URINARY TRACT INFECTION & VESICOURETERAL REFLUX (UTI & VUR) Flashcards
FEBRILE
UTI
Severe disease ,
complicated with renal
scars, if postponed ,or
incorrect treatment
RENAL SCARS
99m Tc DMSA renal scan/ scintigraphy
ACUTE PYELONEPHRITIS ( PNF)
CLINICAL PRESENTATION
In little child, in newborn, or infant, PNF
appears like a systemic infection→ urosepsis
It is a severe form of nephritis, starting point
being a pyelitis; the inflammatory intrarenal
process involves tubules and renal papilae.
PNF = tubulointerstitial nephritis
It is a debilitating condition , a febrile disease,
which needs often hospitalization
UTI. ETIOLOGY
gram- negative, are predominantly involved
grame-negative bacilli
E.coli, Enterobacter, Citrobacter, Proteus.,
Pseudomonas aeruginosa, Providencia stuartii, Klebsiella,
Morganella morganii, Gardenella vaginalis)
grame – negative cocci
(Neisseria gonorrhea)
grame -positive cocci
Staphylococcus aureus, Staphylococ epiderm., Staf
saprophyte,
Streptococcus D ( fecal,bovis), Streptococcus B ( in
neonates!!).
other pathogens: Chlamidia, Mycoplasma si Candida.
They were also diagnosed viral UTI , both high located,
(pylonephritis) and low located ( cystitis ).
APN PATHOGENESIS
& Markers
E.coli invadates urothelium by fimbriae. Lipopolysaccharides
chelators bind CD14 receptors, cluster of differentiation 14 (human
gene) and activates tool-like receptors (TLR-4).Thus, kB –nuclear
factor (NFkB) migrates inside nucleus of cell and promotes inflamation .
**The markers are: fever , PMN aglutination
and high vascular permeability.
The same mechanism is descibed in renal scars pathology ↑levels of procalcitonine corelates with **renal scars **( argued also by ↑reactive C proteine and high leucocitosis ) it is an
important marker in APN
PYELONEPHRYTIC
NEPHROPATHY
- Delay in initiating
appropriate antibiotic treatment / - The existence of one or more
predisposing risck factors , e.g severe renourinary anomalies lead to -> - definitive renal scarring
- can occur after a single
acute pyelonephritis
UTI – Bacteria contributing factors
Certain types of E. Coli contain P- fimbriae (pili) = surfaces structures of
protein origin which mediates E. Coli attachement to uroepithelial mucosa
prevents proper empting of the bladder
prevents ureteric normaly peristalsis
Hemolysin = cytolytic protein that destroy plasma protein membrane
Siderofores = proteins responsible of iron chelation, prolonging life bacteria.
Contain the capsular polysaccarides which interfere with the alternative
complement pathway
UTI – Bacteria contributing factors
Certain types of E. Coli contain P- fimbriae (pili) = surfaces structures of
protein origin which mediates E. Coli attachement to uroepithelial mucosa
prevents proper empting of the bladder
prevents ureteric normaly peristalsis
Hemolysin = cytolytic protein that destroy plasma protein membrane
Siderofores = proteins responsible of iron chelation, prolonging life bacteria.
Contain the capsular polysaccarides which interfere with the alternative
complement pathway
High / Lower congenital anomalies responsibles of urinary stasis, correlated with UTI
OBSTRUCTIVE CONGENITAL UROPATHYES
ANATOMIC OSTRUCTION
UPPER URINARY TRACT
Pyeloureteral stenosis extrinsic or intrinsic
LOWER URINARY TRACT
Vesicoureteral stenosis
Posterior urethral valves
(Hinman Disease)
Urethral strictures or stenosis
Ureteroceles / Duplications of urinary tract
Ectopic uretheres
Diverticulae bladder
FUNCTIONAL OBSTRUCTION
Vesicoureteral reflux
Neurogenic / Nonurogenic bladder
(Hinman Disease)
UTI– Host contributing factors
- Massive colonization of periurethral /preputial space , in infant boys, 3-6 months of age
- Obstructive anomalies, anatomic or functional
- Neurogenic bladder and bladder disfunction
- Frequent and quantitatively reduced micturation in small hyperactive bladder
- Constipation
- Rare micturations that define “lasy” bladder
UTI- Host contributing factors
Pathophysiology
results from a combination of 3 causes :
- Incomplete empting of the bladder
- Urinary stasis
- High pressure in the uper urinary system.
UTI . LABORATORY
1.Bacterial culture of an appropriately urine sample
2. Suggestive urinalysis exam
In newborn and infants, urine collection is done
in sterile plastic bags attached to perineum (maintained not more than 30 min) or, in the middle of urinary flow in children with urinary continence, after a correct genitourinary toilet
A correct collection of urine could also be carried out, by bladder catheterization, or by suprapubic aspiration
Other tests needed :blood inflammatory tests,
(leucocytosis, ↑procalcitonin,↑C-reactive protein, asotemia, blood gases & electrolytes, etc )
ITU . IMAGING ( imaging targets )
UTI location in acute stage:
99m Tc - DMSA renal scan (scintigraphy), Renal CT and MRI,
are diagnostic investigation, but not rutinely performed
because they are expensive
Underlying obstructive anatomical renourinary anomalies or VUR diagnosis:
US, voiding cystourethrograpy/nuclear cistography, urography, 99m Tc – DTPA or MAG3 renal scan with/without wash out, (diuretic renography) and
renourinary CT
Renal scars quantification :
US and 99m Tc – DMSA ( cortical renography).
ANTIINFLAMATORY TREATMENT IN APN
ANTIBIOTICS
Adecvate use vs restrictive use
Agresiv & Empiric treatment
Personalised treatments
To assess the cost of antibiotic treatment against the entire cost of treatment
Resistence to cefalosporins of : E.coli, enterobacteriacees, proteus, pseudomonas, acinetobacter
Resistence to fluorokinolons of E. coli
! New recommendated AB are β-lactamase inhibitors ( cephalosporins, penicillines, carbapenemes)
ACUTE PYELONEPHRITIS. TREATAMENT. 1
Complicated UTI (acute PNF), in infant, little child and any debilitated clinical situation: really ill pacient, high fever, toxic ill pacient, impossibility to receive liquids orally more than 1,5 normally for age, any child who
needs parenterally administration of fluids, and immunocompromised patients, treatment in hospital is recommended.
We start empirically antibiotic treatment (e.g. aminoglycoside + ampicillin, cephalosporins third gen, or, aminoglycosides + cephalosporins. )
