Fungal Urinary Tract Infections Diagnosis and Management Tristan T. Berry, M4 Medical College of Virginia Objectives • • • • • • • • • History Definition of the fungal UTI. Epidemiology Predisposing conditions Presenting symptoms Common organisms and important rare organisms Diagnosis imaging ,cytology/culture (blood and urine) Treatment Resistance to antifungals History 1890 Schmorl reports renal involvement in patient with disseminated candidiasis. 1910 Rafin recognizes candidal cystitis 1931 Lundquist reports primary renal mycosis 1948 Moulder reports cystoscopic findings of candidiasis in the urinary bladder 1963 Twelve cases of candidal infection of the kidney reported 1980 Increased reporting of fungal infection of urinary tract . Likely multifactorial. Epidemiology and Predisposing Factors Fungal pathogens are the cause of increasing nosocomial infections in hospital communities. Epidemiology and Predisposing Factors From 1980-1990 the nosocomial fungal infection rate for urinary tract infections had risen from 9.0 to 20.5 per 10,000 hospitalized patients. Epidemiology and Predisposing Factors Three distinct groups of pathogens are noted for causing fungal UTIs: 1) Opportunistic organisms 2) Environmental 3) Rare and unusual Opportunistic Organisms • normally inhabit human flora or environment. • proliferate when there is a defect in an individual's immune system. Thus causing disease. • Candida species - saprophytes of the skin, oropharyx ,gasrointestinal tract and genital regions. Environmental • include Blastomyces, Histoplasmosis, Coccidoides. • found primarily in soil,environment and guano. inhabit human flora or environment. Rare and unusual • Mucormycosis and others Opportunistic Fungi C. Albicans • oval yeast with a single bud. • in tissues it may appear as pseudohyphae or yeasts. • since Candida is part of normal human flora it is not transmitted. C. Albicans Pathogenesis • Most common opportunistic fungi. • Causes thrush, vaginitis, chronic mucocutaneous candidiasis • When local or systemic host defenses are impaired, disease may result. Pathogenesis • may disseminate to multiple organs esp. in IVDA and right sided endocarditis. • kidney is the most commonly involved organ with systemic fungal infection. >85% • Accounts for 6.9% of nosocomial infections Pathogenesis • Candida Spp are the most common organisms causing fungal UTI. • Candida albicans accounts for 74% • Glabrata 8% • Parapsolosis7% • Tropicalis 3% Predisposing Conditions 1) 2) Diabetes (impaired phagocytic and fungacidal function of neutrophils) Protracted course of antibiotics Predisposing Conditions 4) 5) 6) 7) 8) Neoplasm Oral contraceptives Elderly Population Infants- due to immature T-Cell defense Chronic indwelling catheter Symptoms • Frequency, dysuria and stranguria • Pyuria , hematuria or pneumaturia • classic findings of pyelonephritis, fever, flank pain and CVAT • high index of suspicion b/c fungal UTI may present like bacterial UTI. Diagnostic Features • microscopic urine studies • urine culture can be helpful for species identification and sensitivities • Urine colony counts (significant if >105 without indwelling urinary catheter) Simple vs. Complex UTI Simple UTI • Confined to urinary bladder and urethra. • Pt may present with cystitis.(2% of UTIs) • Cystoscopy may present with white patches on bladder wall. • Bladder wall edema and erythema may be present. • Bladder infections can lead to rupture. (rare) • Microscopic: Inflammatory cells, yeast forms and pseudohyphae may be present Treatment • Bladder irrigation with Amphotericin B 50mg/1L water x10-14 d • Effective in 80-92% of patients • Nystatin and Miconazole useful. -poor colloid dispersion in Nystatin-limits use • Surgical intervention may be required in the form of mucosal debridement • Removal of large fungal bezoars if present. Complex UTI • Complex infections affect the kidneys and ureters • Result of either hematogenous spread or ascending from lower tract infections • Associated with fungal accretions that may lead to obstructive uropathy. Complex UTI • May lead to persistent candiduria. • High potential for disseminated infection • Approximately 88% present with fever and flank pain • 88% associated with hydronephrosis • 81% associated with fungemia Imaging • U/S, Excretory urography, • Retro pyelogram • CT • Renal Scintigraphy Imaging studies typically exhibit filling defects of the urinary system Treatment • Localized Amphotericin B irrigation for infection of the collecting system.. • Systemic or multifocal infection IV Ampho B 6mg/kg (Gold Standard) , Fluconazole 100mg BID x 10 days 5-FC- 150mg/kg- high resistance CASE • HPI:56 year old male with 4 day history of fever , N/V and diffuse abdominal pain. Anuria 24 hrs prior to admission to the hospital. • PMH- Diabetes type II diagnosed 5 years prior, controlled with insulin. UTI 6 months prior tx’d with abx. CASE • Exam- pt. was febrile & appeared acutely ill. Dry mucous membranes Diffusely tender abdomen Bilateral CVAT • LABS: Leu =25x10^9 with 82% pmns BUN 82, Creat 7.9 Glu 280 CASE • U/A: Numerous leukocytes per hpf Many yeast forms. • Pt was initially treated with Ampicillin and Ciprofloxacin. IVF and IV insulin. • Symptoms persisted. CASE • U/S- bil. hydonephrosis • Cystoscopy with RPG was unsuccessful due to bilateral ureteral obstruction. • Bilateral percutaneous nephrostomy tubes were placed (turbid yellow/white urine was recovered. • Antegrade pyelogram- dilation of renal pelvises and ureters. Multiple filling defects. CASE • Urine culture- C.Tropicalis 10^4 - 10^5 • Blood cultures on admission were negative for fungi or bacteria. • Treatment: IV Amphotericin B, direct Ampho B through nephrostomies. • Fragmentation of fungal balls by guide wire manipulation. CASE • Therapy cont.for 3 weeks until U/C were negative. • Dc’d with Creatinine of 2.1mg/dL. • No evidence of hydronephrosis at 6 month follow up. Cryptococosis • Organism: Cryptococcus neoformans • Properties: oval, budding yeast • Epidemiology: Occurs widely in nature, found in pigeon droppings • Transmission: Inhalation of organism • Clinical manifestations: Pulmonary infection to virulent pneumonia & meningitis. Cryptococosis • Predisposition: HIV, DM, lymphoma, ETOH abuse • GU involvement: Adrenal-infarction Renal- pyelonephritis,abscess Prostate- bladder outlet obstruction or prostatitis Penis- ulcers of glans Cryptococosis • Tx: Adrenal-Amphotericin B • Renal- IV Amphotericin B • Prostate-Fluconazole 200-600mg/d x 4 wks • Penis- Resection followed by systemic Ampho B Apergillosis • Organism: A. fumigatus and A.Flavus • Properties: Only mold form (V shaped branches) • Epidemiology: Widely distributed in nature. Grow on decaying vegetables. Linked to hospital construction and central air conditioning . • Transmission: Airborne conidia. Apergillosis • Predisposition: abraded skin, wounds, cornea, ext. ear and sinuses, immunocompromised • GU involvement: Renal- DM, malignancy or AIDS (Fever, CVAT, obstructive uropathy) Prostate and Genital-DM, Met colon ca, steroid use & AIDS • DX:Isolation from urine,semen or tissue. Apergillosis-Treatment • Systemic Amphotericin B for 3 months Kidney-Percutaneous aspiration, nephrostomy & J- stents • Very little data to support use of itraconazole Environmental Fungi Coccidioidomycosis • Organism: Coccidioides immitus • Properties:dimorphic exists as mold in soil and spherule in tissue • Location: Western U.S and Mexico. Thrives in arid desert regions. • Transmission: Airborne infection of the pulmonary system Coccidioidomycosis • Clinical manifestations: mild influenza or flu like illness Valley fever. • Predisposition: Age >65 and HIV+ • Disseminated infection: less than 1% of pulmonary infection become disseminated • Men, pregnant women, immunocompromised and non white persons more likely to have disseminated infection Coccidioidomycosis • GU involvement: • : kidney disease in 36-46% of persons with disseminated disease-microbscess & granulomas • prostate in 3-6% • GU manifestations: Voiding dysfunction Scrotal swelling Hematuria Pneumaturia Histoplasmosis • Organism: H. Encapsulatum • Properties: dimorphic- mold in soil; yeast in tissues • Epidemiology: endemic in central and eastern states, esp Mississippi and Ohio grows in soil contaminated with bird droppings and guano. • Transmission and pathogenesis: Inhaled spores are engulfed by macrophages and develop into yeast forms. Histoplasmosis • Majority of involvement is spleen and liver. Pulmonary involvement results in cavitary lesions. • Clinical manifestations: pneumonia • Predisposition: HIV+, transplant pts & children. Histoplasmosis • GU involvement: • Kidneys- noncaseating granulomas,cutaneous fistulas. • Adrenal-Addison’s dz- will require hormone replacement. • Prostate- Abscesses Histoplasmosis • Dx- Identification of organism in urine,semen or tissue. Culture or skin test. • Tx- IV Amphotericin B(>2g) total dose followed by long term Itraconazole 200mg/d x12 wks • Surgical management- Surgical excision or drainage of prostate abscess. Blastomyces • Organism: Blastomyces dermatitidis • Properties: Dimorphic, mold in soil, yeast in tissue • Broad-based budding • Epidemiology: North and Central America, also Africa. Grows in moist soil. Blastomyces • Transmission: Inhalation of mold form. Primarily affects lungs, skin, bone and CNS • Manifestations: flu-like illness, high fever, respiratory illness that mimics TB or Cancer • Often subclinical infection. • GU- prostate, epididymis, tubo-ovarian abscess Blastomyces • Dx: Fungus in urine, semen or • Detection of blastomyces A antigen by immunodiffusion. • Tx: Ketoconazole 400mg/d x 12mos for prostate and epididymis involvement. Amphotericin B for disseminated infxn and immunocompromised Rare Fungi Mucormycosis • Organism- Mucor • Properties-mold • Epidemiology-widely in nature • Transmission- Inhalation of airborne spores • Predisposition- DKA,AIDS, liver abnormalities Mucormycosis • Manifestations- primarily rhino cerebral, sinusitis and brain hemorrhage • GU- Primarily fever and flank pain • Dx- biopsy showing mold with nonseptate hyphae • Tx-IV amphotericin B >1gram for 1 month Rare Fungi 1) 2) 3) 4) 5) 6) Geotrichum candidum Paecilomyces Paracoccidioides brasilensis Penicillim glaucum Penicillium citrinum Trichosporon Rare Fungi 7) Fusarium 8) Pseudallescheria boydii 9) Cunninghamella 10) Rhinosporidium seeberi 11) Sporothrix schenckii Summary: – The number of urinary tract infections caused by fungi is increasing. Although the majority of fungal UTIs are caused by Candida species, physicians must maintain a high index of suspicion in order to identify the rare and environmental fungi that cause disease. Summary: Many factors such as overuse of antibiotics, immunosuppression , antifungal resistance and disseminated fungal infections predispose individuals to developing fungal UTI. The astute physician must identify predisposing medical conditions and anatomical defects; then treat them accordingly. Summary: Before beginning antifungal therapy first obtain a U/A (rule out contamination). Urine and blood cultures should be obtained in order to identify the organism and sensitivities.( This helps to prevent overuse of abx and avoids contrubuting to the increasing amount of resistance antifungal agents.) Summary: If obstruction or structural abnormalities are suspected then imaging of the urinary system is warranted. If defects are visualized, only then should surgical management be employed.