尿路感染12187課件

尿路感染_12187UrinaryTractInfection(UTI)

UTIoccursinallpopulations,fromtheneonatetothegeriatricpatient,butithasaparticularimpacton:femalesofallages(especiallyduringpregnancy)malesatthetwoextremesoflifekidneytransplantpatientsanyonewithfunctionalorstructuralabnormalitiesoftheurinarytractUrinaryTractInfection(UTI)upperUTI－pyelonephritislowerUTI－cystitisPyelonephritis

DEFINITIONBACTERIOLOGYPATHOGENESISPATHOLOGYCLINICALPRESENTATIONSDIAGNOSTICEVALUATIONTREATMENTDEFINITION

Pyelonephritismeansinflammationofthekidneyanditspelvis,butfromahistoricalpointofviewandthroughcommonusage,thetermhascometodesignateadisorderofthekidneyresultingfrombacterialinvasion.PyelonephritisDEFINITION

BACTERIOLOGYPATHOGENESISPATHOLOGYCLINICALPRESENTATIONSDIAGNOSTICEVALUATIONTREATMENTBacteriologicFindingsAmong250Outpatientsand150InpatientswithUTI

BacterialSpeciesOutpatients(%)Inpatients(%)

Escherichiacoli

89.2

52.7

Proteusmirabilis3.212.7Klebsiellapneumoniae2.49.3Enterococci2.07.3Enterobacteraerogenes0.84.0Pseudomonasaeruginosa0.46.0Proteusspecies0.43.3Serratiamarcescens0.03.3Staphylococcusepidermidis1.60.7Staphylococcusaureus0.00.7FungalPathogensThemostcommonformoffungalinfectionoftheurinarytractiscausedbyCandidaspecies.Mostsuchinfectionoccursinpatients:withindwellingFoleycathetersreceivingbroad-spectrumantibacterialtherapydiabetesmellitusoncorticosteroidsOtherPathogensC.Trachomatis---importantcauseoftheacuteurethralsyndromeU.Urealyticum,M.Hominis---lesscommonAdenoviruses---1/4~1/2ofhemorrhagiccystitisinschoolchildrenPyelonephritisDEFINITIONBACTERIOLOGY

PATHOGENESISPATHOLOGYCLINICALPRESENTATIONSDIAGNOSTICEVALUATIONTREATMENTPATHOGENESIS

Howmicroorganisms,especiallybacteria,reachtheurinarytractingeneralandthekidneyinparticular?PATHOGENESIS

Twopotentialroutes:(1)thehematogenousroute,withseedingofthekidneyduringthecourseofbacteremia;(2)theascendingroute,fromtheurethratothebladder,thenfromthebladdertothekidneysviatheureters.

HematogenousInfectionBecausethekidneysreceive20%to25%ofthecardiacoutput,anymicroorganismthatreachesthebloodstreamcanbedeliveredtothekidneys.ThemajorcausesofhematogenousinfectionareS.aureus,Salmonellaspecies,P.aeruginosa,andCandidaspecies.HematogenousInfectionChronicinfections(skin,respiratorytract)bloodcirculationkidney(cortex)smallabscessrenaltubularrenalpelvisrenalpapillaryAscendingInfection

Thereservoirfromwhichurinarytractpathogensemergeisthegastrointestinaltract.Females,becauseoftheproximityoftheanustotheurethra,areatincreasedriskforUTI.

AscendingInfectionTheabilityofhostdefenseUrinarytractmucosalcellsdamagedThepowerofbacterialadhesions(toxicity)organismsurethra,periurethraltissuesbladderuretersrenalpelvisrenalmedullaPATHOGENESISThenormalbladderiscapableofclearingitselfoforganismswithin2to3daysoftheirintroduction.Defensemechanisms

(1)theeliminationofbacteriabyvoiding(2)theantibacterialpropertiesofurineanditsconstituents(3)theintrinsicmucosalbladderdefensemechanisms(4)anacidvaginalenvironment(female)(5)prostaticsecretions(male)PATHOGENESISFactorspredisposingtopyelonephritisUrinaryTractObstructionVesicoureteralRefluxInstrumentationoftheUrinaryTractPregnancyDiabetesMellitusDiabetesMellitusUTIare3-4timesmorecommonindiabeticwomenthaninnondiabeticonesDiabeticneuropathyaffectsbladderemptyingDiabeticvasculardiseaseincreasespressureswithintheurinarytractresultingfrompoorbladderemptyingTheeffectsofhyperglycemiaonhostdefensePATHOGENESISRelapsinginfectionReinfectionRelapsinginfectionThisisdefinedasrecurrenceofbacteriuriawiththesameorganismwithin3weeksofcompletingtreatmentwhich,duringtreatment,renderedtheurinesterile.Relapseimpliesthattherehasbeenafailuretoeradicatetheinfection.Thismostoftenoccursinassociationwithrenalscars,stones,cysticdisease,orprostatitis,orinthosewhoareimmuno-compromised.ReinfectionItisdefinedaseradicationofbacteriuriabyappropriatetreatment,followedbyinfectionwithadifferentorganismafter7to10days.Reinfectiondoesnotrepresentfailuretoeradicateinfectionfromtheurinarytractbutisduetoreinvasionofthesystem.Prophylacticmeasuresmustbeinitiated.PyelonephritisDEFINITIONBACTERIOLOGYPATHOGENESIS

PATHOLOGYCLINICALPRESENTATIONSDIAGNOSTICEVALUATIONTREATMENTPATHOLOGY

Acutepyelonephritis

Macroscopic:kidneysareenlargedandcontainavariablenumberofabscessesonthecapsularsurfaceandoncutsectionsofthecortexandmedullaHistologic:interstitialedema,inflammatorycellsinfiltration,tubularcellnecrosisPATHOLOGY

Chronicpyelonephritis

Macroscopic:kidneysaresmallerthannormal,renalscarring,consistingofcorticopapillaryscarsoverlyingdilated,blunted,ordeformedcalicesHistologic:unequivocalevidenceofpelvocalicealinflammation,fibrosis,anddeformityPyelonephritisDEFINITIONBACTERIOLOGYPATHOGENESISPATHOLOGY

CLINICALPRESENTATIONSDIAGNOSTICEVALUATIONTREATMENTCLINICALPRESENTATIONS

Cystitisdysuria(burningordiscomfortonurination)frequencynocturiasuprapubicdiscomfort

CLINICALPRESENTATIONSAcutePyelonephritisrecurrentrigorsandfeverbackandloinpaincolickyabdominalpainnauseaandvomitingdysuria,frequency,andnocturiaGram-negativesepsissepticshockCLINICALPRESENTATIONSThephysiologicderangementsthatresultfromthelong-standingtubulointerstitialinjury

hypertensioninabilitytoconserveNa+decreasedconcentratingabilitytendencytodevelophyperkalemiaandacidosisComplicationsSepsisPeri-renalabscessAcuterenalfailureRenalpapillarynecrosisPyelonephritisDEFINITIONBACTERIOLOGYPATHOGENESISPATHOLOGYCLINICALPRESENTATIONS

DIAGNOSTICEVALUATIONTREATMENTDIAGNOSTICEVALUATION

HistoryandPhysicalExaminationChemicaltestsforthepresenceofbacteriuriaUrinaryconcentratingabilityMeasurementofurinaryenzymesMeasurementofC-reactiveproteinMeasurementofantibodyresponsestobacteriaRadiologicandUrologicEvaluationsLaboratoryfindingsUrinedipstickpyuriaonmicroscopicexaminationurineWBCMiddlestreamurineculturebacterialaccount>105/mlbloodcultureLaboratoryfindingsUrinaryconcentratingabilityMaximalurinaryconcentratingtestSGUrinaryenzymesNAG,?2-MGUrinarytractX-rayKUB+IVU(children,adultman,womenrecurrentUTI)

upperUTIlowerUTIFever+-Percussionofthecostovertebralangle+-WBCcasts+-UrinaryconcentratingabilitydecreasenormalUrineNAG,?2-MGincreasenormalAb-coatedbacteriainurine+-Recurrentearly,samebacterialate,newbacteriaIVUmayabnormalusuallynormal

PyelonephritisDEFINITIONBACTERIOLOGYPATHOGENESISPATHOLOGYCLINICALPRESENTATIONSDIAGNOSTICEVALUATION

TREATMENTTreatmentRestDrinkinglargeamountofwaterAntibiotics:10-14daysuntilsymptomfreeTreatrelateddiseases:diabetes,renalstones,vaginalinfection,etcAntimicrobialtherapyThreegoals-controlorpreventionofthedevelopmentofurosepsis-eradicationoftheinvadingorganism-preventionifrecurrencesMedications-trimethoprim-sulfamethoxazole-fluoroquinolones-ampicillin,amoxicillin,first-generationcephalosporinsAntimicrobialtherapyShort-coursetherapysingle-dosetherapya3-daycourseoftherapyExtendedcourseaprolonged4-to6-weekcourseoftherapyLow-doseprophylacticregimenlow-doseantibioticsthreetimesweeklyatbedtimefor?to1yearWomenwhopresentwithcomplaintsofdysuriaandfrequencyTreatwithshort-coursetherapyFollow-up4-7dayslaterAsymptomaticSymptomaticNofurtherurinalysis,urinecultureinterventionBothpyuriabacteriurianegativenobacteriuriawithorwithoutpyuriaobservetreatfortreatwithtreatwithchlamydiaextendedurinarytrachomatiscourseanalgesiaThankYou!1、病毒性肝炎：由病毒造成的肝炎按照其病毒系列不同分為甲、乙、丙、丁、戊和庚共六種類型病毒性肝炎。能引起肝臟細(xì)胞腫脹，是世界上流傳廣泛，危害很大的傳染病之一。1908年，才發(fā)現(xiàn)病毒也是肝炎的致病因素之一。1947年，將原來的傳染性肝炎（infectioushepatitis）稱為甲型肝炎（HepatitisA,HA）；血清性肝炎（serumhepatitis）稱為乙型肝炎（HepatitisB,HB）。1965年人類首次檢測(cè)到乙型肝炎的表面抗原。我國(guó)經(jīng)濟(jì)和科學(xué)技術(shù)日益發(fā)展，學(xué)術(shù)文化領(lǐng)域百家爭(zhēng)鳴，（df高血壓958心臟病983u6糖尿病87fr）特別是思想家的革新精神，為中醫(yī)學(xué)理論的創(chuàng)新和突破性進(jìn)展，提供了有利的文化背景。宋代陳無擇著《三因極一病證方論》一書，（45傳染病q566丙肝964jo乙肝28jgsx甲肝gh）提出三因?qū)W說；并產(chǎn)生了最具盛名四大學(xué)派，劉完素倡導(dǎo)火熱論；張從正力倡“攻邪論”；李杲提出“內(nèi)傷脾胃，百病由生”的理論；朱震亨創(chuàng)造性地闡明了相火的演變規(guī)律。編輯本段明清時(shí)期（df肺25s血液f369血小板t5172紅血球gdf55m白血球fd2）是中醫(yī)學(xué)理論綜合匯編、深化發(fā)展，臨床各科辨證體系豐富、提高階段。如明代樓英的《醫(yī)學(xué)綱目》和王肯堂的《證治準(zhǔn)繩》，清代吳謙等編著的《醫(yī)宗金鑒》和陳夢(mèng)雷主編的《古今圖書集成·醫(yī)部全錄》等。王清任著《醫(yī)林改錯(cuò)》，注重實(shí)證研究，（df高血壓958心臟病983u6糖尿病87fr）糾正了古醫(yī)籍中關(guān)于解剖知識(shí)的某些錯(cuò)誤，肯定了“腦主思維”，發(fā)展了瘀血理論。溫病學(xué)說的形成和發(fā)展，標(biāo)志著中醫(yī)理論的創(chuàng)新與突破，吳有性著《溫疫論》，葉天士著《溫?zé)岵∑?，吳鞠通著《溫病條辨》等，在藥物學(xué)研究方面，（45傳染病q566丙肝964jo乙肝28jgsx甲肝gh）李時(shí)珍著的《本草綱目》，總結(jié)了16世紀(jì)以前我國(guó)藥物學(xué)研究的成就。醫(yī)的診察疾病能參考現(xiàn)代醫(yī)學(xué)的微觀分析，將辨證與辨病相結(jié)