Urinary Tract Infection 盛 望 徽 台大醫院 內科部 感染科

Urinary Tract Infection
盛 望 徽
台大醫院 內科部 感染科
Urinary Tract Infection
The most common community- and hospitalacquired infections
In USA
• 7 million clinic visits, 100,000 admissions,
cost > $1 billion annually
•15% community prescribed antibiotic for UTI
UTI in female
•Affect 20% of women 20- 56 y/o per annum
•25%–30% recurrent UTI not related to
functional or anatomical abnormality
Importance of UTI
• In-hospital mortality of UTI: 15%
• associated with bacteremia, advanced age,
severity and underlying diseases
Changing Etiology of UTI
• Gram-positive bacteria
• Drug resistant Gram-negative bacilli
• GNB other than E. coli, KP, Proteus
• Prominent Candida in nosocomial UTI
Pathogenesis
• Urinary stasis
• Obstruction
• P fimbriae
• Sticky epithelial cells
• Atrophic epithelium
E. coli (Ascending infection)
S. aureus (Hematogenous
spread)
Classification of UTI
• Complicated versus uncomplicated UTI
• Upper versus lower urinary tract UTI
• Suprapubic pain, dysuria, frequency
• Fever >38oC, chills, flank pain
• High risk for upper or complicated UTI
• Diabetes, pregnancy, immunosuppression,
previous APN, symptoms > 14 days,
structural abnormality of urinary tract
Complicated or Uncomplicated?
 Uncomplicated
UTI: in patients with normal
structural and functional urinary tract.
 Complicated
UTI: in patients with anatomical,
functional, or metabolic defects of the urinary
tract, or altered host defenses.

Renal abscess, diabetes, infective stone, reflux,
pregnancy, catheter-related …
Emphysematous Pyelonephritis
Risk factors for UTI
• Female
• History of past UTI
• Sexual intercourse
• Neurogenic bladder
• Diabetes, menopause, GU tract abnormality,
lack of circumcision, homosexual, AIDS…
UTI Needs Work-up
• Frequent attacks (3 in a year) in women
• Male first attack
• Age < 15 y/o or > 55 y/o (without urine retention)
• Urosepsis, septic shock or organ failure
• Poor response to antibiotics (>7 days)
• Hematuria
Incidence of APN per
10,000 person-years, USA.
Czaja CA, et al. Clin Infect Dis 2007; 45:273–80.
Etiology: Community UTI
• E. coli: 75-90%
• Enterococcus, Staph. saprophyticus : 5-15%
• Klebsiella, Proteus and others : 5-10%
• 30% polymicrobial infections
• Nursing home: Pseudomonas, enterococcus
or Candida
N Engl J Med 2003;349:259-66
Etiology: Hospital-Acquired UTI
• E. coli, KP, Proteus : 41%
• Enterobacter, Serratia, Morganella : 25%
• Pseudomonas aeruginosa : 21%
• Candida albicans 16%
• Enterococcus 14%
• Staphylococcus spp. : 13%
N Engl J Med 2003;349:259-66
Hospital-acquired UTI
• >40% of all hospital-acquired infections
• Almost catheter-associated
develops in 25% if urinary catheter for > 7 days
• An nosocomial UTI add $500-1,000 cost of
hospitalization
Pathogens caused UTI
Ramakrishnan K. Am Family Physician 2005: 71, 933-42.
Pathogens of Acute Pyelonephritis
Czaja CA, et al. Clin Infect Dis 2007; 45:273–80.
Uropathogens Cause Community-Acquired UTI, USA
Gupta K, et al. Clinical Infectious Diseases 2001; 33:89–94
Pathogens of NI, NTUH, 2007-2009
1.6
Proteus
S. aureus
All NI pathogens
5
UTI pathogens
3.9
7.3
1.3
12.1
E. coli
22.4
14.4
Candida spp.
24.1
12.5
9.9
10
9.6
P. aeruginosa
Klebsiella spp.
Enterococcus spp.
7.3
Enterobacter spp.
6.7
5.9
7.2
Acinetobacter spp.
4
0
10.1
0%
5
10
15
20
25
Clinical Presentations
Lower UTI (cystitis, urethritis)
•
•
Dysuria, frequency, urgency, suprapubic pain...
Low grade fever or absent
APN
•
•
Lower UTI s/s; flank pain, fever, nausea, vomit
Systemic toxic sign; CV angle knocking pain.
Prostatitis
•
•
Fever, voiding discomfort, perineum/rectum pain
Prostate massage contraindicated if acute prostatitis
診斷泌尿道感染以臨床症狀最重要
Pyuria
Bacteriura*
Leukocyte esterase
Sensitivity
Specificity
95%
71%
40-70%
45-70%
75%
82%
The most reliable is urinary symptoms
*Clean-catch urine, >100,000 CFU/mL specificity
*頻尿、解尿、灼熱疼痛或有分泌物、腰痛、發燒
泌尿道感染
• Asymptomatic bacteriuria:無症狀菌尿症
No treatment is indicated except…
• Pregnant woman after second trimester
• During or after urological procedure
• Severe immunocompromised hosts
• Caution while sampling:收集尿液需知
• Voiding urine: mid-stream(中段尿液送檢)
• Catheterized urine: don’t use the urine in bag
Urine dipstick test: Nitrate
Nitrate to nitrite
Proteus, Providentia, Morganella, Klebsiella.
Negative:
•
Nitrate reductase-negative bacteria (Enterococci, S.
saprophyticus, Acinetobacter, Pseudomonas).
•
•
•
Elevated urobilinogen levels, vitamin C
Too dilute of urine
Longer processing time
Urine culture
•
Routine culture not necessary in uncomplicated cystitis
•
Midstream urine specimens
- Asymtomatic women : with >105 CFU/ml.
- Symptomatic women with pyuria : with 102 to104 /ml.
- Males, G(+) and fungi : > 103 /ml.
•
Catheter or suprapubic aspirate: 102 to 104 /ml
•
Low bacteria counts: lower UTI, early infection, urethritis,
vaginitis, high urea/osmolarity, low pH
•
•
False (-) : obstruction, antimicrobial use, diuresis
False (+) : delay processing
Urinary Pathogens Resistant to Selected
Antimicrobial Aagents
Czaja CA, et al. Clin Infect Dis 2007; 45:273–80.
Management
•
Asymptomatic bacteriuria : treat only in
-- pregnant p’t.
-- who undergo invasive GU procedure.
-- before insertion of permanent indwelling devices.
-- Severe immunosuppressed hosts
-Antibiotics
-- Nitrofurantoin, 1°or 2°cepha, TMP/SMX.
-- Ampicillin or amoxicillin, ampicillin/sulbactam,
amoxicillin/clavulanate
Treatment for UTI
• Cystitis, urethritis
• TMP-SMX
• Fluoroquinolones
• Pyelonephritis
• Fluoroquinolones
• Ampicillin + aminoglycosides
• Extended spectrum cephalosporins
IDSA guideline 2005: Am J Med 2005;118(7A):7-13.
Need Hospitalization for APN
Empirical Therapy for APN
IDSA Recommendations
No hospitalization
•
•
Oral fluoroquinolone
 Fluoroquinolone
Amoxicillin-clavulanate
 Ampicillin or AMP-sul 
aminoglycoside
• Pregnant, GPC
•
•
Hospitalization
Cephalosporin
Trimetoprimsulfamethoxazole
 Extended-spectrum
cephalosporin 
aminoglycoside
Immunocompetent (7-14 days); immunocompromised (14-21 days)
Short-course therapy (<7 days) for cystitis only
Warren JW et al. Clin Infect Dis 1999;29:745-58.
Guideline for Antimicrobial Therapy of Urinary Tract
Infections in Taiwan J Microbial Immunol Infect 2000:33,271-272
Indication
Drug of Choice
Alternative choice
Acute bacterial cystitis /
Urethritis
Nitrofuantoin
Ampicilin or Amoxacillin
Baktar
Unasyn / Augmentin
Quinolones
Acute complicated UTI /
pyelonephritis
1 or 2 cephalosporins
3 or 4 cephalosporins
Ampicilin / amoxicillin
Ticacillin / piperacillin
± Aminoglycosides
Aztreonam
Baktar
Imipenem / meropenem
Fluoroquinolones*
Guideline for Antimicrobial Therapy of Urinary Tract
Infections in Taiwan J. Microbial Immunol Infect 2000:33,271-272
Indication
Drug of Choice
Alternative choice
Acute uncomplicated
Baktar
Ampicillin, amoxcillin
1or 2 cephalosporin
Ampicilli/sulbactam
Aminoglycosides
Amoxicillin/clavuante
UTI / pyelonephritis
Chronic bacterial
Baktar or
prostatitis
Fluoroquinolones*
Nosocomial UTI
3,4 cephalosporins
Imipenem
/catheter-related
Ureiodopenecillins
Meropenem
Fluoroquinolones*
*norfloxacin, ofloxacin, enoxacin, ciprofloxacin, pefloxacin, lomefloxacin
Prostatitis
• Men > 50 of age, > 50% have BPH symptoms
• Penetrate prostatic barrier
• Acute: b-lactams, TMP-SMZ, Quinolone x 10-14 d
• Chronic: TMP-SMZ x 1-3 m, Quinolone x 4-6 wks
• PSA mildly elevated in acute/chronic prostatitis
• FQs (CIP or LVX) x 4 weeks, 94% clinical cure,
89% bacterial eradication
Drugs 1999,58 suppl.2 :341-343
Nosocomial UTI (Bacteria)
• Fluoroquinolones
• Antipseudomonal b-lactams
+/- aminoglycosides
• Carbapenems
• Aztreonam
+/- aminoglycosides
Treatment Duration
Acute uncomplicated cystitis
Single-dose therapy
Short course: 3-7 days
Complicated infections  prolonged therapy.
APN
Oral therapy: if uncomplicated APN
Immunocompetent, no underlying illness: 7-14 days
Severe: 14-21 days, abscess :4 weeks
Safrin S, et al. Am J Med 1988;85:793-8. Bach D, et al. J Urol 1995;154:19-24.
Thank you for attention!
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