泌尿系統感染

Urinarytractinfections(UTI)尿路感染2EpidemiologyThe

incidence

is

secondafterrespiratoryinfections50%-60%ofallfemaleshaveatleastoneepisodeofaUTIatsometimeintheirlives.AnatomyoftheurinarysystemKidneysfilterbloodUreterscarryurinetobladderBladderstoresurineuntilitisexpelled(throughurethra)OnlylowerpartofurethrahasaresidentbacterialfloraRestoftheurinarytractisnormallysterileUrinaryTractTermsUTI:thefindingofmicroorganismsinbladderurinewithorwithoutclinicalsymptomsandwithorwithoutrenaldiseaseSignificantbacteriuria（有意義細菌尿）: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)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)（反復發作，醫院獲得性）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心內膜炎血行感染hematogenousroute：少見。發生在原存在嚴重尿路梗阻或免疫力差患者常見為腎皮質感染，致病菌多為金黃色葡萄球菌。腎結核。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機體抗病能力減弱DiabetesmellitusPregnancyRenalfailureImmunosuppressedpatientsIatrogenicfactors醫源性因素CatheterisationSurgery,e.g.prostatectomy導尿與尿路感染泌尿外科及術后病人中40%的醫院內感染(Nosocomialinfection)發生在泌尿系統，而其中的80%與留置尿管有關一次導尿的感染機會為1%-2%留置導尿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尿管者（＞30天），細菌尿的發生為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+實驗室化驗+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尿標本的采集Urinecollection

：中段尿、導尿、穿刺-最可靠。

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

InfectionContamination

Morethan105Organisms/mllessthan104

Organisms/ml

Asinglebacterialspp.MorethanoneorganismWhitebloodcellcastsHighlysignificant!Presencesuggestspyelonephritis白細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：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