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Dr. Sandeep Kumar Garg M.D (Internal Medicine) D.M (Nephrology)
Consultant NephrologistKidney Transplant Physician
MEERUT 9837285283www.sandepgargkidney.com
EPIDEMIOLGY UTI are the most common bacterial infection
Additionally , UTI is the most common cause ofnosocomial infection
Women make a significant proportion of UTI suffer”swith annual incidence of 12.1%
Peak incidence of UTI in women occurs between theages of 20-40 yrs
20-30% of women who have a UTI will have recurrentUTI(RUTI)
Epidemiology RUTI results in significant discomfort & have a high
impact on ambulatory health care cost as a result ofOPD visits, diagnostic tests & prescriptions.
RUTI is more common in post menopasal females dueto residual urine after voiding, which often associatedwith bladder or uterine prolaspe
In addition, the lack of estrogen causes markedchanges in vaginal microflora, including a loss oflactobacilli & increased colonization of E.Coli.
DEFINATION UTI is diagnosed in women by presence of at least
100,000 colony forming units (cfu)/ml in pure cultureof voided clean catch urine.
RUTI are caused by either re-emergence of bacteriafrom a site within the urinary tract (bacterialpersistence) or new infections from bacteria outsidethe urinary tract (reinfection).
RUTI is defined as three episodes of culture confirmedUTI in the last 12 mths or 2 episodes in last 6 mths.
RISK FACTORSWomen
Infections tend to recur.
Short urethra
Frequent sexual intercourse
Spermicidal cream
Diaphragm
.
RISK FACTORS
Menopausal females have decrease inestrogen, which leads to thinning of liningof the urinary tract, which increasessusceptibility to bacterial infections.
Pregnancy does not increase the risk ofgetting UTI but it can increase the risk ofdeveloping a serious infection that couldpotentially harm the mother & fetus
PATHOGENESIS The interaction between bacterial virulence & host
defense factors can ultimately results in UTI
More virulent bacteria are necessary to infecthealthy hosts with normal urinary tract, whereasless virulent bacteria may easily infectcompromised hosts
The cause of UTIs in women is usuallycolonization of the vagina & urethera with bacteriafrom the intestinal tract
BACTERIAL VIRULENCE
The initial step in pathogenesis of UTI is bacterialadherence to urothelium by pilli.
Pilli are filamentous adhesvie organelles inUropathogenic strains of E.coli (UPEC)
Bacterial colonization causes a host inflammatoryresponse, which includes neutrophil influx,followed by apoptosis & exfoliation of thebladder”s epithelial cells in an effort to rid thebladder of bacteria.
PATHOGENS IN UNCOMPLICATED UTI
E.Coli – 70 – 95 %
Staph Saprophyticus - 5- 20 %
Klebsiella
Entrococcus Faecalis
Proteus Mirabilis
HOST RISK FACTORS IN PATHOGENESISGenetic, anatomic, functional, & behavioralfactors that affect the host susceptibility touropathogens & its ability to overcome them.
Anatomical/FunctionalCongenital Abnormalties
Urinary Obstruction
Urinary Incontinence
Calculi
Residual Urine
Cathers or Foreign Bodies
Atrophic Vaginitis
Genetic
Blood group Antigen
Nonsecretor status
Density of adhesinreceptors
Behavioral
Sexual activity
Diaphragm use
Spermicide Use
Antimicrobial use
Risk Factors differ in Pre & Post Menopausal In sexually active pre-menopausal risk factors are:
Frequency of sexual intercourse
Spermicide Use
Age of First UTI (< 15 yrs of age indicates > risk of RUTI)
H/O UTI in the Mother (genetic factor or long term environmental exposures)
In Post menopausal risk factors are:
Vesical Prolaspe
Incontinence
Post Voiding residual Urine
Management of RUTI
Initial Evaluation of Females with RUTI Most women with RUTI do not have anatomic
abnormalities & do not need a X Ray
Assesment should include
History & physical Exam that include a pelvicexam
Pelvic USG for residual urine
Urine C/S for documenting that UTI is the cause ofsymptoms (typically , frequency, dysuria, &Haematuria)
Specialized Evaluation for RUTI
Congenital Abnormalities -
Either CT scan or IVP should be done
Prior Pelvic Surgery –
USG for checking HDN HU because of uretermay be caught in scarring due to stitch or clip during prior surgery
Cystoscopy to check the bladder for stitches which can form a nidus for stone or infection
Specialized Evaluation for RUTIUTI with Klebsiella, Pseudomonas or
Proteus bacteria – USG KUB is done becausethese bacteria have urease splitting enzymethat can alkalinize urine & may causeformation of struvite stones
Kidney Stones – check NCCT for stones,evidence of urinary obstruction.
Pyelonephritis – diagnosed by positive urineC/S , back pain and High fever
DIFFERENTIAL DIAGNOSIS OF RUTI Not all women with frequency, dysuria &
haematuria have UTI
In the case of RUTI, especially with negativecultures; a urogical & gynaecological evaluationshould be performed in order to exclude
Bladder cancer
Obstructive problems
Detrusor failure
Vaginal infections
Genital infection
Interstitial cystitis
Neurogical disease
Complications of RUTI
Acute Papillary necrosis
Overwhelming sepsis syndrome with shockdue to
Loss of vasomotor tone
Capillary Leak
Impaired myocardial performance
Perinephric abscess
TREATMENT of RUTI Primary Tt for RUTI should be guided by C/S
Commonly used antimicrobials that act on gramnegative uropathic organism include
Trimethoprim (TMP) & Co-trimoxazole (TMP-SMX)
Fluroquinolones (ciprofloxacin, levofloxacin, norfloxacin,ofloxacin, moxifloxacin)
Nitrofurantin
Beta–Lactams penicillins (amoxycillin, ampicillin-likecompounds, cefadroxil, cefuroxime, cefpodoxime)
Duration of Tt of 7-10 days increases rate of eradication& minimize resistance to drugs
DOSES RECOMMENDED
PREVENTION OF RUTIApproaches proposed for the prevention:
Non Pharmacological therapies,
Local estrogens for post menopausalfemales
Antimicrobial prophylaxis therapy: givenregularly or postcoital prophylaxis insexually active women
Immunoactive Prophylaxis
NON PHARMACOLOGICAL THERAPIESNon Pharmacological therapies have
doubtful role & include:
Adequate fluid intake
Voiding after sexual intercourse
Ingestion of cranberry juice
Eating yogurt ( lactobacilli Cultures)
Vaginal application of lactobacilli
Avoiding constipation
PROPHYLACTIC ANTIMICROBIAL
Continuous prophylactic antimicrobialtherapy
Post coital antimicrobial therapy
Self start antimicrobial therapy
CONTINUOUS PROPHYLACTIC ANTIMICROBIAL THERAPY
One effective approach for Mgmt is the prevention ofinfection by use of long term, prophylacticantimicrobials taken on a regular basis at bedtime
It is not known
Which antibiotic schedule is best
Optimal duration of prophylaxis
Incidence of adverse events
Recurrence of infections after stopping prophylaxis
Treatment compliance
CHOICE OF ANTIBIOTIC
TMP, Co-trimoxazole or nitrofurantin canstill be considered as the standard regimen.
In cases of Breakthrough infection due toresistant pathogens, low doses offlouroquinolones may be used
During pregnancy an oral first – generationcephalosporin is recommended
POST COITAL ANTIMICROBIAL THERAPY
It is an alternative prophylactic approach forwomen in whom episodes of infection areassociated with sexual intercourse
Same drugs can be used in the same doses asrecommended for continous prophylaxis
SELF START ANTIMICROBIAL THERAPYSuitable for mgmt in well informed women
in whom the rate of recurrent episodes isnot too common
This is not prophylaxis but early treatment
It has emerged in an effort to decreaseoverall antibiotic usage
It relies on pt’s intelligence andrecognization of UTI
Pt takes same antibiotics for 2-3 days
EFFICACY & SIDE EFFECT OF PROPHYLACTIC THERAPYNumber of pts with RUTI decreased by
eightfold after prophylaxis
UTI episode /pt year is reduced by 95%during prophylaxis
However, prophylaxis does not appear tomodify the natural history of RUTI or exerta longterm effect on the baseline infectionrate
EFFICACY & SIDE EFFECT OF PROPHYLACTIC THERAPYAfter stopping prophylaxis even after
extended periods, approximately 60 % ofwomen will become re–infected within 3-4mths
Side effects of prophylactic antimicrobialsinclude vaginal & oral candidiasis and GIsymptoms
RUTI IN PREGNANCYWomen with bacteria in urine during
pregnancy should be put on prophylaxis tilldelivery (penicillin or first generationcephalosporin)
Other options for pts whom are allergic isNFT or TMP-SMX
Women with bacteria with no symptoms andwhom are not pregnant do not need to betreated with antibiotics
CRANBERRY Cranberry (Botanical name - Vaccinium macrocarpon)
is a small evergreen shrub grown in bogs in dampforests and open ponds. It requires wet, boggy, acidicsoil
CRANBERRYCranberry is a North American native
Cranberry was a popular Tt of UTI prior tothe introduction of antibiotics, & continuesto be used widely for this purpose.
Cranberries (Proanthocyanidin) can inhibitthe attachment of bacteria to the epitheliallining of the urinary tract.
In vitro studies have observed potentinhibition of bacterial adherence of E.coli &other gram-negative uro-pathogens.
CONCLUSIONS FROM STUDIES
Cranberry has direct antibacterial activityCranberry may offer an alternative
methodology to antibiotic prophylaxis.Effect on type P-fimbriated E. coli was
observed to be specific to cranberry400 mg / day of shows reduction in RUTI In one uncontrolled study, more than 50%
of pts had a positive clinical response in UTI
D-MANNOSED-Mannose is a sugar monomer of the
alsohexose series of carbohydrates. Mannoseis a C-2 epimer of glucose.
D-mannose prevents binding of type 1-piliated E. coli to the human bladder cell line& reduces both adhesion & invasion of theE.coli.
It significantly reduce bacteriuria within 1day
Pts who were treated daily with D-Mannose,94% reported symptom improvement.
THE RIGHT COMBINATION‘ALTERNATIVE MEDICINE REVIEW’
suggests the use for Cranberry & D-Mannose as a natural option for the
mgmt of UTI. At the same time, Potassium salts are suggested to
alkalize the urine and reduce dysuria.
URIKIND-KM SACHETCranberry Extract...200mgD-Mannose...300mgPotassium Magnesium Citrate...978mgPer 5gm Sachet
Recommended doses:1 Sachet BID in 200ml water.
INPATIENT CARE FOR RUTI Necessity of admission depends upon Age, Host
factors, Risk of complicated infection, Likelihood ofmorbidity with failed OPD treatment
Pts with
Structural abnormality ( eg, calculi, Urinary tractabnormality , indewelling catheter , obstruction)
Metabolic disease ( eg, DM, CKD)
Impaired Host defense ( eg, HIV, Currentchemotherapy, underlying active
INPATIENT CARE FOR RUTIPts with uncomplicated Pyelonephritis
should be admitted
Pts unable to maintain oral hydration, shock, fever unresponding to antipyretic therapy
Pts with deblitating pain or dehydration that cannot be corrected in OPD
Pts with inadequate home care or resources to comply with medical regimen
TAKE HOME MESSAGE RUTI are a major issue for many women because
they are common, costly, & cause considerablemorbidity
Pts with RUTI should be properly investigatedby Lab & radiological techniques to excludecomplicated causes or gynecological problems.
Prophylactic therapy proved efficacy withdecrease rate of recurrence, minimal sideeffect & drug resistance but without alterationin natural history of disease
Thanks
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