Diagnostic approach and microorganism resistance pattern ... · Diagnostic approach and...
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Diagnostic approach and microorganism
resistance pattern in UTI
Yeva Rosana , Anis Karuniawati, Yulia Rosa, Budiman Bela
Microbiology Department
Medical Faculty, University of Indonesia
Urinary Tract Infection (UTI)
Upper urinary tract : ureters and kidneys
Lower urinary tract: bladder and urethra
urinary tract inflammation that results
from any one of a number of distinct
syndromes
It is most commonly caused by a
bacterial infection
Urinary Tract Infection Lower urinary tract : bladder and urethra
The bladder wall is covered with a surface mucopolysaccharide that inhibits the attachment of bacteria via their adhesins
Uropathogenic strains of bacteria can attach to the cell wall of the bladder
Diagnostic approach in UTI Symptom UTI: localization of the site of infection 1. Acute bacterial pyelonephritis: - Fever, loin pain - Significant bacteriuria
2. Acute bacterial cystitis: - Frequency, & dysuria syndrome - Significant bacteriuria
3. Acute prostatitis - Perineal pain after sitting, a tender prostate, & fever - Significant bacteriuria
4. Symptomatic patients without significant bacteriuria urethritis, subacute or chronic bacterial prostatitis
UTIs INTO PERSPECTIVE
Upper urinary tract : ureters and kidneys
Lower urinary tract : bladder and urethra
150 million UTIs
(uncomplicated and complicated)
occur yearly in the world
UNCOMPLICATED UTIs are
the most frequent
BACTERIAL INFECTION
IN WOMEN
Stamm and Norrby, CID, 2005
The shorter urethra is a predisposing factor for Cystitis in women
Women lack the bacteriostatic properties of prostatic secretions: UTI >>
Risk factors for UTI: In females:
pregnancy, spermicidal contraceptives,
diaphragm, estrogen deficiency.
In males:lack of circumcision, prostatic hypertrophy,
use of catheter.
old age, obstruction, vesicoureteric reflux,
instrumentation, neurogenic bladder, renal
transplantation.
UTI frequency is roughly equal in women and men among the elderly
Men: an enlarged prostate in older men obstructs the urethra, leading to increased
frequency of urinary retention UTI
Menopause women: the loss of estrogen will be thins the lining of the urinary tract, which increases susceptibility to bacterial infection.
Struthers, Clinical Bacteriology, 2005
Epidemiology of UTI
Overview by sex and age
Diagnostic approach in recurrent bacterial cystitis :
• Someone who have had one bacterial cystitis have a risk recurrences, which follow the resolution of a previous treated or untreated episode
• Recurrent: at least 2 infections of the bladder in 6 months, or 3 infections in 1 year
Risk Factor for Recurrent UTI:
• Patients who do not empty their bladder completely
• Some large kidney stones
• Other foreign objects in the urinary system
Methods of urine collection :
No Methods Comments
1. MSU (main method) If possible, collect 2 specimens
to increase the percentage confidence of
organisms detection 2. a. Adhesive bags-infants
b. Clean-catch
specimen (CCS)-
infants
3. Suprapubic aspiration occasionally necessary in infants
4. Catheterization of urethtra - should never occur just to obtain a urine
specimen introducing infection
- If already catheterized, collected from the
catheter into a syringe and needle before
- it enters the drainage bag
5. Ureteric catheterization during operation
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Transport to laboratory
• Urine sample in sterile container should reach the microbiology laboratory for culture within 2 h of collection
• The following methods can be used in delay transportation:
1. Refrigeration at 4 0C (24 - 48 h)
2. Dip-slide technique
3. Boric acid (1.8% boric acid in the urine)
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Microscopic, Culture urine and determination of bacterial counts:
1. The white cells are counted
2. A. Surface viable count
B. Semi-quantitative
- Filter paper screening method
- Standard loop method
- Dip-slide method
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Mid-stream, clean-catch, & adhesive bag urine samples
No Interpretation Comments
1. Significant bacteriuria - >105 bacteria per ml
- usually a pure growth of one organism
- confidence ~ symptoms & pyuria
2. No evidence of infection - <104 bacteria per ml & not receiving
antibiotic
3. Equivocal results - 104 -105 bacteria per ml, especially if
Proteus or staphylococci are present
- Suggest repeat culture
4. Probable contamination - mixed growths in MSU sample
- < 104 bacteria per ml
- epithelial cells in microscopy
suggesting vaginal contamination
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Catheter or suprapubic urine samples:
Evidence of infection:
>105 bacteria per ml when infected urine
two organisms common when indwelling catheter
< 104 -105 bacteria per ml, may still be significant
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Interpretation of sterile pyuria: No Interpretation Comments
1. Possible
tuberculosis - consider early morning specimen of urine (EMSU)
X 3 for acid fast bacilli culture esp.if persistent pyuria
2. Treatment / non-
infective causes - antibiotic therapy; tumours or foreign bodies incl.
catheters; recent surgery; analgesic nephrophaty
3. Urethritis /
abacterial cystitis
- pus cells from ‘urethritis’ & ‘abacterial cystitis’
if low to moderately high counts of white cells
4. Vaginal discharge - pus cells from vaginal contamination
5. Other possible
causes
- due to a fastidious organism such as M. hominis,
Ureaplasma urealyticum
- look at Gram-stain of urine deposit. If numerous
short bacilli are present, infection due to diphtheroids
or anaerobes is a possibility
ESSENTIAL OF DIAGNOSIS:
Acute Cystitis-Urethritis
– Women and girls older than 2 years
– Acute onset dysuria, increased frequency of urination
– Pyuria: more than 10 leucocytes (high power field of centrifuged urine) or positive leukocyte esterase test
– Positive urine culture : 1,000-100,000 CFU/ml urine
ESSENTIAL OF DIAGNOSIS:
Acute Pyelonephritis
Fever, chills, costovertebral angle pain
Pyuria
Positive urine Gram stain
Positive urine culture (> 100.000 CFU) or blood culture
ESSENTIAL OF DIAGNOSIS:
Acute Prostatitis (subjects older than age 35)
◦ Fever, chills, dysuria, increased frequency of urination, low back or pelvic pain
◦ Pyuria
◦ Positive urine culture for gram-negative bacilli or enterococci
Chronic urinary tract infection
◦ persistence or frequent re-infection of the kidney, bladder, or prostate
• To know the most common bacteria-causing cystitis
• Resistance pattern to be able to perform adequate therapy
Microbial Pattern of UTI
0
5
10
15
20
25
30
35
40
45
E. coli (%) K. pneumoniae (%) Proteus mirabilis (%) Staphylococcus aureus(%)
Pseudomonasaeruginosa (%)
2009
2010
2011
2012
Resistance Pattern
• E.coli Antibiotic 2009
%S
2010
%S
2011
%S
2012
%S
Fosfomycin 92 92.3 90 73
Ciprofloxacin 32.3 42.9 40 27
Trimthoprim/ Sulfamethazole
45.2 21.4 40 35
Piperacilin/
Tazobactam
85.7 85.7 92 66
Imipenem 96.7 100 90 78
LMK Mikrobiologi FKUI,
2009-2012