Diagnostic approach and microorganism resistance pattern in UTI Yeva Rosana, Anis Karuniawati, Yulia Rosa, Budiman Bela

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1 Diagnostic approach and microorganism resistance pattern in UTI Yeva Rosana, Anis Karuniawati, Yulia Rosa, Budiman Bela Microbiology Department Medical Faculty, University of Indonesia

2 Urinary Tract Infection (UTI) urinary tract inflammation that results from any one of a number of distinct syndromes It is most commonly caused by a bacterial infection Upper urinary tract : ureters and kidneys Lower urinary tract: bladder and urethra

3 Urinary Tract Infection Lower urinary tract : bladder and urethra

4

5 The bladder wall is covered with a surface mucopolysaccharide that inhibits the attachment of bacteria via their adhesins

6 Uropathogenic strains of bacteria can attach to the cell wall of the bladder

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8 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

9 UTIs INTO PERSPECTIVE 150 million UTIs Upper urinary tract : ureters and kidneys (uncomplicated and complicated) Lower urinary tract : bladder and urethra occur yearly in the world UNCOMPLICATED UTIs are the most frequent BACTERIAL INFECTION IN WOMEN Stamm and Norrby, CID, 2005

10 The shorter urethra is a predisposing factor for Cystitis in women

11 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.

12 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.

13 Struthers, Clinical Bacteriology, 2005

14 Epidemiology of UTI Overview by sex and age

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16 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

17 Risk Factor for Recurrent UTI: Patients who do not empty their bladder completely Some large kidney stones Other foreign objects in the urinary system

18 Methods of urine collection : No Methods Comments 1. MSU (main method) If possible, collect 2 specimens 2. a. Adhesive bags-infants b. Clean-catch specimen (CCS)- infants to increase the percentage confidence of organisms detection 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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20 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 0 C (24-48 h) 2. Dip-slide technique 3. Boric acid (1.8% boric acid in the urine) 20

21 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 21

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23 Mid-stream, clean-catch, & adhesive bag urine samples No Interpretation Comments 1. Significant bacteriuria - >10 5 bacteria per ml - usually a pure growth of one organism - confidence ~ symptoms & pyuria 2. No evidence of infection - <10 4 bacteria per ml & not receiving antibiotic 3. Equivocal results bacteria per ml, especially if Proteus or staphylococci are present - Suggest repeat culture 4. Probable contamination - mixed growths in MSU sample - < 10 4 bacteria per ml - epithelial cells in microscopy suggesting vaginal contamination 23

24 Catheter or suprapubic urine samples: Evidence of infection: >10 5 bacteria per ml when infected urine two organisms common when indwelling catheter < bacteria per ml, may still be significant 24

25 Interpretation of sterile pyuria: No Interpretation Comments 1. Possible tuberculosis 2. Treatment / noninfective causes - consider early morning specimen of urine (EMSU) X 3 for acid fast bacilli culture esp.if persistent pyuria - 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 25

26 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 CFU/ml urine

27 ESSENTIAL OF DIAGNOSIS: Acute Pyelonephritis Fever, chills, costovertebral angle pain Pyuria Positive urine Gram stain Positive urine culture (> CFU) or blood culture

28 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

29 To know the most common bacteria-causing cystitis Resistance pattern to be able to perform adequate therapy

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33 Microbial Pattern of UTI E. coli (%) K. pneumoniae (%) Proteus mirabilis (%) Staphylococcus aureus (%) Pseudomonas aeruginosa (%)

34 Resistance Pattern E.coli Antibiotic 2009 %S 2010 %S 2011 %S 2012 %S Fosfomycin Ciprofloxacin Trimthoprim/ Sulfamethazole Piperacilin/ Tazobactam Imipenem LMK Mikrobiologi FKUI,

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