Documenti di Didattica
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PRESENTATION
1
OVERVIEW
• CASE
• Background
• Definitions and criteria
• Disease characteristics – causative organisms,
pathogenesis, clinical features & complications
• Clinical assessment
• Role of the medical microbiologist
• LABORATORY DIAGNOSIS
• Treatment
• Prevention 2
CASE
• A 64 year old male with chief complaints of:
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HISTORY OF PRESENTING ILLNESS:
• Patient was apparently well, developed
abdominal distention, gradual onset since 4
days associated with decreased frequency and
urine output past 2 days
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HISTORY OF PRESENTING ILLNESS:
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PAST HISTORY
• K/C/O chronic liver disease with portal hypertension
since 2 years with recurrent episodes of pedal
edema and abdominal distention
• Four hospital admissions past two years for the
same
• Hepatic encephalopathy two months ago, treated
and recovered
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Twelve days prior to the current admission
underwent PCNL ( Percutaneous nephrolithiostomy)
with a DJ stent in situ in the left kidney, had multiple
small calculi in upper and mid lower calyces, no
hydronephrosis, no perinephric collection
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COURSE IN THE HOSPITAL
• The patient came to the casualty with the
present complaints
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CLINICAL EXAMINATION
• General physical examination:
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• Vital signs:
• Body temperature: afebrile
• Pulse: 80/ minute, regular rhythm
• Blood pressure: 130/ 70 mm of Hg, right arm supine
position
• Systemic examination:
• Cardiovascular system : Normal heart sounds, no
abnormal findings
• Respiratory system: clear, no added sounds 11
• Per abdomen:
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Investigations
• On admission:
PARAMETER REPORT NORMAL RANGE
PT CONTROL 14.9
INR 3.00
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• Urine analysis report
PARAMETER REPORT NORMAL RANGE
Colour Yellow
Specific gravity 42
Urine reaction 118 136-149
Glucose 5.4 3.5-5.3
Ketone 86.3 95-111
Protein 21.9 23-27
Urobilnogen normal
Bile salts +
Bile pigments +
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• Urine analysis report
PARAMETER REPORT NORMAL RANGE
Casts nil
Crystals nil
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Urethral meatal swab culture:
Gram stain: PMNLS+, epithelial cells++, Gram positive cocci+++,
Gram positive bacilli+++, Gram negative bacilli+++
Organism Growth Susceptible Intermediate Resistant
isolated
Klebsiella spp Heavy Amikacin Cefaperazone Ampicillin
growth Chloramphenicol Cefotaxime
Ceftazidime(6mm)
Ciprofloxacin
Ertapenem
Ofloxacin
Piperacillin
Piperacillin-
tazobactam
ESBL PRODUCER- Ceftazidime clavulinic acid(22mm)
Enterococcus Heavy Ampicillin, Chloramphenicol Amikacin, high
spp growth Cotrimoxazole Piperacillin- level gentamycin
Tetracycline tazobactam & streptomycin,
Vancomycin Erythromycin,
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Penicillin
• Ascitic tap was done and 550 ml of fluid was drained
• Urologist reference:
Catheterization
USG Abdomen
Urine culture
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Urine Culture
First sample – Mixed growth
Repeat sample-
Wet mount: Numerous pus cells,
no RBCs seen/HPF
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Treatment
• Admission to the ICU
• Serum electrolytes and renal function parameters
monitored on a daily basis
• Fluid intake and urine output monitored
• Condom catheterization was done
• RT feed and bowel wash
• Inj Cefotaxime 1g given 8 hourly
• Inj Ranitidine 50mg iv 8 hourly
• Tab Aldactone 50mg 1-1-0
• Tab Rifagut 50 mg 1-1-1
• Inj Vitamin K 10mg 22
• Patient was shifted to the ward following
improvement
• Urine culture though showed growth, signs and
symptoms of UTI did not worsen, antibiotics were
therefore not initiated
• However his liver function test parameters and
consciousness state worsened
• He developed spontaneous bacterial peritonitis
therefore was shifted back to the ICU: 23
DIAGNOSIS
Acute urethritis (post PCNL) and
portal hypertension in
medical care
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• Guideline recommendations for antibiotic
treatment of UTI are often not implemented in
practice
31
Recurrent UTIs:
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CHARACTERISTICS OF COMPLICATED UTI:
• Causative organisms
• Genitourinary abnormalities
• Patient population
• Clinical presentation
• Complications of infection
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Causative organisms:
• Most common: Escherichia coli
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35
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• Other Gram negative organisms: Klebsiella
pneumoniae, Proteus mirabilis, Providencia stuartii and
Morganella morganii, Pseudomanas aeruginosa
• Candida spp
*Elderly, chronic urological devices: POLYMICROBIAL
*Repeated antibiotics & nosocomial infection:
antimicrobial resistance
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Genitourinary abnormalities:
• Interference with normal voiding leads to
impaired flushing of bacteria
Mechanism of infection:
• Obstruction with incomplete urinary drainage
• Persistence of bacteria in bio films on stones or
indwelling devices
• Increased introduction of organisms into the
genitourinary tract through instrumentation
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MECHANISM ASSOCIATED CONDITIONS
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URINARY STONES VESICO URETRIC REFLUX
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BENIGN PROSTATIC HYPERTROPHY
CATHETERIZATION 43
Patient population
• Male UTIs
• Postmenopausal women with recurrent UTIs
• Children and pregnant women
• Structural and functional abnormalities
• Immunosuppressed patients
• Urological or renal disease, kidney stones
• Post catheterizated patients, inpatients discharged
within previous two weeks
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Clinical features
Asymptomatic presentation- most common
clinical presentation
• When symptomatic:
-Dysuria - Costovertebral angle tenderness
-Urgency - Suprapubic pain
-Frequency - Fever
-Flank pain
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• Severe obstructive acute pyelonephritis & urosepsis
co morbidities
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MANAGEMENT
• CLINICAL ASSESSMENT:
• Symptomatic patients- clinical features are
straightforward
• Neurological illnesses, chronic catheterization
assessment is difficult
increased bladder, leg spasms- autonomic
dysreflexia, fatigue, fever etc
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ROLE OF THE MEDICAL MICROBIOLOGIST
• Physicians rely on a small number of laboratory
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• Recurrent UTIs, treatment failures, complications,
inpatients – urine culture is advised
Method of collection
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Specimen collection
• Clean catch midstream urine sample
• Indwelling catheter
• Straight catheterization
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Specimen transport
• Urine specimens should be
a preservative
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Macroscopic examination
1. turbid due to the presence of pus cells and
microorganisms
2. milky colour - chyluria
3. red in colour - haematuria
4. brown/greenish brown- bilirubin
5. brown and cloudy - haemoglobin
6. yellow-orange - urobilin
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Specimen processing
• Detection of pyuria and bacteruria by urine
microscopy:
WET MOUNT
GRAM STAIN
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WET MOUNT
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WET MOUNT
Advantages:
• Direct observation of leukocytes
• Rapid and practical technique
Disadvantages:
• Leukocytes deteriorate quickly if the sample is not
fresh or adequately preserved
• Inaccurate because of inadequate standardization
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GRAM STAIN
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GRAM STAIN
Advantages:
• Immediate information of the infective
organism, guides antimicrobial therapy
Disadvantages:
• Sensitive only if concentration of bacteria >105
cfu/mL
• May not detect bacteria in the range of 102-
103cfu/mL
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Other nonculturable methods:
• Detection of bacteriuria by nitrite and catalase test
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Significance of urine analysis in UTIs
• Pyuria is present in asymptomatic bacteriuria
• Non infectious causes of urinary tract
inflammation in patients at risk for developing
complicated UTIs also cause pyuria
• Pyuria is consistent with but not diagnostic of
UTI
• High negative predictive value
• Casts are non specific
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Urine culture
Differential/selective medium
B. Quantitative methods:
i) Pour plate method
ii) Surface viable count - Spreading method
- Miles Misra method
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• Semi quantitative method using the calibrated
loop
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• Incubated overnight at 35-370C in ambient air
for 24 hours
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• Advantages:
Quantifies the magnitude of the infection regarding
the number of organisms in CFU/mL
Yields a continuous dilution of specimen and dilution
of inoculum results in the growth of individual
colonies of bacteria
Provides isolated colonies for subsequent
identification and ASTs
Practical and fast
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Interpretation
• The relevance of microbial growth needs adequate
interpretation
• No growth, gross contamination – usually
unambiguous and easy to report
• Mixed culture in varying quantities are difficult to
interpret
• Algorithms and interpretative guidelines are made
to establish the clinical relevance
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Result Specific specimen type/ Workup
associated clinical
condition, if known
>104 CFU/Ml of a single CCMS urine/ Complete
potential pathogen or pyelonephritis, acute
for each of two cystitis, asymptomatic
potential pathogens bacteriuria or
catheterized urine
>103 CFU/ml of a single CCMS urine/ Complete
potential pathogen symptomatic males or
catheterized urines or
acute urethral syndrome
> Three organism types CCMS urine None. Because of
with no predominant possible
organism contamination, ask
for another
specimen 70
Result Specific specimen type/ Workup
associated clinical
condition, if known
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Follow up culture
• Advised for patients who:
Do not respond to therapy
Recurrent UTI
Anatomic or functional abnormalities
Unexplained urine analysis findings
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FILTER PAPER METHOD DIP STICK METHOD
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Treatment
• Empirical treatment is difficult- a wide variety
of microorganisms cause UTI and increased
likelihood of resistance