腎內科uti的課件資料第1頁/共48頁Generalremarks

Inthischapter,UTIresultingfrombacterialinvasionisdiscussed.Anatomically.

Itisdividedintouppertracturinaryinfection(pyelonephritis)andlowertracturinaryinfection(cystitis)incidence：UTIisacommondisease(2%inpopulation),particularlyinfemaleadults(10%).第2頁/共48頁第3頁/共48頁Etiologyandpathogenesis

Pathogen：

gram-negativebacteria（Specificallycoliformbacteria,proteusbacteria）Pyocyanicinfectionisfrequentlyseeninpatientswithinstrumentation.Proteusbacteriaisoftenseeninpatientswithcalculus.第4頁/共48頁BacterialvirulencefactorsAhighdegreeofbacterialadherence,whichismediatedbythebacterialfimbriae.Somebacteriacanproducehemolysinwhichcanresistthebody’sdefensesystem.Drugresistancestrains第5頁/共48頁第6頁/共48頁HostdefensemechanismsEfficientemptyingofthebladderwithvoiding.Aprotectiveglycosaminoglycanlayer.ThehighosmolalityandextremesofpH.IgG,IgAandorganicacidsecretedbyurinarytractmucosa.第7頁/共48頁HostsusceptibilityfactorsurinarytractObstructionsuchascalculus,vesicoureteralrefluxorintrarenalreflux.

(thepresenceofUTIwithstructurallyorfunctionallyabnormalurinarytractiscalledcomplicatedUTI)ThedeformityofurinarysystemInstrumentationoftheurinarytractHostdefensesystemgetweak,forinstance,diabetesmellitusPregnancy,genderneurogenic

bladderGenetic

factor第8頁/共48頁InfectionrouteTheascendingroute:periurethraltissues→urethra→bladder→ureter→renalpelvis→renalmedullaThehematogenousrouteLymphogenousspreadDirectextensionfromotherorgansmayoccur第9頁/共48頁第10頁/共48頁第11頁/共48頁ClinicalmanifestationcystitisIrritativevoidingsymptomsfrequency,urgency,dysuria(burningordiscomfortonurination),suprapubicdiscomfortUrinalysispyuria,bacteriuria,hematuriaBloodtest:generallynormal

第12頁/共48頁Acutepyelonephritis

Irritativevoidingsymptoms,flankpain.Systemictoxicityfever,shakingchills,nausea,vomitingSigntendernessofureterspotonpalpation,exquisitetendernessonpercussionofthecostovertebralangle.LaboratoryfindingsBloodtest:leukocytosisandaleftshit.Urinalysis:pyuria,bacteriuria,hematuria.Bloodculture:maybepositive.第13頁/共48頁

Asymptomaticbacteriuria

nosymptomispresent,yetbacteriuriaexists.第14頁/共48頁Laboratoryfindings

Urinalysisafindingof≥5WBC/Hpor≥8000WBC/ml↓UTIwhitecellcasts→pyelonephritis.hematuria,proteinuria第15頁/共48頁LaboratoryfindingsDetectionofbacteriuriaCollectionofurinesample:Theurineiscollectedinmidstreambeforedrugisusedoratleast7daysafterdrugadministration.Avoidingcontamination,beingsenttothelaboratorywithin1h.第16頁/共48頁

UrinecultureCFUs≥105/ml→significantbacteriuria.CFUsbetween104~105/ml→suspectedUTI→reexaminationCFUs＜104/ml→maybecontamination

(Qualitative

urineculture:iftheurineforcultureisfromcystpuncture,thenwhenpositive,itindicateatrueUTI)第17頁/共48頁第18頁/共48頁

Urinesmearexaminedbymicroscopy

when≥1bacteriuria/oil-immersedHP

Chemicaltestforbacteriuria

Nitratereductiontest

thetestisdependentonthebacterialreductionofnitrateintheurinetonitrite.itiseffectiveinidentifyinginfectionduetogram-negativebacteria.第19頁/共48頁Imaging

IndicationAllmalepatientsFemalepatientrecurrentUTIcomplicatedUTIdisappointingresponsetoantimicrobialtherapy4.everinfectedduringpregnancy第20頁/共48頁ImagingstudiesincludeUltrasonographyIntravenouspyelogram(IVP)Computedtomography

Notice

IVPshouldnotbedoneintheacutephaseofUTI.第21頁/共48頁DiagnosisOFUTIsignificantbacteriuriaApositiveresultofurinecultureinwhichurinespecimenisfromcystpuncture.Quantitativeurineculture:apatientbeingsymptomatic,CFUs≥105/mlforonce.apatientbeingasymptomatic,CFUs≥105/mlfortwice(itshouldbethesamespecies)

第22頁/共48頁DiagnosisOFUTIwhenafemalepatientwithirritativevoidingsymptomandCFUs≥102/ml,UTIshouldbeconsideredandtreatmentforUTIshouldbegiven.

第23頁/共48頁Infection-localizingdiagnosisurinecultureafterbladderwashouttheassayforantibody-coatedbacteria（ACB)urinaryconcentratingability,urineβ2-MG，urinewhitecellcast.第24頁/共48頁

bilateralureteralcatheterrization.

itistooinvasiveforgeneraluse.clinicalpractice1.acutepyelonephritisfever(T＞38℃),shakingchills,backpain,WBC↑tendernessonpercussionofthecostovertebralangle2.3daysofantibioticstreatment,ifbeingcured→cystitis,ifnot→pyelonephritis.第25頁/共48頁Chronicpyelonephritis：

thecorticalscarringacorrespondingcalicealdeformitytubuledamageandinterstitial

inflammationandscarring

第26頁/共48頁Differentialdiagnosis

1.renaltuberculosis

aprominentirritativevoidingsymptomnullitytocommonantibioticsmycobacteriuminurinePPD（+）stricture,cavities,calcificationinIVP第27頁/共48頁第28頁/共48頁第29頁/共48頁第30頁/共48頁第31頁/共48頁2.urethralsyndrome:

exhibitirritativevoidingsymptomnosignificantbacteriuriaInfectiveurethralsyndrome:

causedbyotherpathogenssuchasvirus,mycoplasms,chlamydia.Urinalysisshowpyuria.

Non-Infectiveurethralsyndrome:noWBCisseenwithurinalysis.Probablyitisbecauseofpsychologicalproblems.第32頁/共48頁treatmentAntibiotics

G—Bacillus（sulfonamide,quinolones,β-lactamdrugsemisytheticpenicillins,cephalosporins）Afterthedrugsensitivitytestforoffendingorganismsisavailable,thenantibioticsaregivenaccordingtothetest.

第33頁/共48頁Acutecystitis:singledosetherapyanda3-daycourseoftherapy

↓followeduptoseewhethertheinfectioniscontrolledornotitshouldnotbeusedinpatientswithpregnancy,complicatedinfection,suspectedpyelonephritisormalepatients第34頁/共48頁

Acutepyelonephritis

intensiveantimicrobialtherapyshouldbeadministrated.antibioticsfor14daysorally.noeffectwithin72h→adjustthetreatment.

Moderateacutepyelonephritis:intravenoustherapyofantibiotics↓defervescesfor72horalagentatleast14days

第35頁/共48頁

Acutepyelonephritis

Severeacutepyelonephritis:

acombinationofantibioticsaregivenintravenously,oftenanaminoglycosidecombinedwithaβ-lactamdrugorcephalosporins.第36頁/共48頁

TherapyforrecurrentUTI：Relapsinginfection：

infectionoccurwithin6wofthecessationofantimicrobialtherapyandiscausedbythesameorganism.Reinfection：

causedbyanorganismwhichisdifferentfromtheoriginalone.第37頁/共48頁

TherapyforrecurrentUTI：

receiveshortcoursetherapyof7days→followedup7daysaftercessationoftherapy.Ifnosymptom，bacteriuriaandpyuria→curereinfection；Stillwithsymptoms,bacteriuriaandpyuria→treataccordingtodrugsensitivitytest.IfsucceededReinfection,iffailed→abigdoseantimicrobialsfor6weeks.patientswithmorethan3UTIs/years→longtermprophylaxistherapy.第38頁/共48頁treatmenturinarytractinfectioninpregnancychoosedrugsthataresafetofetus(ampicillincephalexin)asymptomaticbacteriuriaWomeninpregnancy,childrenbeforeschool-age,previoussymptomaticUTI,withcomplicatedfactors---shouldreceivetreatment.第39頁/共48頁Complication

Acuterenalpapillarynecrosis：accompaniedbydiabetesorurinarytractobstruction.leadtosepsisorARF.presentwithhighfever,severebackpain,hematuria,andureterobstructiontreatment:strengthenantimicrobialtherapy,andobstr