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tractinfection tractinfe ction infection tract infection infectionppt infection尿路感染
Urinary Tract Infection 尿路感染 Nephrology Department Xuan Wu Hospital The Capital University of Medical Sciences Outline 提纲 • Definition • Epidemiology • Classification • Microbiology • Pathogenesis • Presentations Acute cystitis Acute pyelonephritis Chronic pyelonephritis • Complications • Diagnosis • Differentiation • Recurrent infection • Asymptomatic bacteriuria • Urethral syndrome • Therapy Definition 定义 • Urinary tract infection is a general term indicating the invasion of microorganisms into a previously sterile urinary system. Urinary tract 尿路 Intravenous pyelography 静脉肾盂造影 Epidemiology 流行病学 • Be seen most frequently in women. -Symptomatic infection: childbearing years, 18 to 40 years. Approximately 10%~20% of women experience symptomatic urinary tract infections during their lifetime. -Asymptomatic bacteriuria: elderly women. • Infections in males most frequently occur after 40 years associated with prostatic obstruction or calculi. Classification 分类 • Type of microorganism: bacterial, fungal, viral • Site of infection: lower, upper urinary tract • Presence or absence of symptoms • Acute or chronic infection • Presence or absence of complicating diseases or urinary tract abnormalities • First or persistent infection Microbiology 微生物学 • Escherichia coli 大肠埃希杆菌(90%) • Klebsiella 克雷伯杆菌 • Enterobacter 肠菌属 • Pseudomonas 假单胞菌属 • Proteus 变形杆菌属 • Staphylococcus 葡萄球菌 • Enterococcus 肠球菌 • Chlamydia trachomatis 沙眼衣原体 Pathogenesis 发病机理 • The routs of bacteria to the kidney -Ascending infection: principal pathway urethra, bladder, ureter, pelvis, parenchyma -Hematogenous spread -Lymphogenous spread Pathogenesis 发病机理 • Local host defense -Length of male urethra -Prostatic antibacterial factor -Normal vaginal flora 菌群 -Cervicovaginal antibody production -Voiding 排空 mechanism -Bladder surface glycosaminoglycan 葡糖胺 -Competent vesicoureteral 膀胱输尿管 valves -Urinary acidification, concentration, ammoniagenesis -Tamm-Horsfall mucoprotein Pathogenesis 发病机理 • Organism virulence factors -Pili attachment mechanisms -Glycocalyx 多糖蛋白质复合物–mediated adherence -K antigen -Urease 脲酶 production -Resistance to serum bactericidal 杀菌的 activity -Hemolysin 溶血素 production -Aerobactin 有氧素 production -Motility -Capacity to persist as cell wall-free protoplasts 原生质体 Pathogenesis 发病机理 • Causes of urinary tract obstruction -Prostatism: benign prostatic hypertrophy, carcinoma -Renal or bladder calculi -Gravid uterus 妊娠子宫, pregnancy-related vascular hypertrophy 肥大 -Congenital 先天, postinfectious strictures 狭窄 -Primary or metastatic 转移 malignancy 恶性肿瘤 -Retroperitoneal fibrosis 腹膜后纤维化 -Blood clots -Cyst -Nephrocalcinosis 肾脏钙化 -Uric acid nephropathy 尿酸性肾病 -Intrarenal parenchymal scarring 肾内实质斑痕 Clinical presentations 临床表现 • Dysturia 尿痛: the painful passage of urine. • Cause: -Urinary tract infection -Vaginitis 阴道炎 -Genital 生殖器 infection -Estrogen 雌激素deficiency -Interstitial cystitis -Chemical irritants -Impedance flow -Systemic or regional disease -Bladder tumor Clinical presentations 临床表现 • Frequency of urination (pollakiuria 尿频) is more prominent than dysuria and may occur alone. • Frequency≠polyuria • Cause: bladder abnormalities (contraction or obstruction). • Burning 灼热, frequency 尿频, urgency 尿急, and the sensation of incomplete voiding are present. Acute cystitis 急性膀胱炎 • Acute cystitis is an infection of the bladder most commonly due to coliform bacteria and occasionally gram-positive bacteria. • Symptoms: dysuria, frequency, urgency, suprapubic 耻骨上 pain, without fever and back pain. • Signs: suprapubic tenderness 压痛 • Lab: pyuria 脓尿 and bacteriuria, urine culture is positive. Acute pyelonephritis 急性肾盂肾炎 • Acute pyelonephritis is an infectious inflammatory disease involving the kidney parenchyma and renal pelvis. • Symptoms: fever, flank 胁腹 pain, shaking chills, irritative voiding symptoms 排空刺激 症 (urgency, frequency, dysuria), nausea, vomiting, diarrhea. • Signs: tachycardia, costovertebral 肋椎 angle tenderness. Acute pyelonephritis 急性肾盂肾炎 • Lab: -Leukocytosis and a left shift -Pyuria, bacteriuria, hematuria -White cell casts -Urine culture is positive • Image: -Hydronephrosis 肾盂积水 from a stone or other source of obstruction in complicated pyelonephritis Chronic pyelonephritis 慢性肾盂肾炎 • Recurrent episodes of acute pyelonephtitis producing kedney damage. Chronic pyelonephritis 慢性肾盂肾炎 • Signs and symptoms: Impaired kidney function Loss of urine concentrating ability • Diagnosis: Ultrasonography IV pyelography Urinary sediment Urine bacteriology Complications 并发症 • Sepsis related to gram-negative organisms • Intrarenal and perirenal abscesses • Papillary necrosis Complications 并发症 • Causes: -Diabetes mellitus -Immunosuppression -Urinary tract obstruction -Clinical deterioration or failure of fever to respond to appropriate antibiotic therapy within 72 hours • Diagnosis: -Severe renal infection with delayed response to antibacterial therapy, CT is sensitive in detecting. Diagnosis 诊断 • Criterion: -Bacteriuria: ≥100,000 bacteria per milliliter from a voided clean-catch specimen. -Pyuria: ≥5 WBC per high power field. Differentiation 鉴别 • The site of infection between upper and lower tract -Clinical findings: fever -Cystoscopy 膀胱镜 -Bladder washout technique -Renal concentrating defects -Radiologic appearances -Serum antibody titers to the somatic O antigen of gram-negative bacilli -Serum antibodies to Tamm-Horsfall protein Differential diagnosis 鉴别诊断 DiseaseDistinction Appendicitis 阑阑尾炎a normal urinalysis Cholecystitis 胆囊炎a normal urinalysis Pancreatitis 胰腺炎a normal urinalysis Diverticulitis 憩室炎a normal urinalysis Lower lobe pneumonia 下叶肺炎 an abnormal chest radiograph Acute epididymitis 急性附睾炎location of pain Acute prostatitis 急性前列腺炎location of pain Recurrent infection 反复感染 • Relapse 复发: a prompt recurrence with the same organism following treatment within a short period. • Reinfection 再感染: recurrence with a different organism at variable time interval. Asympomatic bacteriuria 无症状菌尿 • The presence of reproducibly significant urinary bacterial growth in patients evaluated for nonrenal complaints or on screening surveys. Urethral syndrome 尿道综合症 • Approximately 50% of women with frequency and dysuria syndrome but no bacterial growth or colony counts below 100,000 organisms per milliliter on urine culture. Therapy 治疗 Acute cystitis 急性膀胱炎 • Single-dose antibacterial therapy for 1~3 days. amoxicillin 阿莫西林 3g sulphamethoxazole 磺胺甲唖唑 2.0g ofloxacin 氧氟沙星 0.4g • Relapse in women, first infection in men, immunocompromised patients and patients with bladder catheter: antibacterial therapy for 7~14 days. • Chronic relapsing infection: 6 months discontinue medication. Therapy 治疗 Acute pyelonephritis 急性肾盂肾炎 • Broad-spectrum coverage for gram- negative organisms and enterococci • Urine cultures are indicated for definitive identification of the pathogen and its antimicrobial sensitivities. • Parenteral therapy should be maintained for 24 hours after the temperature falls to normal, and oral treatment can be started to complete a 14-days course. Therapy 治疗 Chronic pyelonephritis 慢性肾盂肾炎 • Long-term treatment if elimination of obstruction is not possible. • Modify dose in impaired renal function, monitor blood levels if possible. Reference • Textbook of Nephrology Vol.1 • Cecil Textbook of Medicine 22th Edition Vol.1






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