Surgery II 6.3 Dr.

Jose Benito Abraham

GENITO-URINARY INFECTIONS February 16, 2015

OUTLINE PATHOGENESIS OF URINARY TRACT INFECTIONS

I. Urinary Tract Infection
ROUTES OF INFECTION
a. Epidemiology
b. Pathogenesis ASCENDING INFECTION
c. Diagnostic Principle Common in females
d. Imaging Studies Most enter from the bowel reservoir via ascent through the urethra
e. Prophylactic Antimicrobial Therapy into the bladder2
f. Classification of UTI Adherence of pathogens to the introital and urothelial mucosa plays a
g. Categories of UTI significant role2
h. Specific UTI
II. Vesicourethral Reflux
Perineal soilage with feces
III. Specific Complicated Genitourinary Infectious State o Mostly seen in the elderly
IV. Key Points In-dwelling catheters
Spermicidal agents

REFERENCES 2
Most common pathogen: Escherichia coli
1. Lecture PPT
2. 2015B trans
HEMATOGENOUS ROUTE
3. 2015A trans
4. Schwartz Renal cortical abscesses
5. Sabiston Need to look for other sites of infection
6. Centers for Disease Control and Prevention: Most common offending agent: Staphyloccocus aureus
http://www.cdc.gov/std/treatment/2010/urethritis-and-cervicitis.htm Commonly seen in diabetes mellitus
Lecture recording Uncommon in normal individuals2
7. Unicorn 2015
LYMPHATIC ROUTE
URINARY TRACT INFECTION
Rare
Inflammatory response of the urothelium to bacterial invasion
Contagious infections with the bowel
Associated with bacteriuria and pyuria
Direct extension of bacteria from the adjacent organs via lymphatics
Bacteriuria
may occur in unusual circumstances such as2
o Presence of bacteria in the urine
o Severe bowel infections
o May represent specimen contamination
o Retroperitoneal abscesses
Presence of bacteria is not synonymous with UTI. If only
bacteria, then it is due to contamination, poor handling
BACTERIAL ADHERENCE
technique, or catheter contamination.
Crucial step in colonization and eventual infection
o Symptomatic or asymptomatic (screening bacteriuria)
Facilitated by the presence of pili that are the adhesive arms of the
Pyuria
bacteria
o Prerequisite for the diagnosis of UTI
o Inflammation of the urothelium
TYPE I (MANNOSE-SENSITIVE PILI)
o Pyuria with bacteriuria confirms INFECTION
o Bacteriuria without pyuria indicates colonization without Both pathogenic and non-pathogenic E. coli
infection Bacterial colonization of vaginal mucosa and bladder
o Pyuria without bacteriuria indicative of tuberculosis, stones or Mediate hemagglutination of guinea pig erythrocytes, which is
cancer inhibited by mannose causing mannose-sensitive hemoagglutination
o if negative culture sterile pyuria, think of other diseases
1,3 (MSHA)

EPIDEMIOLOGY
UTIs are the most common bacterial infection
Account for 7 million visits to the physicians office
1 million visits to the emergency room
100,000 hospitalization annually
They account for 1.2% of all office visits by women and 0.6% of all
office visits by men
Infection in females increases at the onset of sexual intercourse.
o Starts to rise around 18 years of age.
o Staph saphrolyticus causes symptomatic UTI to young sexually
7 Figure 1. Type I is composed of thin helical rods of FimA subunit joined to a
active female (10%)
distal tip FimH, which is responsible for adhesion to the mannosylated host
Infection in males increases at elderly age, because of prostate receptors present in the urothelium, and it is critical to the ability of E. coli to
enlargement.
colonize the vaginal introitus, urethra, bladder, and can cause cystitis.
Institutionalization and concurrent disease
o 24%nursing home residents TYPE P (MANNOSE-RESISTANT PILI)
o 12% of healthy domiciliary subjects
Confer tropism to the kidney
o 38% of nosocomial infection/year
P for pyelonephritis
o >80% nosocomial UTIs due to indwelling catheters
Mediate hemagglutination that is not inhibited by mannose (mannose-
o Increased in pregnancy, spinal cord injury, diabetes mellitus, MS,
resistant hemagglutination (MRHA))
HIV

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 SURGERY II 6.3

TYPE S DIAGNOSTIC PRINCIPLES

Rare PROPER URINE COLLECTION METHOD
Binds to sialic acid residues found in both bladder and kidney A properly collected urine specimen is key to diagnosis
epithelium Retraction of foreskin (for uncircumcised men)
Spreading the labia
Table 1. Factors that Contribute to UTI o Get midstream catch urine specimen
UROPATHOGEN FACTORS HOST FACTORS Catheterized specimen
Integrity of immune system Suprapubic tap
Virulence 3
Foreign bodies o Ideal technique but invasive
Load of inoculum
Functional or anatomical o Precaution when doing a suprapubic tap:3
Opportunistic organisms Proper hydration is necessary to increase bladder distention.
obstruction
o Indications:
NATURAL HOST DEFENSES Any child who is unable to void for a sample of urine. (done
PERIURETHRAL REGION on pediatric patients to collect uncontaminated urine3)
Normal flora 2 Patients in retention where foley catheter insertion is
o Lactobacilli difficult.
o Coagulase-negative Staphylococcus aureus
o Corynebacteria DIPSTICK URINALYSIS
o Streptococci Easy to perform
Estrogen Relies on color change
Cervical IgA Early detection of red and white cells
Low vaginal pH Leukocyte esterase
o Changes in the vaginal environment related to estrogen, cervical o Compound produced by the breakdown of WBCs in the urine.
3
IgA, and low vaginal pH might alter the ability of bacteria to o Has higher sensitivity.
colonize2 Nitrites
Use of antibiotics o Produced by reduction of dietary nitrates by many gram-negative
o May eradicate normal flora bacteria. Esterase and nitrite can be detected by a urine dipstick
Spermicidal agents and are more reliable when the bacterial count is >100,000
o Frequent use of antibiotics and spermicidal agents alter the CFU/mL.3
normal flora and increase the receptivity of the epithelium to o Most specific3
uropathogens2 Proteinuria
Should never be used to replace a routine urinalysis which makes
URINE DEFENSES microscopic confirmation possible.3
Protective factors
o Dilution dilution risk of infection MICROSCOPIC URINALYSIS

3
o Low pH acidic urine can overcome infection Correlate with dipstick urinalysis
o Uromodulin (Tamm-Horsfall protein) binds to the binding sites of Superior to dispstick urinalysis
pili, which blocks their the adhesion to the urothelium Can be used to localize or even lead you to proper diagnosis.
Risk factors o Hyaline casts
o Glucose facilitates infections Erythrocyte casts: suggest glumerulonephritis
Consistently seen in the higher infection rates of patients Leukocyte casts: suggest pyelonephritis
with diabetes mellitus Granular casts: advanced kidney disease
Epithelial casts: necrosis of the tubules
BLADDER DEFENSES o Crystals
The main protective mechanism of the bladder against infection is its Calcium oxalate
ability to empty itself completely Uric acid
Patients with anatomical and functional obstructions are more prone to Triple phosphate
developing UTI because of significant bladder residual volume Cystine
o Squamous epithelial cells
ALTERATION IN HOST DEFENSE MECHANISMS If there are numerous squamous epithelial cells, it suggests
Obstruction that the collection is poor and must be repeated.
2
o Causes urine stasis and bacterial proliferation
Vesicoureteral reflux AUTOMATED FLOW CYTOMETER
o Predisposes an individual to recurrent infection because of urine Faster turn-around time
stasis
2
High sensitivity and specificity
Underlying disease High positive predictive value
o May render the patient immunocompromised, increasing the risk Correlates well with cultures
of developing infection2
Diabetes mellitus BIOCHEMICAL AND ENZYMATIC TESTS
o 3 times the hospitalization for acute pyelonephritis in women 2 Greiss test detects nitrite
o 4 times the pyelonephritis in autopsies in diabetes mellitus
2
Leukocyte esterase
Renal papillary necrosis Nitrite and leukocyte esterase
Sensitivity of 71% and a specificity of 83%

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 SURGERY II 6.3

COLONY COUNTS CT SCAN

100,000 col/cc is diagnostic o Best imaging of choice
In asymptomatic patient, count must be >10,000 col/cc to o Offers best anatomic detail
diagnose UTI. o Requires contrast in most cases
20-40% symptomatic women counts <10,000 col/cc o Plain CT (Stonogram)
o In a symptomatic patient, a count of 10,000 col/cc is sufficient. May be enough to diagnose calculi and hydronephrosis

2
10 is sufficient for dysuric women Rapid diagnosis
For suprapubic taps, low counts of gram-negative and gram-positive Able to detect radiolucent and radiopaque stone
organisms are indicative of an infection.
3
No contrast required
For catheterized specimens, counts of at least 104 is diagnostic.3 o Improves the approach to surgical drainage and permits
percutaneous approaches.3
SELECTIVE URETERAL CATHETERIZATION MRI
Seldom performed as first line treatment o Has not superseded CT in the evaluation of renal inflammation
Separation of bacterial persistence into upper and lower urinary tracts o has provided some advantages in delineating extrarenal extension
o Upper urinary tract localization: bladder is irrigated with sterile of inflammation.3
water and a ureteral catheter is placed into each ureter.
3 Radionuclide scan
o A specimen is collected from the renal pelvis.
3
Key Points
o Culture of this specimen will determine if there is infection.3 o They should be done whenever you suspect complicated UTI
Localization of laterality o Imaging studies are not required in most women with UTIs
o Whenever there is a question of laterality or localization of the UTI, But it is indicated to women with relapsing UTI
can use this to know where the infection comes from o Men who develop UTI generally need imaging to rule out anatomic
o Localization of infection to ectopic ureters or to nonrefluxing abnormalities
ureteral stumps o CT and MRI provide the best anatomic data on the site, cause, and
Voided Bladder Urine: extent of infection
o VB1
First 10 20 cc of voided urine PROPHYLACTIC ANTIMICROBIAL THERAPY
Determine if there is infection in the urethra such as Prevention of onset of infection of the urinary tract
gonococcal urethritis No active infection
o VB2 More commonly referred to surgical antimicrobial prophylaxis
Midstream urine o Usually done 1 hour prior to a procedure and can avoid life-
o VB3 threatening infections
Do prostatic massage first through rectal exam and then ask
patient to urinate UNCOMPLICATED PROCEDURES NOT REQUIRING PROPHYLAXIS
Urethral catheterization
Urodynamics study
Patients with risk factors such as the diabetics, the elderly, and the
immunocompromised, should be treated with:
o Oral fluoroquinolone
o Bactrim DS (Cotrimoxazole)

UNCOMPLICATED PROCEDURES REQUIRING PROPHYLAXIS

TRUS-Prostate Biopsy
o Oral or IV fluroquinolones
o Consider culture-directed treatment if catheterized
Figure 2. Localization of lower urinary tract infection. A positive culture Extracorporeal shock wave lithotripsy
in the voided bladder urine (VB1) specimen suggests infection of the o Ideal host
urethra, VB2 urine indicates an infection of the bladder, and in EPS Bactrim DS
(expressed prostatic secretion) or VB3 indicates infection of the Oral fluroquinolone
prostate.
3 o Host with risk factors
For infectious stone, treat preoperatively for UTI
IMAGING STUDIES Ideal hosts and hosts with risk factors should be treated with:
Plain Film o Oral or IV fluoroquinolones
Excretory urogram o If catheterized, consider culture-directed treatment
o Normal renal function is requisite
o IV contrast SURGICAL ANTIMICROBIAL PROPHYLAXIS
o Sensitive in diagnosis of radiopaque calculi and hydronephrosis Diagnostic Cysto-urethroscopy
o Complements findings on ultrasound o Ideal host
o Rarely done due to toxicity No absolute indication
o Cannot be done to patient with hypersensitivity to contrast and o Host with risk factors
impaired renal function Cefazolin
Retrograde pyelogram Oral fluroquinolone
Bactrim DS
Voiding cystourethrogram
Ultrasonography
o Gives you image of dilated kidney
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 SURGERY II 6.3

Transurethral surgery ACCORDING TO ONSET AND TIMING

o Ideal hosts and hosts with risk factors First or isolated infection
Ampicillin + Gentamicin Unresolved infection: not responding to antimicrobial therapy
Oral or IV fluroquinolones Recurrent infection
Endoscopic urologic procedures Reinfection
o Uteroscopic lithotripsy Bacterial persistence
o Percuataneous nephrolithotripsy Relapse
o Ideal hosts and hosts with risk factors CHRONIC UTI poor term to be used
Ampicillin + Gentamicin o More appropriate for describing chronic bacterial prostatitis and
IV fluroquinolones chronic pyelonephritis
Open and laparoscopic urologic surgery
o Potentially contaminated CATEGORIES OF UTI
E.g. Radical or simple nephrectomy COMPLICATED
Procedures with open urinary tract Occurs in the setting of underlying abnormalities of physiology or
Low and high risk: Cefazolin, Clindamycin or Vancomycin (for anatomy of genitourinary system
beta lactam allergy) Factors suggesting complicated UTI
o Contaminated o In all male gender
Bladder with excision with bowel reconstruction o Pregnancy
Dirty wound with abscess, perforation of the GU tract o Elderly
Use of intestines in urologic surgery o Immunocompromised host
o Ileal conduit o Childhood UTI
o Orthotopic neobladder o Indwelling urinary catheter
o Mitrofanoff procedure o Urinary tract instrumentation
o Potentially contaminated o Hospital-acquired urinary tract infection
Low and high risk patients: Cefoxitin, Clindamycin + Complicated UTI in men is result of:
Gentamycin, Ciprofloxacin (for beta lactam allergy), o Urolithiasis
Aztreonam o Benign Prostatic Hyperplasia
Suppressive antimicrobial therapy o Prostate Carcinoma
o Suppression of a focus of bacterial persistence
o Low nightly dose UNCOMPLICATED
o Also for poor risk surgical patients with staghorn Considered in immunocompetent host
Risk factors
CLASSIFICATION OF UTI o Prior infections
ACCORDING TO SITE OF ORIGIN o Sexual activity
BLADDER INFECTION o Uncircumcised penis
Presentation
o Dysuria SPECIFIC UTI
o Frequency LOWER URINARY TRACT INFECTIONS
o Urgency CYSTITIS
o Suprapubic pain Risk factors
Differential Diagnoses o Reduced urine flow
o Urethritis Outflow obstruction
o Interstitial cystitis Neurogenic bladder
o Bladder carcinoma o Inadequate fluid intake
o Bladder calculi o Promote colonization
Sexual activity increased inoculation
KIDNEY INFECTION Spermicide increased bleeding
Unique to cystitis because pyelonephritis involves fever and chills Estrogen depletion increased binding
Acute Pyelonephritis Wiping from back to front after a bowel movement may force
o Presentation germs into urethra
Flank pain o Facilitate ascent
Fever Catheterization
Chills Urinary incontinence
Chronic Pyelonephritis Fecal incontinence
o Post-infectious changes Urinary retention
o Chronic inflammation Causative organisms
o Coarse focal scarring o E. coli (most common) 75-90%
o Generalized thinning of renal cortex o Klebsiella, Proteus and Enterococcus
o Rarely associated with acute PN o Staphylococcus saprophyticus 10-20%
o Majority are asymptomatic Diagnosis of cystitis
o Clinical symptoms
o Microscopic analysis for bacteriuria, pyuria, hematuria
o Must be differentiated from vaginitis, urethritis, and sexually
transmitted diseases
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 SURGERY II 6.3

o Urine culture is definitive test o Recent antimicrobial agent use

Management o Diabetes mellitus
o Uncomplicated cystitis should be treated for 3 days o Immunosuppression
o Asymptomatic bacteriuria should be treated only in pregnant o Pregnancy
women and prior to urologic intervention o Hospital-acquired infection
o Recurrent UTIs due to bacterial persistence require urologic
4
management PROSTATITIS
ACUTE PROSTATITIS
ACUTE CYSTITIS Bacterial infection in the prostate gland, most commonly by urinary
Dysuria, urgency, frequency and suprapubic discomfort pathogens.
Foul-smelling urine Signs and symptoms
Hematuria (hemorrhagic cystitis) o Fever
Incomplete bladder emptying o Dysuria
Present in 50-90% of women with cystitis o Perineal or back discomfort
A digital rectal examination may indicate an indurated and tender
UNCOMPLICATED gland.
Most cases occur in women Brisk digital rectal examination should be avoided, as it is extremely
Occasionally in prepubertal girls uncomfortable for patients and is thought to cause bacteremia.
Increases in adolescence Patients require a 4- to 6-week course of antibiotic therapy, typically a
25-30% in 20-40 year-old females quinolone.
Not common in men o Imaging studies if no improvement in 48 hours to rule out
Healthy women prostatic abscess
o Oral fluoroquinolone o Large abscesses managed with transurethral unroofing or
o TMP/SMX percutaneous drainage.
o Nitrofurantoin
Healthy men <50 years old CHRONIC PROSTATITIS
o Oral fluoroquinolone Signs and symptoms
o TMP/SMX o Continued lower urinary tract symptoms
o Pelvic pain
COMPLICATED ACUTE CYSTITIS Bacterial chronic prostatitis
Women with o Frequent cause of recurrent urinary tract infections
o DM o Treated with a prolonged course of antibiotics
o >65 years Chronic nonbacterial prostatitis
o Symptoms >7 days o Does not respond to antibiotics or most other medications
o Recent UTI o Treated with biofeedback, physical therapy, and other
o Diaphragm use nonprostate-specific treatments
Treatment Pre- and post-prostatic massage urine
o Mild to moderate illness, without nausea/vomiting, outpatient o Culturing method to distinguish bacterial to non-bacterial
therapy
Oral norfloxacin, ciprofloxacin for 10-14 days URETHRITIS 4
o Severe illness possible urosepsis Urethritis, as characterized by urethral inflammation, can result from
Parental ampicillin + gentamicin, ciprofloxacin, norfloxacin, infectious and noninfectious conditions.
ticarcillin-clavulanic, imipinem-cilastin, aztreonam until the Symptoms (if present)
fever is gone then oral TMP/SMP, norfloxacin, o Discharge of mucopurulent or purulent material
ciprofloxacin, levofloxacin for 14-21 days o Dysuria
o Urethral pruritis
ACUTE CYSTITIS IN PREGNANCY Asymptomatic infections are common
Pregnant women Etiologic agents: N. gonorrhea, C. trachomatis, Mycoplasma genitalium
o Amoxicillin
4
o Cephalexin EPIDIDYMO-ORCHITIS
o Nitrofurantoin crystals Result of bacterial infection originating in the urinary tract.
Complications of UTI IN pregnancy Signs and symptoms
Prematurity o Unilateral painful swelling of the epididymis and/or testis
Increased prenatal mortality o Fever (often)
Maternal anemia o Erythematous scrotum on the side of involvement
o Elevated WBC count (often)
COMPLICATED CYSTITIS o +/- reactive hydrocele may be present
Compromised urinary tract Rapid onset
Very resistant pathogen Ultrasound may show increased blood flow to epididymis
Failed initial antimicrobial therapy Treatment
May lead to life-threatening kidney infection o Oral antibiotics if the patient is not markedly febrile and is
Complicating host factors otherwise stable.
o Abnormalities or urinary tract
o Recent urinary tract instrumentation
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 SURGERY II 6.3

o Hospitalization and parenteral antibiotics are required if the o Grade IV dilation of the renal pelvis and calyces with moderate
patient has high fevers, significantly elevated WBC, or ureteral tortuosity
hemodynamic instability o Grade V gross dilatation of the ureter, pelvis and calyces,
ureteral tortuosity, loss of papillary impressions
UPPER URINARY TRACT INFECTIONS (KIDNEYS)
Symptoms
o Classic: Fever, chills, flank pain
o Nausea and vomiting
o Generalized body malaise
Less prevalent than bladder infection
Varied presentation
o May be nonspecific
o May be asymptomatic
High index of suspicion + radiologic and lab evaluation

ACUTE PYELONEPHRITIS
Evaluation
o Blood and urine cultures
o Radiographic imaging is mandatory to rule out complicating
factors
Management
o Oral or intravenous antibiotics Figure 3. International grading of VUR according to its affectation of the
o Repeat urine cultures after therapy ureter and pelvocalyceal system.
o Drain abscess or remove focus

OTHERS
Chronic Pyelonephritis
Reno-cortical abscess
Perinephric (retroperitoneal abscess)
Ureteritis

VESICOURETERAL REFLUX
Congenital anomaly caused by insufficient intramural tunneling of the
distal ureter4
o Primary danger is the development of recurrent episodes of
pyelonephritis can cause cumulative renal damage through Figure 4. This is a VCUG done on a child with recurrent UTI showing bilateral
scarring Grade II-III reflux on both kidneys. Note that on the left side, the calyces are
Common cause of recurrent febrile UTI in children still sharp while they are blunted on the right side. 3
o Second most common cause of hydronephrosis after ureteropelvic
junction (UPJ) obstruction4
Defect in anti-reflux mechanism
o Up to two-thirds of infants presenting with urinary tract infections
o Majority of cases occur in females

4
Treatment depends on severity of grade
o Surgical repair with ureteral reimplantation is effective
o Conservative management, consisting of antibiotic prophylaxis,
may result in breakthrough infections with resistant organisms.
o Submucosal injection of bulking agents at the ureteral orifice Figure 5. A radionuclide imaging is useful in determining cortical perfusion
Minimally invasive technique that may obviate the need for and excretory function. This DMSA scan shows significant scarring on the left
open surgical repair or long-term suppressive antibiotics kidney.
Not effective in every case- patients with severe reflux may
still need reimplantation. SPECIFIC COMPLICATED GENITOURINARY INFECTIOUS STATE
Most cases could be treated medically XANTHOGRANULOMATOUS PYELONEPHRITIS
Urologic interventions Long-standing urinary obstruction with infection and urinary calculi
o Endoscopic injection of DEFLUX agent that causes dysfunction of the kidney
o Ureteral reimplantation (open, laparoscopic or robotic-assisted) if Majority are middle-aged women
it is severe Destruction of renal parenchyma
INTERNATIONAL GRADING OF VUR ACCORDING TO ITS AFFECTATION Staghorn in 80% of cases
OF THE URETER AND PELVOCALYCEAL SYSTEM: The following typify the findings in xanthogranulomatous PN with
o Grade I reflux into non-dilated ureter pararenal extension
o Grade II reflux into the renal pelvis and calyces without Most common etiologic agent: Proteus7
dilatation
o Grade III mild/moderate dilatation of the ureter, renal pelvis and
calyces with minimal blunting of the fornices
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 SURGERY II 6.3
GENITOURINARY TUBERCULOSIS
Most common site of TB, after the lungs
Active disease leads to renal parenchymal destruction as a result of
caseation necrosis
Chronic disease leads to multiple ureteral strictures (rosary beading)
and a small scarred calcified urinary bladder
Medical treatment is the mainstay of therapy
Urologic complications are treated surgically with ureteral replacement
and bladder augmentation
Endemic to the Philippines, which may occur even years after an occult
pulmonary tuberculosis infection.
Figure 6. Genitourinary TB: This retrograde pyelogram shows the typical
appearance of a scarred kidney with pipe stem fibrosis, rosary beading, and
a kidney with a moth-eaten appearance.3
RENAL ECHINOCOCCUS
Parasitic infection caused by tapeworm Echinococcus granulosus
Definitive host: dog
Presents as a slowly growing tumor
Most are asymptomatic
Anaphylaxis may ensue when the cyst ruptures, which is highly
antigenic
May present as flank mass, dull pain, or hematuria
Definitive diagnosis: finding hydatid cysts in the urine
Treatment
o Surgical drainage
o Aspiration
o Marsupialization
o Injection of scolicidal agents
o Nephrectomy
Figure 7. Renal Echinococcus. Clockwise (A) Gross specimen. A cystic mass
measuring 7 11 cm in lower pole. Smaller daughter cysts are identified
within the larger cystic mass. (B) Gross specimen. Daughter cysts represent
brood capsules that have detached and move freely. (C) Photomicrograph.
Brood capsules (B) arising from the germinal layer. This CT scan shows the
markedly enlarged right kidney with multiple hydatid cysts.
2 the left is cushioned by sigmoid from compression
Group 14 |QUIJANO, QUIMBO, QUITOY, RAMIREZ, RAMOS. L.
RENAL MALAKOPLAKIA
Malakoplakia, Greek word for soft plaque
Usually affects the bladder, but may also affect the kidneys, lungs,
bones and mesenteric lymph nodes
Large histiocytes called von Hansemman cells containing Michaelis-
Guttman bodies
Clinical Presentation
o > 50 years. F:M ration is 4:1
o Debilitated, immunocompromised patients
o Masses affecting bladder, ureter and kidney
o Ureteral stricture, hydronephrosis
o Renal vein and vena caval thrombosis
o Epididymo-orchitis
o May mimic prostate adenocarcinoma
Figure 8. Renal Malakoplakia.
Left: Cut surface of the kidney demonstrates extensive cortical and upper
medullary replacement by multifocal, confluent, tumor-like masses.
Right: Characterized by von Hansemman as soft, yellow-brown plaques
with granulomatous lesions in which the histiocytes contain distinct
basophilic inclusions or Michaelis-Gutmann bodies (represents
incompletely destroyed bacteria surrounded by lipoprotein membrane.)
DIABETES AND UTI
Gas forming or emphysematous infection is common6
o Present as fulminant infection involving the renal parenchyma
o Commonly caused by E. coli
Treatment
o Upper tract obstruction: retrograde or antegrade tube drainage
o Purulent collection: percutaneous drainage
o Unstable: nephrectomy
Increased incidence of UTIs in women
o Both symptomatic and asymptomatic UTIs are increased women
with diabetes, although there is no substantial increase in men.
3x hospitalization for acute pyelonephritis in women
4x pyelonephritis in autopsies in DM
BACTERIURIA IN PREGNANCY
Asymptomatic bacteriuria is one of the most common infectious
complications of pregnancy.
Prevalence is 2-7%
Incidence increases with the duration of pregnancy
Also increased in lower socioeconomic class, sickle cell traits and
multiparity
Anatomic and physiologic changes during pregnancy
o Increase in renal size
o as a result of increased blood flow
o Augmented renal function
o Smooth muscle atony of collecting muscle and bladder
o Bladder becomes hyperemic and gets displaced
There is actually a tendency for the creatinine to be lower due to
dilution, so a normal creatinine in pregnant women doesnt exclude a
renal problem.
Hydronephrosis in pregnant women is more common on the right since
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 SURGERY II 6.3

ACUTE PYELONEPHRITIS HEMO-

Arterial hypotension
Bacteriuria unlikely to resolve unless treated DYNAMIC
o SBP <90 mm Hg
1-4% of all pregnant women develops acute pyelonephritis (Not
o MAP <70, or
20-40% of untreated bacteriuric patients develop acute pyelonephritis included in
o SBP decrease >40 mm Hg in adults or 2 SD below
60-75% occur in last trimester Docs ppt
normal for age
but it is in
mixed venous oxygen saturation (SvO2) >70%
BACTERIURIA IN ELDERLY the original
Cardiac index >3.5 L/min
Morbidity is significant article)
Sepsis and shock are common Arterial hypoxemia (PaO2/FIO2 <300)
Broad spectrum antibiotics Acute oliguria (urine output <0.5 mL/kg/hr or 45
Culture-guided therapy mmol/L for at least 2 hrs)
Consider drug toxicities ORGAN Creatinine increase 0.5 mg/dL
Age related risk factors: DYS- Coagulation abnormalities (INR 1.5 or aPTT >60 secs)
o Decline in immunity FUNCTION Ileus (absent bowel sounds)
o Neurogenic bladder dysfunction Thrombocytopenia (platelet count 100,000 /L)
o Increased perineal soilage from incontinence Hyperbilirubinemia (plasma total bilirubin > 4 mg/dL or
o Increased catheter placement 70 mmol/L)
o Estrogen depletion TISSUE Hyperlactatemia (>1 mmol/L)
PERFUSION Decreased capillary refill or mottling
Table 1. Frequency of Significant Bacteriuria Related to Underlying Disease. (From Levy MM, Fink MP. Marshall JC., et al: 2001 SCCM/ESICM/ACCP/ATS/SIS
Routine Medical examination 5% International Sepsis Definitions Conference. Crit Care Med 2003;31: 1250-1256)
Diabetes Mellitus 20%
With cystocele 23% CATHETER-ASSOCIATED
Indwelling catheter (closed system) 37 50% Most common cause of hospital-acquired infections
Condom catheter (non-cooperative patient) 50% Accounts for 40% of hospital infections (US)
Congenital urologic disease 57% Inevitable bacteriuria results from catheterization at a rate of 10%/day
Hydronephrosis. Nephrolithiasis 85% Intermittent catheterization is also a risk for bacteriuria
Indwelling catheter (open system) 98% To avoid catheter infections
(Adapted from Jackson GG. Arana-Sieler JA, Andersen BR: PROFILES of o Aseptic technique
PYELONEPHRITIS. Arch Intern Med 1962; 110: 663-675) o Closed dependent drainage
o Treat symptomatic patients
BACTEREMIA o Treatment based on cultures
SYSTEMIC INFLAMMATORY RESPONSE SYNDROME o Antimicrobials may be given x 3 days after catheter
o Manifests as extremes of body temperature, heart rate, removal to avoid bacterial colonization
respiratory rate, and WBC count that occurs in response to an
infection. BACTERIURIA IN SPINAL CORD INJURY
SEPSIS SYNDROME UTIs are among most common urologic complication
o Progresses to shock as a result of peripheral vasodilatation caused 33% have bacteriuria at any time (Strover et, 1989)
by gram negative endotoxins Almost all become bacteriuric
o Hyperventilation: reliable early clinical indication of septicemia7 Many will suffer significant morbidity and mortality
o Management of Urosepsis with Septic Shock Bacteriuria and SCC (spinal cord compression) patients
Resuscitation o Impaired voiding
Supportive therapy o Bladder overdistention
Intensive monitoring o Increased intravesical pressure
Broad spectrum antibiotics o Increased risk of obstruction
Drainage and elimination of infection o Vesicoureteral reflux
BACTEREMIA o Increased instrumentation
o Presence of viable bacteria in the bloodstream o Stones
Risk factors
Table 2. Diagnostic Criteria for Sepsis o Decreased fluid intake
Fever (core temperature >38.3C) o Poor hygiene
Hypothermia (core temperature <36C) o Perineal colonization
Heart rate >90 bpm or >2 SD above the normal value o Decubitus ulcers
for age o Evidence of local tissue trauma
Tachypnea o Reduced host defenses
GENERAL Clinical presentation
Altered mental status
Significant edema or positive fluid balance (>20 ml/kg o Mostly asymptomatic
over 24 h) o Fever in elderly
Hyperglycemia (plasma glucose >120 mg/dL or 7.7 o Catheter leakage
mmol/L) in the absence of diabetes o Increased spasticity
o Malaise, lethargy
Leukocytosis (WBC count >12,000 /L )
INFLAMMA
Leukopenia (WBC count < 4000/ L )
-TORY
Normal WBC count with >10% immature forms
Group 14 |QUIJANO, QUIMBO, QUITOY, RAMIREZ, RAMOS. L. Page 8 of 9
 SURGERY II 6.3

Diagnosis APPENDIX
o High index of suspicion URINARY CASTS AND ASSOCIATED PATHOLOGIC CONDITIONS
o Bacteriuria AND Pyuria
o Urine culture is mandatory TYPE OF CAST COMPOSITION ASSOCIATED CONDITIONS
o Pyuria alone is not diagnostic because of presence of catheter Pyelonephritis, chronic renal
Treatment HYALINE Macroproteins disease,
o Urine and blood cultures May be a normal finding
o Change of indwelling catheter Glomerulonephritis, May be a
o For afebrile patients: Oral fluoroquinolones ERYTHROCYTE Red blood cells normal finding in patients
o Febrile patients: Parenteral aminoglycosides and penicillin or third who play contact sports
generation cephalosporin Pyelonephritis,
White blood glomerulonephritis,
FUNGIURIA LEUKOCYTE
cells interstitial nephritis, renal
Risk factors inflammatory processes
o Indwelling catheters Acute tubular necrosis,
o Antimicrobial therapy interstitial nephritis,
o Diabetes Mellitus Renal tubule eclampsia, nephrotic
o Prolonged hospitalization EPITHELIAL
cells syndrome, allograft rejection,
o Immunocompromised host heavy metal ingestion, renal
Clinical presentation disease
o May affect the kidney via hematogenous spread from other Various cell
sources of infection or the gastrointestinal tract. GRANULAR Advanced renal disease
types
o Candida albicans (50%) Various cell
o Candida glabrata (10-15%) WAXY Advanced renal disease
types
o Fungal culture, pyuria Lipid-laden renal Nephrotic syndrome, renal
o Fungal balls, bezoars FATTY
tubule cells disease, hypothyroidism
Key Points Various cell
o Remove or change catheter BROAD End-stage renal disease
types
o Repeat cultures to guide you if the treatment is working or not
o Irrigate the bladder or kidney with antifungal agent (FIRST-LINE of
therapy)
o If persistent infection, consider systemic therapy with
Amphotericin B or Fluconazole

Figure 9. Fungiuria. (Left) This CT scan shows a Renal Fungus infection

complicated with emphysematous pyelonephritis. Unenhanced CT scan
reveals gas in the right renal collecting system (open arrow) and renal
parenchyma (straight arrow). Some fungus balls were misdiagnosed as
urorthelial tumors. (Right) Retrograde pyelogram reveals round filling
defects in the collecting system (arrows) consistent with Mycetomas.

KEY POINTS: URINARY TRACT INFECTION

Infection of the urinary tract occurs when bacterial virulence increases
and/or host defense mechanisms decrease.
Early identification and treatment of complicated UTIs is essential to
prevent major sequelae or death.
UTI vary in presentation and sequelae.
Careful diagnosis and treatment is essential.
Imaging should be done whenever complicated UTI is suspected.
Appropriate choice of antibiotic therapy is crucial. The majority of
patients respond promptly to short courses of antimicrobial therapy

Edited by: RZ
Group 14 |QUIJANO, QUIMBO, QUITOY, RAMIREZ, RAMOS. L. Page 9 of 9