Urinary Tract InfectionClinical Presentation * A 30 years female patient presented with frequencency and urgency in Urination with raise of body temperature since 3 days. * She also presented with lower abdominal pain since 4 days * What can be your Provisional Clinical Diagnosis ?Signs and Symptoms of Urinary Tract Infection * Elevated temperature—(vital signs) Elderly require > time to present with fever, may not have any increase in temperature > may even be hypothermic Elderly at 7d risk for masked or absent fever response due to antipyretics, corticosteroids, chemo Rx, alcoholism, hypothyroidism, malnutrition and renal insufficiency Studies indicate fever is a marker for serious infection & most important clinical indicator for antibiotic treatment ¢ Other studies, fevers can resolve without treatment; antibiotics did not improve outcomes in elderly Not always due to UTI—consider differential diagnoses: pulmonary or skin infections @ Lack of fever may delay diagnosis* The provisional diagnosis can be a Urinary tract infection (UTI ) * Define Urinary Tract Infection ? What are the possible etiological agents ?+ Kidney - Bladder Ureters Do not include Urethra, Infections of Urethra is Called as Urethritis, dealt __under different clinical syndromes* Aninfection of one or more structures in the urinary system. Most UTIs are caused by gram negative bacteria, most commonly Escherichia coli or species of Klebsiella, Proteus Pseudomonas, or Enterobacter, although other strains, such as Staphylococcus and Serratia, are emergingNotes on pathogens * Escherichia coli : the commonest urinary pathogen causing 60-90 % of urinary infections * Pseudomonas, Proteus, Klebsiella and S. aureus are associated with hospital acquired infections because their resistance to antibiotics favor their selection in hospital patients (catheterization, gynaecological surgery) * Proteus infections are associated with renal stones Proteus produce a potent urease which act on ammonia, rendering the urine alkaline * 5, saprohyticus infections are found in sexually active young womeneo . | Streptococci ‘ + ANS ii) a dernella vaginalisNotes on pathogens * Candida urinary infection is usually found in diabetic patients and immunosuppression * Infection of the anterior urinary tract (urethritis) is mainly caused by N. gonorrhea, staphylococci, streptococci and chlamydia * M. tuberculosis is carried in blood to kidney from another site of infection (e.g. respiratory T.B.)What is the Basis of Diagnosis of Urinary Tract Infection ?Diagnostic Criteria Pyuria * Ahost response to infecting bacteria causing an increase of white blood cells or pus in the urine * Associated with presence of both symptomatic and asymptomatic UTI’s in elderly * Level of pyuria is 4’ when infected with a gram negative organism * Most research finds this is so common that it has questionable value in UTI detection and as an indicator for Rx in the absence of clinical symptomsCollecting the Urine * There are several different methods for collection of a urine sample. The most common is the midstream clean-catch technique. Hands should be washed before beginning. For females, the external genitalia (sex organs) are washed two or three times with a cleansing agent and rinsed with water. In males, the external head of the penis is similarly cleansed and rinsed. The patient is then instructed to begin to urinate, and the urine is collected midstream into a sterile container.Collected in wide mouthed container * The urine collected in a wide mouthed container from patients * Amid stream specimen is the most ideal for processing | * Female patients passes urine with a labia separated and mid stream sample is collectedEarly inoculation a Priority * Urine collected in sterile specimen container must be processed within 2 hours, or refrigerated and processed within 24 hours * Urine collected in sterile specimen container with * borate preservative , should be processed i r within 24 hours (no refrigeration required)Collection of Urine Catheterized Patients “4 * Another method is the catheterized urine specimen in which a lubricated catheter (thin rubber tube) is inserted through the urethra (tube-like structure in which urine is expelled from the bladder) into the bladder. This avoids contamination from the urethra or external genitalia.Suprapubic aspiration * Onrare occasions, the health care provider may collect a urine sample by inserting a needle directly into the bladder (suprapubic tap) and draining the urine; this method is used only when a sample is needed quickly and technically competent staff are availableSpecimen collected in Infants and Children * Non invasive methods are safe and ideal * Follow the Broomhall et al method By tapping just above the pubis with two fingers place on suprapubic region after 1 hour of feed, tapping on at the rate of 1 tap/second for period of 1 minute, if not successful tapping is repated once again. - The child spontaneously pass the Urine and to be collected in a sterile containerTransport of Urine for Culturing Urine All collected specimens of urine to be transported to laboratory with out delay Delay of 1-2 hour deter the quality of diagnostic evaluations. ; If the delay is anticipated the specimens are at preserved — at 4% In field conditions Boric acid can be added at a concentration of 1.8 %All wet films to be examined with high power ( x 40 ) objective. Prepare the drop of urine after mixing the urine Without centrifugation Transfer 0.05 ml on the middle of the microscope Slide and cover slip is applied. * The prepared specimen show ‘a small excess of fluid along the edges of the cover slip Aapproximate finding of 1 leukocyte / 7 high power fields corresponds to presence of pyuria~ Selection of Loop for Semi quantitative core Method* Semi quantitative culture Select the Media For common isolates MacConkey agar helps in differentiation of Lactose fermenting organisms from non lactose fermenting pathogens ithBlood agar helps in isolation of fastidious, extracting strains May extended incubation for isolation of pathogens for more than 48 hours with added atmosphere of 5 -10% co,What you understand by Significant bacteriuria ? «Significant bacteriuria in an asymptomatic patient is 100,000 or more colonies per milliliter of urine from a midstream, en clean-catch ees specimen;Mac Conkey’s agar showing Proteus and E.ColiUp to 10*/ml considered normal i.e. Insignificant 10°/ml and above considered to be Significant Concept valid only for voided specimen of urine Exceptions - slow growing organisms, patient on antibiotic therapy, diuretic therapyMost important point in Interpretation Yet many theories on Significant bactenuria are controversial. The reporting of results should be mainly based on clinical history. Even a true infection may contain only 103 In such circumstances tests to be reported as probably or possibly significant A good coordination between a Microbiologist and Physician is the best solution to patients with Urinary tract infections.What are different Biochemical tests you perform different isolates ? * Catalase test * Oxidase test | © Nitrite reduction test * Indole test | * Methyl red test ; * VP test _ * Citrate test _ © Decarboxylation tests Lysine, ornithine, Arginine testsAntibiotic Sensitivity Always use a pure growth of the isolates. Perform testing for antibiotic sensitivity with inoculum which is comparable to defined McFarland Standards.How you perform Antibiotic Sensitivity Testing ? * All the isolated bacteria identified as pathogenic to be tested for Antibiotic Sensitivity/Resistance pattern by disk diffusion methods~ Issues on Urinary Tract — infectionf Causative Pathogens and other implication UTI in Women * Escherichia coli—gram (-) etiologic ageat in ~ 80% of all UTI’s * Research indicates primary source of microbial invasion is retrograde colonization by intestinal pathogens * Other factors influencing colonization: vaginal pH, urethral length, capacity of bacteria to adhere to urothelium Osborne, 2004Urinary Tract Infection Why it is Important = Urinary tract infection—most common source of bacteremia, a dangerous systemic infection in long- term care facilities u Bacteremia—40 times more likely to occur in catheterized than non-catheterized residents = Bacteremia leads to significant morbidity and mortality in the vulnerable elderlyClinical Problems manifesting as Urinary tract Infections * An infection of the Genitourinary tract where the Microbes do not grow on selected media as in Mycobacterium tuberculosis Gonococcus Nutritionally exacting or anaerobic bacteria* Contamination most frequent cause of multiple microorganisms ° 25-33% in LTCF’s may be polymicrobic due to fistulas, urinary retention, infected stones, or cathetersNon Specific Urethritis * Several conditions mimic Urinary tract infection which are associated with organism other than routinely isolated in simple and few selective media, they can be Can be urethral or Bladder infections with Chlamydia Ureplasma Trichomonas, Few virusesSerious Infections associated with UTI * Acute pyelitis * Pyelonephritis * May lead to Bacteremia's detected by Blood culture * A prominent infection with Staphylococcus aureus can cause above manifestations. * Be prompt to diagnose Urinary Tract Infections