內(nèi)科學(xué)英文課件：Urinary tract infection尿路感染

1Urinarytractinfection

尿路感染1Urinarytractinfection

尿路感染2IntroductionUrinarytractinfection(UTI)ofthebladder,kidney,or(inman)theprostateisoneofthemostcommonhumaninfections.2IntroductionUrinarytractinf3DefinitionsUTIisthepresenceofbacteriaorothermicroorganismsintheurineorgenitourinarytissues.Symptomatic:maymanifestasbladderinfection

Asymptomatic:bacteriuriawithoutsignsorsymptomsUncomplicatedUTI:occursinwomenusually

ComplicatedUTI:occursinindividualswithfunctionalorstructuralabnormalities3DefinitionsUTIisthepresenc4upperpelvic腎盂

calyx腎盞

ureter輸尿管pyelonephritis腎盂腎炎prostatitis前列腺炎intrarenal&perinephricabscesseslowerbladder膀胱

urethra尿道

cystitis膀胱炎u(yù)rethritis尿道炎AnatomicCategorieskidney4upperpelvic腎盂Anatomic5PathogenHostObstructionGenderandSexualactivityPregnancyNeurogenicBladderDysfunctionVesicoureteralRefluxHowtohappen5PathogenHostObstructionHowt6PathogenGram-negativeorganismsismostcommon95%

E.coli大腸桿菌60-80%Proteus變形桿菌Klebsiella克雷伯桿菌Pseudomonas綠膿桿菌Serratia沙雷桿菌Gram-positiveorganisms5-10%

Staphylococcussaprophyticus腐生葡萄球菌Streptococcusfaecalis糞鏈球菌Staphylococcusaureus金黃色葡萄球菌Staphylococcusalbus白色葡萄球菌Chlamydiatrachomatis沙眼衣原體Neisseriagonorrhoeae淋球菌Viruses病毒HerpessimplexvirusFungi真菌Yeasts原蟲6PathogenGram-negativeorganis7BacterialVirulenceFactorsInfectingorganismshaveavariablecapacitytostimulateorevadeactivationoftheimmuneresponse.Uropathogenicproducehemolysin

(溶血素)andaerobactin（菌素）Fimbriae（菌毛）:I,P,SSpecificO,KandHserogroups.Escherichiacoli大腸桿菌7BacterialVirulenceFactorsIn8HostdefensesofthenormalurinarytractValveatthejunctionofureterandbladder.Thedilutionandremovalofbacteriainurinewhichoccurswithmicturition.Hostdefensesotherthanvoidingthatcontributetomaintainingsterilityofurine.DefenseExampleUrinecharacteristicsPH↓,osmolality↑,concentrationoforganicacidsUrineproteinsTamm-Horsfallprotein;secretoryIgA,IgG;lactoferrin(乳鐵蛋白),lipocalin（載脂蛋白）,ectInflammatorycellsPolymorphonuclearleukocytesUroepitheliumMucopolysaccharidelayer,CytokineproductionProstatesecretionsChemokines,immunoglobulins8HostdefensesofthenormaluHostgeneticfactorsHostgeneticfactorsinfluencesusceptibilitytoUTIwomenwhohaveexperiencedrecurrentUTIsthenumberandtypeofreceptorsonuroepithelialcells9HostgeneticfactorsHostgenet10Obstructionstone

obstructionhydronephrosisAnyimpedimenttothefreeflowofstone,urine-tumor,stricture,orprostatichypertrophyresultinhydronephrosisandagreatlyincreasedfreguencyofUTI.10Obstructionstoneobstruction11GenderandSexualactivity（♀：♂=8：1）11GenderandSexualactivity（♀12PregnancyUTIsaredetectedin2-8%ofthepregnantwomenSymptomaticuppertractinfectionsareuncommonUppertractinfectionresultfromdecreasedureteraltoneandperistalsis,temporaryincompetenceofvesicoureteralvalvespregnancy12PregnancyUTIsaredetectedi13NeurogenicBladderDysfunctionThesepatientusuallyaccompanywithspinalcordinjury,tabesdorsalis,multiplesclerosis,diabetes,andotherdiseasesInterferencewithbladderenervationTheinfectionmaybeinitiatedbytheuseofcatheterforbladderdrainagecatheter13NeurogenicBladderDysfuncti14

VesicoureteralReflux

UrinerefluxfromthebladdercavityupintotheuretersandsometimesintorenalpelvisItoccursduringvoidingorwithelevationofpressureinthebladderDisturbenceofimmunecapacity

suchasdiabetes,anemia,chronichepaticdisease,chronickidneydisease,tumorandsoonInflammationofnearareaProstatitisVaginitismanOthers14VesicoureteralRefluxmanOt15Possibleroutesofinfection

Ascendingroute

MostUTIarebelievedtooccurbytheascendingroute.urethra→bladder→ureter→pelvis→calyx→parenchymal

Hematogenousroute

RelativelyrareStaphylococcalbacteremia金葡菌血癥Directinfection

trauma

organsinfectionaroundthekidneyLymphaticrouteIntestinetokidneybywayoflymphatics

appendicitis

colitisAscending15Possibleroutesofinfection16Pathology-AcutePhase

Macroscopicexamination:Mucosaisedematousandcongestive,andcontainavariablenumberofabscessesonthecapsularsurfaceandoncutsectionsofthecortexandmedulla.Occasionally,areasofinflammationextendfromthecortexintothemedullaintheshapeofwedge.AcuteCystitis16Pathology-AcutePhaseMacr17Pathology-AcutePhase

Histologicchanges:Tubularepithelialcellsareedematous,necrosisanddetachfrombasementmembrane.Sometubulesaredamagedandothersaredestroyed,manytubulescontainleukocytes.Acuteinflammationwithpolymorphonuclearleukocyteinfiltrationmaybefound.Theglomeruliandbloodvesselsarerelativelyfreeofinflammatorychanges.17Pathology-AcutePhaseHist18Pathology-ChronicPhase

Macroscopicexamination:Parenchymalscarringandunderlyingcaliceal

deformity.Thekidneysarefrequentlyirregular,andreductioninsizeisoftenunilateral.Thekidneyusuallyhasflat-basedorU-shapedscars.18Pathology-ChronicPhaseMa19Pathology-ChronicPhase

Histologicchanges:increaseininterstitialfibroustissuetubuleatrophyandnecrosisperiglomerularfibrosis19Pathology-ChronicPhaseHCystitisCystitisisacommonsyndromethataffectsotherwisehealthywomen10%ofyoung,sexuallyactive,premenopausalwomenexperienceaUTIeachyear60%ofallwomenhaveoneormoresuchinfectionsintheirlifetimeFrom2-5%ofwomenexperiencefrequentrecurrentinfectionViaascendingrouteE.coliisthemostcommonagent20CystitisCystitisisacommons21Cystitis-ClinicalpresentationLocalmanifestations:urgency,frequency,

dysuria,

stranguria,orhesitancy.

andsuprapubicpainSystemicsymptoms:absenceUrine:grosslycloudyandmalodorous,bloodyinabout30%ofcases;whitecellsandbacteriacanbedetected21Cystitis-ClinicalpresentaAcutepyelonephritisLesscommon

thancystitisThehighestincidenceisamongyoungwomenaged20-30yearsHospitalizationisrequiredforasmanyas20%ofaffectednonpregnantwomenE.coliisisolatedin85%to90%ofwomenRiskfactors:recentsexualintercourse,diabetes22AcutepyelonephritisLesscommo23Acutepyelonephritis-ClinicalpresentationLocalmanifestations:Backandloinpain(withexquisitetendernessonpercussionofthecostovertebralangle).Dysuriafrequancy,andnocturia.Prominentsystemicsymptoms:rigorsandhighfever,oftenwithfatigue,nauseaandvomiting,abdominalpainordiarrhea.Urine:Cloudyurine,pyuria,hematuria,leukocytecastsBlood:leukocytecount↑,C-reactiveproteinandprocalcitonin(降鈣素原)↑

23Acutepyelonephritis-CliniChronicpyelonephritisAsymptomaticbacteriuria,dysuriaandfrequency,vaguecomplaintsofflankorabdominaldiscomfort,andintermittentlow-gradefevers.Maybedividedintothefollowingfivetypes:Recurrenttype;Low-gradefevertype;Hematuriatype;Insidioustype;Hypertensiontype24ChronicpyelonephritisAsymptom25UrethritisApproximately30%ofwomenwithacutedysuria,freguency,andpyuriahavemidstreamurineculturesshoweithernogrowthorinsignificantbacterialgrowth.Adistinctionshouldbemadebetweenwomeninfectedwithsexuallytransmittedpathogens.25UrethritisApproximately30%26Catheter-associatedUTIsBacteriuriadevelopsinatleast10%to15%ofhospitalizedpatientswithindwellingurethralcathetersGram-negativeorganisms:E.coliorProteus,Pseudomonas,Klebsiella,SerratiaGram-positiveorganisms:Staphylococci,enterococciandCandidausuallycausetheseinfectionsFactorsassociatedwithanincreasedrisk:female,prolongedcatheterization,severeunderlyingillness,etc.MostCatheter-associatedUTIscauseminimalsymptoms26Catheter-associatedUTIsBact27ComplicationsPapillarynecrosisPerinephricabscess27ComplicationsPapillarynecroPapillarynecrosisAnuncommoncomplicationinpyelonephritisOccursmoreoftenindiabeticpatientsSymptomsandsigns:Hematuria,painintheflank,

chillsandfeverTheIVPmayshowlossofpapillae-"ringshadow"28PapillarynecrosisAnuncommonPerinephricabscessRarecomplicationofpyelonephritisOftenassociatedwithobstructionorDMSymptomsandsigns:loinpainaccentuatedbymovement,chillsandfever,urinaryfrequencyanddysuria.Ultra-sound,radiationexamhelptodiagnosis.29PerinephricabscessRarecompli30DiagnosisUrinaryroutineWhitecellsarefrequentlyobserved.HematuiraDetectionofleukocytecastsisalsoanindicationofinvolvementofthekidney.Proteinuria,<2g/d,lowmolecularprotein.Lowgravity,highpH,whenthetubulardysfunctionoccurs.30DiagnosisUrinaryroutine31DiagnosisGram’sstainThesimplestmethodfordetectingsignificantbacteriuriaistoexaminetheurineunderthemicroscope,usingGram’sstain.Ifbacteriaarefoundusingtheoilimmersionobjective,therearelikelytobemorethan105bacteria/ml.31DiagnosisGram’sstain32Diagnosiscleanmid-streamurinecultureThemostwidelyusedmethodofcollectingurineforcultureandisthemethodofchoice.Ifthebacterialcount>105/ml,canbedefinedsignificantresult.Whenbacterialcount<104/ml,canberegardedascontaminated.Coccuscountreaches103~104/mlalsocanbedefinedsignificantresult.32Diagnosiscleanmid-streamur33Cleanmid-streamurineculture,notice:theprocedureshouldbedonebeforeantibiotictherapyor5days

aftercessationantibiotictherapy.thefirstmorningurinationispreferredforthebacteriacangrowmore.strictattentiontoasepsisisnecessary.33Cleanmid-streamurinecultu34DiagnosisBloodroutinetest:WBC，ESR，CRPAntibody-coatedbacteria:helptodistinguishpyelonephritisfromthelowerUTIsRenalfunctiontest:defectinurinaryconcentrating,acidificationcapacityaswellasglomerularfiltrationfunction.Bloodcultures:inpatientwithsuspectedpyelonephritisorurosepsis34DiagnosisBloodroutinetest:35UrologicevaluationImaging:Ultrasound,X-ray,CTscan,MRI

KUB+IVP(intravenouspyelography)(Notice:

shouldbeavoidedduringacutephase)Cystoscopy:obstructionstone

hydronephrosis35UrologicevaluationImaging:36Decisionprocessforupper&lowerUTIupperUTI(Pyelonephritis)lowerUTI(Cystitis)Signs&SymptomsFeverYesNoDysuriaMaybepresentYesFrequencyMaybepresentYesFlankpainYesNoDiagnosisPyuriaYesYesLeukocytecastsMaybepresentNoAntibody-coatedbacteriaMaybepresentNoC-reactionprotionIncreasedNormalBloodculturesPositivein~30%Negative36Decisionprocessforupper&37TreatmentAquantitativeurinecultureoracomparablealternativediagnostictestshouldbeperformedbeforeempiricaltreatmentFactorspredisposingtoinfection,suchasobstructionandcalculiReliefofclinicalsymptomsdoesnotalwaysindicatedbacteriologiccureEachcourseoftreatmentshouldbeclassifiedafteritscompletionasafailureoracureUncomplicatedinfectionsinlowerurinarytractrespondtoshortcourseoftherapy,whileuppertractinfectionsrequirelongertreatmentCommunity-acquiredinfections,especiallyinitialinfections,areusuallyduetomoreantibiotic-sensitivestrainsInpatientswithrepeatedinfections,orrecenthospitalization,thepresenceofantibiotic-resistantstrainsshouldbesuspected37TreatmentAquantitativeurinTreatmentAcuteuncomplicatedcystitisGeneraltreatment:rest,increasefluidintakeAntibiotictreatment:3-dayregimens:oralTMP-SMX(復(fù)方新諾明),TMP(三甲氧芐胺嘧啶),quinolone（喹諾酮）7-dayregimens:Diabetes,males,Pregnancy:7-daytreatmentwithamoxicillin(阿莫西林)orcephalosporin（頭孢菌素）.

38TreatmentAcuteuncomplicatedc39TreatmentAcuteuncomplicatedpyelonephritisGeneraltreatment:restinbed,increasefruidintakeandsoonAntibiotictreatment:Startantibiotictherapyimmediatelyafterurinecollection.Mildtomoderateillness,oralquinolonefor7-14days,orsingle-dosecephalosporinintravenousfollowedbyoralTMP-SMXfor14days.Seriousorpregnantpatientshouldbegivenantibioticdrugsthroughintravenousroute.Theantibioticcourseusuallyis14days.39TreatmentAcuteuncomplicatedTreatmentComplicatedUTIsManyoftheinfectingstrainsareantibiotic-resistantEmpiricalantibiotictherapyideallyprovidesbroad-specturmcoverageWithminimalormildsymptoms,oraltherapywithquinolonefor10-14d.Untilcultureresultsandantibioticsensitivitiesareknown.Insevereillness,hospitalizationandparenteraltherapyEmpiricalregimens:Imipenemalong,

apenicillinorcephalosporinplusanaminoglycosideThetherapyshouldbeadministeredbytheinformationofantimicrobialsensitivityfor10-21days

40TreatmentComplicatedUTIs40TreatmentAsymptomaticbacteriuriaInnoncatheterizedpatientsiscommon,especiallyamongelderlypatients.TheantimicrobialtherapyisunnecessaryHigh-riskpatientsmayrequiretreatment.Thetherapywithanoralagentfor7dBacteriuriainpatientswithcathetershouldnotbetreatedunlessthepatientisfebrileorhasotherevidenceofsystemicinfectionRemovalofthecatheterassoonaspossibleisbeneficialfortherapy41TreatmentAsymptomaticbacteriuPreventionUrinateshortlyaftersexualintercourseinwomenDoubleortriplevoidingIncreasedfluidintakeWomenwhoexperiencefrequentsymptomaticUTIs,arecandidatesfortreatmentwithlong-termandlow-doseantibiotics.42PreventionUrinateshortlyaftePrognosisTheprognosisofuncomplicatedcystitisandpyelonephritisaregenerallygood.Thepatientswithcomplicationsmayleadtofurtherreductionofrenalfunction.Patientswithurosepsishaveapoorprognosis,withfatalityratesofabout30%orhigher.43PrognosisTheprognosisofuncoCaseMissChen,34yearsoldSymptoms:

urgency,frequency,bloodyurine

for2days

44CaseMissChen,34yearsold4whatwillyoudofirst?45historycollection

UTIhistory,underlyingdisease,sexualhistory,

Medicationhistoryphysicalexamination

takeatemperature,

costovertebralanglepain

38.4°C+whatwillyoudofirst?45histoWhatareyougoingtodonext?LabexaminationUrinaryroutineGram’sstaincleanmid-streamurinecultureBloodroutinetestC-reactiveproteinRenalfunctiontestBloodculturesImagingUltrasoundradiographyexamination

46Result:Whiteandredcells,

leukocytecasts↑Gram-negativerodsWhitebloodcells↑↑normally

Whatareyougoingtodonext?Howtodiagnosis?Andwhy?CystitisPyelonephritis47√Howtodiagnosis?Andwhy?CysHowtotreat?Generaltreatment:restinbed,increasefruidintakeAntibiotictreatment:Mildtomoderateillness,oralquinolonefor7-14days,orsingle-dosecephalosporinintravenousfollowedbyoralTMP-SMZfor14days.Seriouspatientshouldbegivenantibioticdrugsthroughintravenousroute.Theantibioticcourseusuallyis14days.48Howtotreat?GeneraltreatmentQuestionsThe

definitionofUTIThemostcommonmicroorganisminUTIRiskfactorsofUTIPossibleroutesofUTIClinicalpresentationofcystitisandpyelonephritisNoticeofcleanmid-streamurinecultureDecisionprocessforupper&lowerUTITreatmentofcystitisandpyelonephritis49QuestionsThedefinitionofUTIRecommendedbooksBrenner“THEKIDNEY”王海燕 《腎臟病學(xué)》50RecommendedbooksBrenner51Thanksforyouattention!51Thanksforyouattention!52Sign,Sympotom,LabCystitisPyelonephritisTMP-SMZ#2Bid×3dOfloxacin0.2Bid×3durineculture7dsymptomaticasymptomaticurineculture(+)urineculture(-)subsequentvisit1mAdministereddrugs,×14dbacteriuria(+)leukocyturia(+)bacteriuria(-)leukocyturia(+)bacteriuria(-)Leukocyturia(-)InfectiveUrethralSyndromeNon-infectiveUrethralSyndromeTreatment

52Sign,Sympotom,LabCystitisPye53Urinarytractinfection

尿路感染1Urinarytractinfection

尿路感染54IntroductionUrinarytractinfection(UTI)ofthebladder,kidney,or(inman)theprostateisoneofthemostcommonhumaninfections.2IntroductionUrinarytractinf55DefinitionsUTIisthepresenceofbacteriaorothermicroorganismsintheurineorgenitourinarytissues.Symptomatic:maymanifestasbladderinfection

Asymptomatic:bacteriuriawithoutsignsorsymptomsUncomplicatedUTI:occursinwomenusually

ComplicatedUTI:occursinindividualswithfunctionalorstructuralabnormalities3DefinitionsUTIisthepresenc56upperpelvic腎盂

calyx腎盞

ureter輸尿管pyelonephritis腎盂腎炎prostatitis前列腺炎intrarenal&perinephricabscesseslowerbladder膀胱

urethra尿道

cystitis膀胱炎u(yù)rethritis尿道炎AnatomicCategorieskidney4upperpelvic腎盂Anatomic57PathogenHostObstructionGenderandSexualactivityPregnancyNeurogenicBladderDysfunctionVesicoureteralRefluxHowtohappen5PathogenHostObstructionHowt58PathogenGram-negativeorganismsismostcommon95%

E.coli大腸桿菌60-80%Proteus變形桿菌Klebsiella克雷伯桿菌Pseudomonas綠膿桿菌Serratia沙雷桿菌Gram-positiveorganisms5-10%

Staphylococcussaprophyticus腐生葡萄球菌Streptococcusfaecalis糞鏈球菌Staphylococcusaureus金黃色葡萄球菌Staphylococcusalbus白色葡萄球菌Chlamydiatrachomatis沙眼衣原體Neisseriagonorrhoeae淋球菌Viruses病毒HerpessimplexvirusFungi真菌Yeasts原蟲6PathogenGram-negativeorganis59BacterialVirulenceFactorsInfectingorganismshaveavariablecapacitytostimulateorevadeactivationoftheimmuneresponse.Uropathogenicproducehemolysin

(溶血素)andaerobactin（菌素）Fimbriae（菌毛）:I,P,SSpecificO,KandHserogroups.Escherichiacoli大腸桿菌7BacterialVirulenceFactorsIn60HostdefensesofthenormalurinarytractValveatthejunctionofureterandbladder.Thedilutionandremovalofbacteriainurinewhichoccurswithmicturition.Hostdefensesotherthanvoidingthatcontributetomaintainingsterilityofurine.DefenseExampleUrinecharacteristicsPH↓,osmolality↑,concentrationoforganicacidsUrineproteinsTamm-Horsfallprotein;secretoryIgA,IgG;lactoferrin(乳鐵蛋白),lipocalin（載脂蛋白）,ectInflammatorycellsPolymorphonuclearleukocytesUroepitheliumMucopolysaccharidelayer,CytokineproductionProstatesecretionsChemokines,immunoglobulins8HostdefensesofthenormaluHostgeneticfactorsHostgeneticfactorsinfluencesusceptibilitytoUTIwomenwhohaveexperiencedrecurrentUTIsthenumberandtypeofreceptorsonuroepithelialcells61HostgeneticfactorsHostgenet62Obstructionstone

obstructionhydronephrosisAnyimpedimenttothefreeflowofstone,urine-tumor,stricture,orprostatichypertrophyresultinhydronephrosisandagreatlyincreasedfreguencyofUTI.10Obstructionstoneobstruction63GenderandSexualactivity（♀：♂=8：1）11GenderandSexualactivity（♀64PregnancyUTIsaredetectedin2-8%ofthepregnantwomenSymptomaticuppertractinfectionsareuncommonUppertractinfectionresultfromdecreasedureteraltoneandperistalsis,temporaryincompetenceofvesicoureteralvalvespregnancy12PregnancyUTIsaredetectedi65NeurogenicBladderDysfunctionThesepatientusuallyaccompanywithspinalcordinjury,tabesdorsalis,multiplesclerosis,diabetes,andotherdiseasesInterferencewithbladderenervationTheinfectionmaybeinitiatedbytheuseofcatheterforbladderdrainagecatheter13NeurogenicBladderDysfuncti66

VesicoureteralReflux

UrinerefluxfromthebladdercavityupintotheuretersandsometimesintorenalpelvisItoccursduringvoidingorwithelevationofpressureinthebladderDisturbenceofimmunecapacity

suchasdiabetes,anemia,chronichepaticdisease,chronickidneydisease,tumorandsoonInflammationofnearareaProstatitisVaginitismanOthers14VesicoureteralRefluxmanOt67Possibleroutesofinfection

Ascendingroute

MostUTIarebelievedtooccurbytheascendingroute.urethra→bladder→ureter→pelvis→calyx→parenchymal

Hematogenousroute

RelativelyrareStaphylococcalbacteremia金葡菌血癥Directinfection

trauma

organsinfectionaroundthekidneyLymphaticrouteIntestinetokidneybywayoflymphatics

appendicitis

colitisAscending15Possibleroutesofinfection68Pathology-AcutePhase

Macroscopicexamination:Mucosaisedematousandcongestive,andcontainavariablenumberofabscessesonthecapsularsurfaceandoncutsectionsofthecortexandmedulla.Occasionally,areasofinflammationextendfromthecortexintothemedullaintheshapeofwedge.AcuteCystitis16Pathology-AcutePhaseMacr69Pathology-AcutePhase

Histologicchanges:Tubularepithelialcellsareedematous,necrosisanddetachfrombasementmembrane.Sometubulesaredamagedandothersaredestroyed,manytubulescontainleukocytes.Acuteinflammationwithpolymorphonuclearleukocyteinfiltrationmaybefound.Theglomeruliandbloodvesselsarerelativelyfreeofinflammatorychanges.17Pathology-AcutePhaseHist70Pathology-ChronicPhase

Macroscopicexamination:Parenchymalscarringandunderlyingcaliceal

deformity.Thekidneysarefrequentlyirregular,andreductioninsizeisoftenunilateral.Thekidneyusuallyhasflat-basedorU-shapedscars.18Pathology-ChronicPhaseMa71Pathology-ChronicPhase

Histologicchanges:increaseininterstitialfibroustissuetubuleatrophyandnecrosisperiglomerularfibrosis19Pathology-ChronicPhaseHCystitisCystitisisacommonsyndromethataffectsotherwisehealthywomen10%ofyoung,sexuallyactive,premenopausalwomenexperienceaUTIeachyear60%ofallwomenhaveoneormoresuchinfectionsintheirlifetimeFrom2-5%ofwomenexperiencefrequentrecurrentinfectionViaascendingrouteE.coliisthemostcommonagent72CystitisCystitisisacommons73Cystitis-ClinicalpresentationLocalmanifestations:urgency,frequency,

dysuria,

stranguria,orhesitancy.

andsuprapubicpainSystemicsymptoms:absenceUrine:grosslycloudyandmalodorous,bloodyinabout30%ofcases;whitecellsandbacteriacanbedetected21Cystitis-ClinicalpresentaAcutepyelonephritisLesscommon

thancystitisThehighestincidenceisamongyoungwomenaged20-30yearsHospitalizationisrequiredforasmanyas20%ofaffectednonpregnantwomenE.coliisisolatedin85%to90%ofwomenRiskfactors:recentsexualintercourse,diabetes74AcutepyelonephritisLesscommo75Acutepyelonephritis-ClinicalpresentationLocalmanifestations:Backandloinpain(withexquisitetendernessonpercussionofthecostovertebralangle).Dysuriafrequancy,andnocturia.Prominentsystemicsymptoms:rigorsandhighfever,oftenwithfatigue,nauseaandvomiting,abdominalpainordiarrhea.Urine:Cloudyurine,pyuria,hematuria,leukocytecastsBlood:leukocytecount↑,C-reactiveproteinandprocalcitonin(降鈣素原)↑

23Acutepyelonephritis-CliniChronicpyelonephritisAsymptomaticbacteriuria,dysuriaandfrequency,vaguecomplaintsofflankorabdominaldiscomfort,andintermittentlow-gradefevers.Maybedividedintothefollowingfivetypes:Recurrenttype;Low-gradefevertype;Hematuriatype;Insidioustype;Hypertensiontype76ChronicpyelonephritisAsymptom77UrethritisApproximately30%ofwomenwithacutedysuria,freguency,andpyuriahavemidstreamurineculturesshoweithernogrowthorinsignificantbacterialgrowth.Adistinctionshouldbemadebetweenwomeninfectedwithsexuallytransmittedpathogens.25UrethritisApproximately30%78Catheter-associatedUTIsBacteriuriadevelopsinatleast10%to15%ofhospitalizedpatientswithindwellingurethralcathetersGram-negativeorganisms:E.coliorProteus,Pseudomonas,Klebsiella,SerratiaGram-positiveorganisms:Staphylococci,enterococciandCandidausuallycausetheseinfectionsFactorsassociatedwithanincreasedrisk:female,prolongedcatheterization,severeunderlyingillness,etc.MostCatheter-associatedUTIscauseminimalsymptoms26Catheter-associatedUTIsBact79ComplicationsPapillarynecrosisPerinephricabscess27ComplicationsPapillarynecroPapillarynecrosisAnuncommoncomplicationinpyelonephritisOccursmoreoftenindiabeticpatientsSymptomsandsigns:Hematuria,painintheflank,

chillsandfeverTheIVPmayshowlossofpapillae-"ringshadow"80PapillarynecrosisAnuncommonPerinephricabscessRarecomplicationofpyelonephritisOftenassociatedwithobstructionorDMSymptomsandsigns:loinpainaccentuatedbymovement,chillsandfever,urinaryfrequencyanddysuria.Ultra-sound,radiationexamhelptodiagnosis.81PerinephricabscessRarecompli82DiagnosisUrinaryroutineWhitecellsarefrequentlyobserved.HematuiraDetectionofleukocytecastsisalsoanindicationofinvolvementofthekidney.Proteinuria,<2g/d,lowmolecularprotein.Lowgravity,highpH,whenthetubulardysfunctionoccurs.30DiagnosisUrinaryroutine83DiagnosisGram’sstainThesimplestmethodfordetectingsignificantbacteriuriaistoexaminetheurineunderthemicroscope,usingGram’sstain.Ifbacteriaarefoundusingtheoilimmersionobjective,therearelikelytobemorethan105bacteria/ml.31DiagnosisGram’sstain84Diagnosiscleanmid-streamurinecultureThemo