like symptoms
• Urinary symptoms
• Tense and tender prostate
• Most isolated E. coli
• Other GNR: Klebsiella, Proteus
• Prostate massage should not performed
Chronic bacterial Prostatitis
Clinical
Pain
• slow, gradual onset, perineal, testicular, tip
of penis, urethral, pain on ejaculation,
worsening by prolonged sitting
Urinary
• dysuria, frequency, urgency, hematuria
• Decrease libido, Lethargy
Chronic bacterial Prostatitis
Treatment
Source
Drug
Dose
Duration
No. Cure rate FU mo
Schaeffer 1990 Norfloxacin
400 BID
28
14
64
6
Pust 1989
Ofloxacin
200 BID
14
21
67
8
Naber 2000
Ciprofloxacin 500 BID
28
34
76
6
Thank you