泌尿系統(tǒng)感染

Urinarytractinfections(UTI)尿路感染2EpidemiologyThe

incidence

is

secondafterrespiratoryinfections50%-60%ofallfemaleshaveatleastoneepisodeofaUTIatsometimeintheirlives.AnatomyoftheurinarysystemKidneysfilterbloodUreterscarryurinetobladderBladderstoresurineuntilitisexpelled(throughurethra)OnlylowerpartofurethrahasaresidentbacterialfloraRestoftheurinarytractisnormallysterileUrinaryTractTermsUTI:thefindingofmicroorganismsinbladderurinewithorwithoutclinicalsymptomsandwithorwithoutrenaldiseaseSignificantbacteriuria（有意義細(xì)菌尿）:thefindingof>105cfu/mlofurine(butlowercountscanbesignificant)EtiologyofUTIE.coli(大腸桿菌）isthemostcommonpathogenHowever,alsocommonareotherEnterobacteriaceae(腸桿菌）Enterococci（腸球菌）:ofteninobstructiveuropathyYeasts（酵母菌）:dysbacteriosis(菌群失調(diào))UrinaryTractInfections:

RoutesofInfection（1）Ascendinginfection–mostcommonE.coli(~70%)大腸桿菌

–uropathogenicstrains腎盂腎炎菌株

Proteus變形桿菌屬,Pseudomonas假單胞菌屬,Klebsiella克雷伯菌屬,etc.(recurrent,hospitalacquired)（反復(fù)發(fā)作，醫(yī)院獲得性）上行感染ascendingroute：又稱逆行感染。最多見。（尿道→膀胱→輸尿管→腎臟）女性易尿感。致病菌：大多為大腸桿菌HematogenousDebilitatedpatients（衰弱病人）KidneyinjuryS.aureus金黃色葡萄球菌,groupAStrepA組鏈球菌,opportunistic(immunocompromised)免疫功能低下Clinicalsetting:septicemia敗血癥，endocarditis心內(nèi)膜炎血行感染hematogenousroute：少見。發(fā)生在原存在嚴(yán)重尿路梗阻或免疫力差患者常見為腎皮質(zhì)感染，致病菌多為金黃色葡萄球菌。腎結(jié)核。淋巴道途徑lymphaticroute

：更少直接感染extendinvaderoute

：最少見UrinaryTractInfections:

RoutesofInfection（2）Mechanical(Hydrokinetic)Chemical(Urine)ImmunologicalCellularVirulenceFactors致病因素HostDefenses宿主防御UrinaryTractInfections:

PathogenesisObstructionpredisposestoinfectionObstructioninterfereswitheradicationObstructionpredisposestorecurrenceObstruction+Infection

↑pressureinflammationischemiadirectinjuryChronicpyelonephritisUrinaryTractObstruction尿路梗阻:

RelationshipwithinfectionHydronephrosisInfectionAcuteRecurrent/persistentChronicobstructivepyelonephritisRenalfailureHypertensionUrinaryTractObstruction:

ConsequencesWeakenedbodyresistancetodisease機(jī)體抗病能力減弱DiabetesmellitusPregnancyRenalfailureImmunosuppressedpatientsIatrogenicfactors醫(yī)源性因素CatheterisationSurgery,e.g.prostatectomy導(dǎo)尿與尿路感染泌尿外科及術(shù)后病人中40%的醫(yī)院內(nèi)感染(Nosocomialinfection)發(fā)生在泌尿系統(tǒng)，而其中的80%與留置尿管有關(guān)一次導(dǎo)尿的感染機(jī)會為1%-2%留置導(dǎo)尿3-4天并行開放引流尿液，50%-70%的患者將有感染長期留置導(dǎo)尿管者（＞30天），細(xì)菌尿的發(fā)生為100%。ImpactofCAUTI(Catheter-associatedUrinaryTract

Infection)Mostcommontypeofhealthcare-associatedinfection>30%ofHAIsreportedtoNHSNEstimated>560,000nosocomialUTIsannuallyIncreasedmorbidity&mortalityEstimated13,000attributabledeathsannuallyLeadingcauseofsecondaryBSIwith~10%mortalityExcesslengthofstay–2-4daysIncreasedcost–

$0.4-0.5billionperyearnationallyUnnecessaryantimicrobialuse50%-60%ofallfemaleshaveatleastoneepisodeofaUTIatsometimeintheirlives.Whyfemales?ShorturethraProximityofurethratotheanusItsterminationwithinthelabiaUseofspermicidecontraceptivesPregnancyMenalsohaveanantibacterialsubstanceintheirprostateglandthatreducestheirrisk.診斷方法：癥狀+體征+實(shí)驗(yàn)室化驗(yàn)+輔助檢查Thesymptomsofurinarytractinfectionsmayvarywithageandthepartoftheurinarysystemthatwasaffected.Inyoungchildren,urinarytractinfectionsymptomsmayincludediarrhea,lossofappetite,nauseaandvomiting,feverandexcessivecryingthatcannotberesolvedbytypicalmeasures.Olderchildrenontheotherhandmayexperienceabdominalpain,orincontinence.Lowerurinarytractinfectionsinadultsmaymanifestwithsymptomsincludinghematuria(bloodintheurine)diagnosis:symptoms(1)LocalizationofupperversuslowerUTI:inpracticeFrequency,dysuria,andurgency(lowerUTIsymptoms)canoccurwithupperUTIaswell.Feverandflankpainindicateacuteupperurinarytractinfection.ScarringofthekidneybyimagingproceduressuggestschronicUTI.Thedistinctionissometimesdifficult.cystitisDysuriaUrgencyFrequencySuprapubicpainCloudy,foulsmellingurineHaematuria30%TendersuprapubisAcutepyelonephritisRapidlydevelopingsymptomsoverafewhoursoradayFever,chills,rigor,myalgiaNausea,vomiting,diarrhoeaRATortendernessondeeppalpationFeaturesofGramnegsepsisHaematuriaintheacutephaselaboratorydata:CollectionofSpecimensCleanmid-streamspecimenofurineEarlymorningsamplepreferredCatheterspecimenSuprapubicaspirationDifferentialspecimenfromtwouretersInstructionstothepatientsEarlytransporttothelabessential尿標(biāo)本的采集Urinecollection

：中段尿、導(dǎo)尿、穿刺-最可靠。

laboratoryUrinalysis:WBCs(>5perhigh-powerfield),RBCs,bacteria,castsUrinecultureDifferencebetweeninfectedandcontaminatedurine

InfectionContamination

Morethan105Organisms/mllessthan104

Organisms/ml

Asinglebacterialspp.MorethanoneorganismWhitebloodcellcastsHighlysignificant!Presencesuggestspyelonephritis白細(xì)胞管型提示腎盂腎炎Investigations(1)

RadiologyIndicatedin:RecurrenceMaleaffectationChildrenSeveresymptomsInvestigations(2)ToolsincludeIVU,USS,CTscanDetectscalculi,obstruction,incompleteemptyingMRIincontrastallergies

CLASSIFICATIONOFUTIs

Traditionally,UTIsareclassifiedbasedonclinicalsymptoms,laboratorydata,andmicrobiologicalfindings.Practically,UTIshavebeendividedinuncomplicatedandcomplicatedUTIs,andsepsis.CLASSIFICATIONOFUTIsEAUGUIDELINE：ANATOMICALLEVELOFINFECTIONsGRADEOFSEVERITYOFINFECTIONsUNDERLYINGRISKFACTORSsMICROBIOLOGICALFINDINGSThesymptoms,signsandlaboratoryfindingfocusontheanatomicallevelandthedegreeofseverityoftheinfection.Theriskfactoranalysiscontributestodefineanyadditionaltherapeuticmeasurerequired(i.e.drainage).

Anatomicallevelofinfection

URETHRAURETHRITISBLADDER

CYSTITISKIDNEYPYELONEPHRITISBLOODSTREAMSEPSIS

Gradeofseverity

complicatedUTIAcomplicatedUTIisaninfectionassociatedwithacondition,suchasstructuralorfunctionalabnormalitiesofthegenitourinarytractorthepresenceofanunderlyingdisease,whichincreasestherisksofacquiringaninfectionoroffailingtherapy.TwocriteriaaremandatorytodefineacomplicatedUTI:apositiveurinecultureandoneormoreofthefactorslistedinTableFactorsthatsuggestapotentialcomplicatedUTI

留置導(dǎo)尿或留有尿路支架、殘余尿超過100ml梗阻返流尿流改道放化療損傷尿路上皮圍手術(shù)期的尿路感染腎功能不全或腎移植、糖尿病TreatmentprinciplesUrineculturemustbedonebeforecommencingempiricaltherapyIdentifyandcorrectpredisposingfactorsIdentifytypeofUTIandtreataccordinglyPreventrecurrenceHowisaUrinaryTractInfectionTreated?restfluidsantibiotics:Thechoiceofdrugandlengthoftreatmentdependonthepatient'shistoryandtheurinetestresults.Thesensitivitytestisespeciallyusefulinhelpingthedoctorselectthemosteffectivedrug.Also:DrinkplentyofwaterQuitSmokingAvoidspicyfoods,coffee,andalcoholUsepainkillertoeasepainProphylaxisofUTI(1)NursingCare:HealthpromotiontopreventUTIFluidintake2–2.5Ldaily,moreifhotweatherorstrenuousactivityisinvolvedb. Emptybladderevery3–4hoursProphylaxisofUTI(2)c. Females1. Cleanseperinealareafromfronttoback2. Voidbeforeandaftersexualintercourse3. Maintainintegrityofperinealtissuesa.Avoiduseofcommercialfemininehygieneproductsordouchesb.Wearcottonunderweard.Maintainacidityofurine(useofcranberryjuice,takeVitaminC,avoidexcessmilkandmilkproducts,sodiumbicarbonate)女性注意事項(xiàng)：1清潔會陰：從前向后2性生活前后排尿3避免會陰受損Uncomplicated(simple)CystitisDefinitionHealthyadultwoman(overage12)Non-pregnantNofever,nausea,vomiting,flankpainDiagnosisDipstickurinalysis(nocultureorlabtestsneeded)TreatmentTrimethroprim/Sulfamethoxazolefor3daysMayusefluoroquinolone(ciprofoxacinorlevofloxacin)inpatientwithsulfaallergy,areaswithhighratesofbactrim-resistanceRiskfactors:SexualintercourseMayrecommendpost-coitalvoidingorprophylacticantibioticuse.ComplicatedCystitisDefinitionFemaleswithcomorbidmedicalconditionsAllmalepatientsIndwellingfoleycathetersUrosepsis/hospitalizationDiagnosisUrinalysis,UrinecultureFurtherlabs,ifappropriate.TreatmentFluoroquinolone(orotherbroadspectrumantibiotic)7-14daysoftreatment(dependingonseverity)Maytreatevenlonger(2-4weeks)inmaleswithUTIPyelonephritisInfectionofthekidneyAssociatedwithconstitutionalsymptoms–fever,nausea,vomiting,headacheDiagnosis:Urinalysis,urineculture,CBC,ChemistryTreatment:2-weeksofTrimethroprim/sulfamethoxazoleorfluoroquinoloneHospitalizationandIVantibioticsifpatientunabletotakepo.Complications:Perinephric/Renalabscess:Suspectinpatientwhoisnotimprovingonantibiotictherapy.Diagnosis:CTwithcontrast,renalultrasoundMayneedsurgicaldrainage.NephrolithiasiswithUTISuspectinpatientwithsevereflankpainNeedurologyconsultfortreatmentofkidneystoneProstatitisSymptoms:Painintheperineum,lowerabdomen,testicles,penis,andwithejaculation,bladderirritation,bladderoutletobstruction,andsometimesbloodinthesemenDiagnosis:Typicalclinicalhistory(fevers,chills,dysuria,malaise,myalgias,pelvic/perinealpain,cloudyurine)ThefindingofanedematousandtenderprostateonphysicalexaminationWillhaveanincreasedPSAUrinalysis,urinecultureTreatment:Trimethoprim/sulfamethoxazole,fluroquinoloneorotherbroadspectrumantibiotic4-6weeksoftreatmentRiskFactors:TraumaSexualabstinenceDehydrationUrethritisChlamydiatrachomatisFrequentlyasymptomaticinfemales,butcanpresentwithdysuria,dischargeorpelvicinflammatorydisease.SendUA,Urineculture(ifpyuriaseen,butnobacteria,suspectChlamydia)Pelvicexam–senddischargefromcervicalorurethralosforchlamydiaPCRChlamydiascreeningisnowrecommendedforallfemales≤25yearsTreatment:Azithromycin–1gpox1Doxycycline–100mgpoBIDx7daysNeisseriagonorrhoeaeMaypresentwithdysuria,discharge,PIDSendUA,urineculturePelvicexam–senddischargesamplesforgramstain,culture,PCRTreatment:Ceftriaxone–125mgIMx1Cipro–500mgpox1Levofloxacin–250mgpox1Ofloxacin–400mgpox1Spectinomycin–2gIMx1Youshouldalwaysalsotreatforchlamydiawhentreatingforgonnorhea!Question#1An18-yearoldwomanpresentswithurinaryfrequency,dysuria,andlow-gradefever.Urinalysisshowspyuriaandbacilli.Shehasneverhadsimilarsymptomsortreatmentforurinarytractinfection.Question#1WhatcategoryofUTIdoesthispatienthave?Doesthispatientrequirefurthertesting?Wouldyoutreatthispatient,andifso,withwhatandhowlong?Question#2An18-yearoldwomanpresentwithherthirdepisodeofurinaryfrequency,dysuria,andpyuriainthepast4months.Question#2Whatfurtherquestionsdoyouhaveforthispatient?WhattypeofUTIdoesthispatienthave?Whattestingmightyouperforminthispatient?Howwouldyoutreather,andforhowlong?Question#3 A24-yearoldwomanpresentswithfever,chills,nausea,vomiting,flankpainandtenderness.Hertemperatureis40°C,pulserateis120/min.,andbloodpressureis100/60mmHg.Question#3Whatfurtherstudiesdoyouwantinthispatient?Howwouldyoutreatthispatient?Whatmightyoudoifshedoesnotimproveafter3-4days?Question#4 A78-yearoldfemalepresentswithanindwellingfoleycatheterandpyuria.Question#4Whatwouldyoudoforthispatientatthistime?Howmightyourwork-up/managementchangeifshewashavingfeversandconfusion?Question#5 58-yearoldmanpresentswithhisfirstepisodeofurinaryfrequencyanddysuria.Urinalysisshowspyuriaandbacilli.Question#5WhattypeofUTIdoesthispatientlikelyhave?Howwouldyoutreatthisman,andforhowlong?WhatactivitieswouldputthispatientatriskforUTI?Question#6A28-yearoldmalehadasexualencounterwithaprostitutewhileonabusinesstripinSeattle1weekago.Afterreturninghome,henotedaburningsensationonurinationandayellowdischargeinhisunderwear.Microsc