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!