UT7 - Infeções do Trato Urinário (2) Flashcards
Uncomplicated cystitis?
◆ Uncomplicated cystitis is defined as acute, sporadic or recurrent cystitis limited to non-pregnant, pre-menopausal women with no known anatomical and functional abnormalities within the urinary tract or comorbidities.
◆ Almost half of all women will experience at least one episode of cystitis during their lifetime.
◆ The spectrum of aetiological agents is similar in uncomplicated cystitis and pyelonephritis, with E. coli being the causative pathogen in 70-95% of cases and Staphylococcus saprophyticus in 5-10%.
Uncomplicated cystitis - Diagnosis?
◆ Diagnóstico clínico!
◆ The diagnosis of uncomplicated cystitis can be made with a high probability based on a focused history of lower urinary tract symptoms (dysuria, frequency and urgency) and the absence of vaginal discharge or irritation
◆ Routine post-treatment urinalysis or urine cultures in asymptomatic patients are not indicated
Uncomplicated cystitis – Tratamento?
◆ Para as mulheres:
– Fosfomicina – tratamento de 1 dia
– Nitrofurantoína – tratamento de 5 dias (bacteriostático)
◆ Para homens:
– Trimethoprim-sulphamethoxazole - tratamento de 7 dias
◆ Na maioria das situações, o tratamento de 3 dias para uma cistite não complicada é suficiente!
Recurrent UTIs?
◆ Recurrent UTIs (rUTIs) are recurrences of uncomplicated and/or complicated UTIs, with a frequency of at least three UTIs/year or two UTIs in the last six months.
◆ Although rUTIs include both lower tract infection (cystitis) and upper tract infection (pyelonephritis), repeated pyelonephritis should prompt consideration of a complicated etiology.
◆ Prevention of rUTIs includes counselling regarding avoidance of risk factors, non-antimicrobial measures and antimicrobial prophylaxis.
◆ These interventions should be attempted in this order.
Recurrent UTIs - Risk Factors?
◆ Young and pre-menopausal women
– sexual intercourse
– use of spermicide
– new sexual partner
– mother with a history of UTI
– history of UTI during childhood
– blood group antigen secretory status
◆ Post-menopausal and elderly women
– history of UTI before menopause
– urinary incontinence
– atrophic vaginitis due to estrogen deficiency
– cystocele
– increased post-void urine volume
– blood group antigen secretory status
– urine catheterisation and functional status deterioration in elderly institutionalized women
Recurrent UTIs – Tratamento?
◆ Antimicrobials may be given as continuous low-dose prophylaxis for longer periods (three to six months), or as post-coital prophylaxis, as both regimens reduce the rate of rUTI.
◆ It is mandatory to offer both options after counseling, and when behavioral modifications and non-antimicrobial measures have been unsuccessful.
◆ Os tratamentos recomendados são geralmente o tratamento da infeção sintomática e o tratamento profilático.
◆ Este consiste numa dose baixa e diária de antibiótico, sendo o mais frequente a toma de 50 a 100 mg de nitrofurantoína por dia.
◆ Do not perform an extensive routine workup in women with recurrent UTI without risk factors
◆ Use vaginal estrogen replacement in post-menopausal women to prevent recurrent UTI
◆ Use immunization prophylaxis to reduce recurrent UTI in all age groups
Uncomplicated pyelonephritis?
◆ Pielonefrite = Infeção parenquimatosa do rim
◆ Não complicada = sem nenhum fator predisponente, não implica um tratamento muito complexo.
◆ Uncomplicated pyelonephritis is defined as pyelonephritis limited to non-pregnant, pre-menopausal women with no known urological abnormalities or comorbidities.
◆ It is vital to differentiate as soon as possible between uncomplicated and complicated mostly obstructive pyelonephritis, as the latter can rapidly lead to urosepsis.
◆ Additional investigations, such as an unenhanced helical computed tomography (CT), should be considered if the patient remains febrile after 72 hours of treatment
Uncomplicated pyelonephritis – Tratamento?
◆ Fluoroquinolones and cephalosporins are the only microbial agents that can be recommended for oral empirical treatment of uncomplicated pyelonephritis.
◆ Routine post-treatment urinalysis or urine cultures in asymptomatic patients are not indicated, except in pregnant women, if asymptomatic bacteriuria is an issue.
◆ Numa pielonefrite não complicada podemos tratar com antibioterapia oral com quinolonas.
◆ Pode haver necessidade de internamento porque o doente está muito sintomático (náuseas, vómitos, etc.), tendo que ser realizada antibioterapia por via endovenosa numa fase inicial.
Variantes de Pielonefrite - Emphysematous Pyelonephritis?
◆ Infeção do parênquima renal por microrganismo formador de gás.
◆ Curiosamente, a E.coli está também muito associada.
◆ Is a urologic emergency characterized by an acute necrotizing parenchymal and perirenal infection caused by gas-forming uropathogens.
◆ In addition to diabetes, many patients have urinary tract obstruction associated with urinary calculi or papillary necrosis and significant renal functional impairment.
◆ E. coli is most commonly identified. Klebsiella and Proteus are less common.
◆ Obstruction is demonstrated in approximately 25% of the cases.
Variantes de Pielonefrite - Emphysematous Pyelonephritis - Tratamento?
◆ Emphysematous pyelonephritis is a surgical emergency. Most patients are septic, and fluid resuscitation and broad-spectrum antimicrobial therapy are essential. If the kidney is functioning, medical therapy can be considered.
◆ Nephrectomy is recommended for patients who do not improve after a few days of therapy.
◆ If the affected kidney is nonfunctioning and not obstructed, nephrectomy should be performed because medical treatment alone is usually lethal.
◆ If a kidney is obstructed, catheter drainage must be instituted.
Variantes de Pielonefrite - Xanthogranulomatous Pyelonephritis?
◆ Xanthogranulomatous pyelonephritis (XGP) is a rare, severe, chronic renal infection typically resulting in diffuse renal destruction.
◆ Most cases are unilateral and result in a nonfunctioning, enlarged kidney associated with obstructive uropathy secondary to nephrolithiasis.
◆ It begins within the pelvis and calyces and subsequently extends into and destroys renal parenchymal and adjacent tissues.
◆ It has been known to imitate virtually every other inflammatory disease of the kidney, as well as renal cell carcinoma, on radiographic examination
◆ The primary factors involved in the pathogenesis of XGP are nephrolithiasis, obstruction, and infection
Variantes de Pielonefrite - Xanthogranulomatous Pyelonephritis - Tratamento?
◆ XGP should be suspected in patients with UTIs and a unilateral enlarged nonfunctioning or poorly functioning kidney with a stone or a mass lesion indistinguishable from a malignant tumor.
◆ Most patients present with flank pain (69%), fever and chills (69%), and persistent bacteriuria (46%).
◆ Additional vague symptoms, such as malaise, may be present. On physical examination, 62% of the patients had a flank mass and 35% had previous calculi
◆ Although review of the literature shows Proteus to be the most common organism involved with, E. coli is also common
◆ The primary obstacle to the correct treatment of XGP is incorrect diagnosis, nephrectomy is usually performed.
◆ A clínica é muitas vezes arrastada, com pielonefrite de repetição, dor lombar e um estado sético que se vai perpetuando.
◆ Quando se chega ao diagnóstico, na maioria das vezes o rim já não tem qualquer recuperação -> nefrectomia.
Renal Abscess?
◆ Renal abscess or carbuncle is a collection of purulent material confined to the renal parenchyma
◆ The current index patient typically has a history of renal disease or obstruction, has no gender predominance and no laterality, and the infection is typically with a gram-negative organism
◆ Ascending infection associated with tubular obstruction from prior infections or calculi appears to be the primary pathway for the establishment of gram-negative abscesses.
◆ Use of IV antimicrobial agents and careful observation of a small abscess less than 3 cm or even 5 cm in a clinically stable patient is appropriate.
◆ Abscesses of all sizes in immunocompromised hosts or those that do not respond to antimicrobial therapy should be drained percutaneously
◆ Percutaneous drainage, however, remains the first-line procedure of choice for most renal abscesses greater than 5 cm in diameter.
Infected Hydronephrosis and Pyonephrosis?
◆ Infected hydronephrosis is a bacterial infection in a hydronephrotic kidney.
◆ The term pyonephrosis refers to infected hydronephrosis associated with suppurative destruction of the parenchyma of the kidney, in which there is a total or nearly total loss of renal function
◆ Where infected hydronephrosis ends and pyonephrosis begins is difficult to determine clinically.
◆ Once the diagnosis of pyonephrosis is made, the treatment is initiated with appropriate antimicrobial drugs and drainage of the infected pelvis (drenagem percutânea com controlo ecográfico ou colocar por via retrógrada e endoscópica um cateter endouretral).
◆ Pionefrose – infeção num rim obstruído (hidronefrose), isto é, pus dentro do sistema excretor, que está a obstruir.
◆ É uma situação bastante grave e que requer uma atitude interventiva muito rápida, pois pode haver evolução para urosepsis fatal.
Perinephric Abscess?
◆ Usually results from rupture of an acute cortical abscess into the perinephric space or from hematogenous seeding from sites of infection.
◆ Patients with pyonephrosis, particularly when a calculus is present in the kidney, are susceptible to perinephric abscess formation.
◆ Diabetes mellitus is present in approximately one-third of patients with perinephric abscesses.
◆ In about one-third of the cases, the perinephric abscess is caused by hematogenous spread, usually from sites of skin infection.
◆ For small perinephric abscesses (<3 cm), antibiotics alone can appropriately treat immune-competent patients.
◆ For larger abscesses, percutaneous drainage or surgical intervention.
