Genitourinary Infections - American Urological Association

Genitourinary Infections
Mantu Gupta, MD
Director of Endourology, Columbia University
Director, NYPH Kidney Stone Center
Associate Professor, Columbia University
Asymptomatic Bacteriuria
• More common in women and elderly pts.
• Antibiotics can lead to more resistance
• Screening and treatment not indicated in nonpregnant females, the elderly, SCI pts, and in
pts with indwelling foley
• Screening and treatment indicated in
pregnancy and prior to GU procedures
Urinary Tract Infection
• Complicated UTI:
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Immunosuppressed (DM, HIV, steroids, chemo pts., transplant)
Pregnant
Male
Pediatric
Indwelling foley, stent, drain
Structural abnormality (VUR, calyceal tic, UPJO)
Urinary obstruction, NGB
Renal insufficiency
Urolithiasis
Sickle cell
PCKD
7-14 days indicated
• Uncomplicated UTI: female with none of above
– Rarely results in renal damage
– 3-5 days sufficient
Diagnosis of UTI
• Positive LE or wbc’s alone not sufficient
• Nitrite positive: not all bacteria can reduce nitrate
to nitrite (e.g. Strep, Enterococcus, Pseudomonas)
• E. Coli (most common) have pili that cause
adherence to epithelial cells:
– Mannose sensitive (type 1): d-mannose inhibits
binding capacity
– P pili: d-mannose ineffective; common in E. Coli that
cause pyelonephritis
Antibiotics
• Fluoroquinolones:
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Mechanism: inhibit DNA gyrase
Avoid in pregnancy or under 16 (cartilage binding)
False positive urine opiate tests
Side effects
• CNS: dizziness, seizures, confusion, insomnia
• Photosensitivity
• Tendon ruptures (Achilles): steroids and CRI predispose
– Hepatic and renal clearance: mild renal dosing
adjustments
Beta-lactams
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Penicillins, cephalosporins, aztreonam: beta-lactam ring
Inhibit bacterial cell wall synthesis
Bacterial resistance: beta-lactamase production
Methicillin, nafcillin, augmentin are resistant to betalactamase
• Some bacteria resistant to methicillin: MRSA
• Ampicillin and amoxicillin often good for enterococcus
• Side effects: anaphylaxis, rash, yeast infections,
interstitial nephritis; 10-15% cross reactivity between
penicillins and cephalosporins
Trimethoprim-Sulfamethoxazole
• Inhibit bacterial folate metabolism
• Contraindicated for < 2 mos.: kernicterus
• Side effects:
– GI (nausea, vomiting, anorexia)
– Renal insufficiency: renal dosing needed
– Rash common
– Hemolytic anemia in pts. with G6PD deficiency
– Interact with coumadin
Nitrofurantoin
• Inhibit multiple bacterial enzymes
• Impaired activity in alkaline urine; poor tissue
penetration
• Contraindicated < 1 month: hemolytic anemia
• Side effects:
– Pulmonary fibrosis with chronic use
– Hemolytic anemia with G6PD deficiency
– Peripheral neuropathy
– Hepatitis
Aminoglycosides
• Inhibit bacterial protein synthesis
• Side effects:
– Ototoxicity
– Acute tubular necrosis
– Renal failure: renal dosing imperative, as well as
monitoring peak (toxicity) and trough (effectiveness)
– Neuromuscular blockade
Tetracyclines
• Inhibit ribosomal function (protein synthesis)
• Wide spectrum, good for STDs
• Do not concentrate well in urine, esp. with
renal insufficiency; resistance common
• Side effects:
– Can not use in pregnancy or in children: tooth
toxicity
– Photosensitivity
Unresolved UTI
• Must distinguish from recurrent UTI: same bug; culture
never became negative
• Causes
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Bacterial resistance
Subtherapeutic levels
Fistula (constant innoculation)
Diverticulae (incomplete eradication)
Stones, esp. struvite; foreign body: unsterilizable reservoir
• Treatment:
– Check/recheck sensitivities and pt. compliance
– Imaging/endoscopy to diagnose stones, fistula, tics
– Irrigate with antibiotics (e.g. renal failure) via catheter, NT
Recurrent UTI
• Culture became negative, now positive again
• Persistence: same bug, same sensitivity profile
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Foreign bodies: stent, catheters, sutures, staples
Stones: struvite, apatite
Tics (calyceal, bladder, urethral)
Prostatitis
• Re-infection: different bug or sensitivities (fistula, retention, vesicoureteral
reflux, immunosuppression, sexual activity, diaphragm, spermicide)
• Evaluation:
– History, exam, renal function, PVR, cath sample, VB3, localization (ureteral
catheterization), cystoscopy, imaging
• Treatment: correct risk factors, treat underlying cause
• Prevention: prophylactic abx (daily or post intercourse), cranberry
(hippuric acid lowers pH, fructose binds mannose sensitive pili,
proanthocyanidin inhibits mannose resistant pili), d-mannose, methenamine
with K-Phos or vitamin C (monitor lft’s)
Antibiotics in Pregnancy
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Rate of asymptomatic bacteriuria not increased (5%)
Early screening for asymptomatic bacteriuria and treatment
indicated to decrease risk of pyelonephritis (20-30x higher)
Safe
• Penicillins
• Cephalosporins
• Clindamycin
• Aminoglycosides
• Avoid 3rd trimester
Unsafe: avoid
• Fluoroquinolones (cartilage
development)
• Chloramphenicol (Grey baby
syndrome)
• Trimethoprim: interferes with
– Sulfa drugs: neonatal jaundice
folate metabolism
– Nitrofurantoin
• Erythromycin: jaundice
– Both cause hemolytic anemia,
• Tetracycline: binds bones/teeth)
esp. in G6PD deficiency
UTI in CIC pts.
• CIC confers lower risk than indwelling catheter
• High intravesical pressure increases risk of UTI and renal
deterioriation
• Sterile vs. clean: recent evidence supports lower risk with sterile
technique
• Prophylactic abx: cause resistance; not proven to decrease rate of UTI
• Cycling abx: may be able to decrease rate without increasing
resistance
• Intravesical abx: can treat and prevent UTIs: get absorbed; side effects
can occur
• Unproven efficacy:
– Cranberry supplements
– Vitamin C
– Methenamine
Indwelling Catheter
• Risk of bacteriuria = 5% per day
• Catheter duration associated with risk of UTI
• Most important factor in prevention: closed
drainage system with few disconnections
• Atraumatic catheter change without history of
symptomatic UTI/endocarditis: no abx needed
• Catheter removal after GU surgery: AUA Best
Practice Guidelines recommend antibiotics
treatment at time of removal (not prior)
Biofilms
• Biofilms are sheets of bacteria in extracellular
matrix that grow on/in stents and catheters
• Abx can not eradicate: must change
catheter/stent before starting abx
• If colonized with urease producing bacteria,
struvite and apatite encrustations can occur
that obstruct lumen
• Renacidin irrigation can prevent encrustation
but can result in hypermagnesemia
Catheters
• Latex and silicone: similar rate of UTI
• Silver alloy and antibiotic coated catheters: delayed
bacteriuria and decreased UTI risk if left in less than 710 days
• SP tubes: may have lower risk of UTI for short term
use; decreased prostatitis/epididymitis
• Prevention: keep bag lower than bladder; changing
catheter/bag often does not help
• Blue bag/catheter syndrome: caused by colonization
with bacteria containing phosphatase-sulfatase enzyme;
benign; treat only if symptomatic UTI/encrustation
Spinal Cord Injury
• Retention, VUR, high pressure voiding (DLLP
> 40 cm H20) increase UTI risk
• Treatment of asymptomatic bacteriuria not
indicated except if urease producing bacteria
present
Antibiotic Prophylaxis for Surgery
• Not indicated for clean procedures or for procedures where mucosal
bleeding not anticipated: cystogram, UDS, diagnostic cystoscopy
(unless risk factor: smoking, malnutrition, fb, structural abnormality,
advanced age, then give fluoroquinolone or TMP-SMZ)
• Most GU procedures are clean contaminated and prophylaxis
indicated; includes ESWL (mucosal bleeding)
• Decreases risk of local and systemic infection
• 1st dose should be within one hour prior to surgical incision
• Discontinue within 24 hrs of surgery unless high risk pt.
• MRSA: vancomycin should be used
• Joint replacement pts: prophylaxis indicated if joint less than 2 yrs old
or if immunsuppressed or history of prosthetic infection or
malignancy
• Endocarditis prophylaxis (in patients with pacemakers, valves): not
indicated in absence of active infection
1st Line Antibiotic Prophylaxis for
Urologic Procedures
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Endoscopic (with manipulation): Single dose FQ or TMP-SMZ
ESWL: if risk factor
TRUS/Bx: FQ p.o. or i.v.; cephalosporin
Prosthesis Implantation: AG + Vancomycin/Cephalosporin
(1st/2nd)
• Open, Perc., Vaginal surgery not entering bowel: 1st or 2nd
generation cephalosporin; AG + metronidazole/clindamycin
• Open surgery with bowel entry: AG + 1st/2nd
cephalosporin/metronidazole/clindamycin
• Less than 24 hours unless high risk
FQ = flouroquinolone
AG = aminoglycoside
TMP-SMZ = trimethoprim-sulfamethoxazole
Upper Tract Infections
• Acute pyelo:
– Usually ascending; E. Coli #1
– Hematogenous (Staph Aureus): IVDA, skin infection; may
not have cystitis symptoms
– May be treated as oupt. if pt. mildly ill
– If fever does not resolve within 72 hrs admit for iv abx, renal
imaging, blood and urine cultures
• Emphysematous pyelo: gas in parenchyma
– E. Coli usual cause; most common in diabetics
– Must relieve obstruction, drain any collections, and proceed
to nephrectomy if pt. does not improve promptly
– Must distinguish from post-infarction gas, which is self
limited
Upper Tract Infections
• Acute bacterial nephritis (focal lobar nephronia)
– Bacterial infection of renal cortex creates an inflammatory mass
– CT: nephromegaly, diminished uptake, mass than can be mistaken for
cancer
• Renal abscess: most often gram negative (E. Coli)
– Rx: iv abx, subcostal perc. drain if > 3cm
• Xanthogranulomatous Pyleonephritis (XGP)
– Proteus most common cause
– Diffuse renal destruction, extending into hilum and fat, severe stranding
– Associated with absent/poor renal function, obstruction and stones
(often small prox. ureter stone seen on CT)
– Often mistaken for renal malignancy
– Diagnosis is by pathology: foamy lipid laden macrophages
– Rx: nephrectomy—usually open
• Malacoplakia: solid intra-renal mass; E. Coli; Michaelis-Gutmann
bodies
Xanthogranulomatous Pyelonephritis
Genital Infections
• Genital Ulcer:
– Genital herpes: painful vesicles; no lymph nodes
– Chancroid: painful ulcers; painful lymph nodes
– Primary syphilis: painless; painless lymph nodes
– Lymphogranuloma venereum: painless ulcer;
followed by painful lymph nodes
– Granuloma inguinale: painless beefy red ulcer; rare
lymph nodes
Genital Herpes
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Herpes Simplex 2
Painful
Diagnosis: culture fluid from vesicle or do serologic tests
IgM rises immediately and decreases over time; IgG rises later
and stays elevated
• Rx: Acyclovir p.o. to shorten course; valcylovir to reduce
transmission
Chancroid
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Hemophilus ducreyi
Gram negative
Painful
Tender lymph nodes
Diagnosis: culture
Rx: azithromycin 1 gm p.o. x 1
Syphilis
• Treponema Pallidum: painless
• Dx: scrape ulcer and do direct fluroscent antibody or darkfield
microscopy; look for sphirochetes
• VDRL and RPR revert to normal after Rx; FTA-ABS & MHATP do not
• Nontender LN’s
• Rx: Benzathine PCN G 2.4 mill u x 1
• If allergic, doxycycline 100 BID 14 days
• Secondary syphilis: cutaneous
• Tertiary: neuro, cardiac, eye
Lymphogranuloma Venereum
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Chlamydia Trachomatis
Rare in U.S.
Painless ulcer, followed in 2-6 wks by tender LN’s (bubos)
Dx: culture or immunofluorescence or nucleic acid detection
Rx: Doxycycline x 3+ wks—requires long term treatment
Granuloma Inguinale
• Rare in U.S.
• Klebsiella granulomatis
• Lymph nodes rare, but primary lesion
can spread to groin, giving appearance
of LN: pseudobubo
• Can not be cultured—need tissue (bx
or crush prep)
• Beefy red painless ulcer that easily
bleeds
• Intracellular Donovan bodies (in
monocytes)
• Rx: Doxycycline for 3 wks
Candidal Vaginitis
• Usually albicans
• Risk factors: DM, abx, immunosuppression,
OCPs
• Vaginal pH is normal; white curdlike d/c; no odor
• Saline wet mount, KOH prep or gram stain show
yeast or pseudohyphae
• Vaginal culture: yeast
• Rx: topical azoles, nystatin, or oral fluconazole
• In pregnancy avoid nystatin and fluconazole
• Treat male partners with balanitis
Bacterial Vaginosis
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Most common cause of discharge and odor
Gardnerella proliferates; pH is high
Risks: IUD, pregnancy, douching, many partners
More than 50% asymptomatic
Diagnosis: culture not recommended
– Clue cells on micro
– Thin white/grey discharge
– Positive whiff test: fishy odor with KOH
• Rx: metronidazole 500 BID for 7 d or clindamycin
cream/metronidazole gel intravaginally for 5-7 days
Trichomonas Vaginalis
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“Strawberry cervix”
Yellow-green frothy discharge
Fishy odor
Saline wet mount: motile trichomonas protozoa;
culture should be done
• Rx: metronidazole 2 gm single dose
• Must treat current partners
• Can cause urethritis in males; urethral swab cx for
diagnosis
Urethritis
• All pts. must be tested for gonorrhea and chlamydia
• Noninfectious
– Reiter’s syndrome: conjunctivitis, arthritis; HLA-B27 phenotype
• Infectious
– Gonococcal
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Neisseria gonorrhoeae (gram – diplococcus)
Profuse purulent discharge
Dx: culture with Thayer-Martin or chocolate agar OR nucleic acid amplified test
Rx: must cover Chlamydia also: Ceftriaxone 125 mg single dose AND Doxycylcine
100 mg BID for 7 d or Azithromycin 1 gram single dose
– Nongonococcal: usually Chlamydia or mycoplasma
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Scant, usually clear discharge
Dx: culture; amplification tests
Test for Trichomonas if no response
Partners need to be treated
Abstain from sex for 7 days after treatment
All of the following STDs in men can be
treated by single-dose antibiotics except:
A. Primary syphilis
B. Chlamydial urethritis
C. Gonococcal urethritis
D. Chancroid
E. Granuloma inguinale
All of the following STDs in men can be
treated by single-dose antibiotics except:
A. Primary syphilis
B. Chlamydial urethritis
C. Gonococcal urethritis
D. Chancroid
E. **Granuloma inguinale**
3 or more wks of doxycycline
(lymphogranuloma venereum also)
Which of the following STDs involves a
painful ulcer?
A. Primary syphilis
B. Lymphogranuloma venereum
C. Human papilloma virus
D. Chancroid
E. Granuloma inguinale
Which of the following STDs involves a
painful ulcer?
A. Primary syphilis
B. Lymphogranuloma venereum
C. Human papilloma virus
D. **Chancroid**
E. Granuloma inguinale
Also, herpes.
Donovan bodies are seen on:
A. Ulcer scraping in primary syphilis
B. Lymph node aspiration in lymphogranuloma
venereum
C. Thayer-Martin medium in gonorrhea
D. Ulcer biopsy in granuloma inguinale
E. Urethral swab in Chlamydia urethritis
Donovan bodies are seen on:
A. Ulcer scraping in primary syphilis
B. Lymph node aspiration in lymphogranuloma
venereum
C. Thayer-Martin medium in gonorrhea
D. **Ulcer biopsy in granuloma inguinale**
E. Urethral swab in Chlamydia urethritis
Need tissue to make diagnosis