Infections of the urinary Tract Flashcards
Nitrofurantoin is effective against most common uropathogens. It is____excreted from the urine but does ____. Therefore it is not useful for upper tract, complicated infections, or blood-borne infections It has minimal/maximal effects on the resident bowel and vaginal flora
Nitrofurantoin is effective against most common uropathogens. It is rapidly excreted from the urine but does not obtain therapeutic levels in most body tissues, including the gastrointestinal (GI) tract. Therefore it is not useful for upper tract, complicated infections, or blood-borne infections. It has minimal effects on the resident bowel and vaginal flora
___ the presence of white blood cells (WBCs) in the urine, is generally indicative of infection and/or an inflammatory response of the urothelium to __,__,___, or other conditions that can contribute to pyuria. Bacteriuria without pyuria is generally indicative of bacterial colonization without overt infection of the urinary tract. Pyuria without bacteriuria, or sterile pyuria, warrants further evaluation
Pyuria, the presence of white blood cells (WBCs) in the urine, is generally indicative of infection and/or an inflammatory response of the urothelium to bacteria, stones, an indwelling foreign body, or other conditions that can contribute to pyuria. Bacteriuria without pyuria is generally indicative of bacterial colonization without overt infection of the urinary tract. Pyuria without bacteriuria, or sterile pyuria, warrants further evaluation
Acute pyelonephritis is a clinical syndrome of __,__ and ___ that is accompanied by__ and __, a combination that is reasonably specific for an acute bacterial infection of the kidney.
Acute pyelonephritis is a clinical syndrome of chills, fever, and flank pain that is accompanied by bacteriuria and pyuria, a combination that is reasonably specific for an acute bacterial infection of the kidney.
Xanthogranulomatous pyelonephritis (XGP) is a rare form of ____ often associated with _____ and characterized by destructive replacement of normal renal parenchyma with ___; it is associated with____of renal function
Xanthogranulomatous pyelonephritis (XGP) is a rare form of chronic pyelonephritis often associated with stone disease and characterized by destructive replacement of normal renal parenchyma with granulomatous inflammation; it is associated with ipsilateral loss of renal function
factors of complicated UTI
UTIs may also be defined by their relationship to other UTIs:
- A first or isolated infection is one that occurs in an individual who has___ or has one ___ from a
previous UTI. - An unresolved infection is one that __ and is documented to be the __ with a similar ___.
- A recurrent infection is one that occurs after documented, successful resolution of an antecedent infection. Consider these two different types of recurrent infection:
a. Reinfection describes a ___ associated with ___ of bacteria into the urinary tract.
b. Bacterial persistence refers to a recurrent UTI caused by the same bacteria ___ within the urinary tract, such as an __ or the ___.
• A first or isolated infection is one that occurs in an individual who has never had a UTI or has one remote infection from a
previous UTI.
• An unresolved infection is one that has not responded to antimicrobial therapy and is documented to be the same organism with a similar resistance profile.
• A recurrent infection is one that occurs after documented, successful resolution of an antecedent infection. Consider these two different types of recurrent infection:
- Reinfection describes a new event associated with reintroduction of bacteria into the urinary tract.
- Bacterial persistence refers to a recurrent UTI caused by the same bacteria reemerging from a focus within the urinary tract, such as an infectious stone or the prostate.
The long-term effects of uncomplicated recurrent UTIs are not completely known, but, so far, there is no/there is association between recurrent infections and renal scarring, hypertension, or progressive renal azotemia has been established
The long-term effects of uncomplicated recurrent UTIs are not completely known, but, so far, no association between recurrent infections and renal scarring, hypertension, or progressive renal azotemia has been established
UTIs occur as a result of interactions between the uropathogen and the host. Successful infection of the urinary tract is determined in part by the virulence factors of the__, __ and___
UTIs occur as a result of interactions between the uropathogen and the host. Successful infection of the urinary tract is determined in part by the virulence factors of the bacteria, the inoculum size, and the inadequacy of host defense mechanisms
Gram-negative bacteria and their endotoxins, pregnancy, ureteral obstruction, and high lower tract pressures have a significant ____
Gram-negative bacteria and their endotoxins, as well as pregnancy, ureteral obstruction, and high lower tract pressures have a significant antiperistaltic effect
hematogenous spread: kidney is occasionally secondarily infected in patients with___ originating from oral sites or with ___
kidney is occasionally secondarily infected in patients with Staphylococcus aureus bacteremia originating from oral sites or with Candida fungemia
Direct extension of bacteria from the adjacent organs via lymphatics may occur in unusual circumstances, such as a __ or ___
Direct extension of bacteria from the adjacent organs via lymphatics may occur in unusual circumstances, such as a severe bowel infection or retroperitoneal abscesses.
___ is by far the most common cause of UTIs, accounting for 85% of community-acquired and 50% of hospital-acquired infections. Other gram-negative Enterobacteriaceae, including ___ and ____, and gram-positive ___ and __ are responsible for the remainder of most community-acquired infections.
E. coli is by far the most common cause of UTIs, accounting for 85% of community-acquired and 50% of hospital-acquired infections. Other gram-negative Enterobacteriaceae, including Proteus and Klebsiella, and gram-positive Enterococcus faecalis and Staphylococcus saprophyticus are responsible for the remainder of most community-acquired infections.
___ is a rare pathogen that causes UTIs in older adults with significant comorbidities, including some urologic malignancies
Aerococcus urinae is a rare pathogen that causes UTIs in older adults with significant comorbidities, including some urologic malignancies
_____, is a gram-negative rod that has been associated with UTIs in immunocompromised patients
____ a gram-negative rod commonly found in environmental sources such as soil, has been identified as the causative agent in UTIs in immunocompromised patients and is particularly dangerous because of its extensive drug resistance
Raoultella planticola, is a gram-negative rod that has been associated with UTIs in immunocompromised patients (Skelton et al., 2017).
Myroides odoratimimus, a gram-negative rod commonly found in environmental sources such as soil, has been identified as the causative agent in UTIs in immunocompromised patients and is particularly dangerous because of its extensive drug resistance
____ merits special attention as a rapidly emerging cause of multidrug-resistant infections, including UTI
E. coli sequence type ST131 (serotype O25b:H4) merits special attention as a rapidly emerging cause of multidrug-resistant infections, including UTI
Urinary tuberculosis (UTB) most commonly occurs with __,, __, ___ and ___ with or without systemic symptoms such as __ and ___. Diagnosis and subsequent treatment are often delayed because of nonspecific symptoms, potentially contributing to impaired renal function and eventual renal failure. _____for M. tuberculosis has replaced acid-fast staining as the ideal method of diagnos
Urinary tuberculosis (UTB) most commonly occurs with hematuria (either gross hematuria, microhematuria, and/or sterile pyuria), storage symptoms, and/or dysuria, with or without systemic symptoms such as fever and weakness. Diagnosis and subsequent treatment are often delayed because of nonspecific symptoms, potentially contributing to impaired renal function and eventual renal failure. Polymerase chain reaction for M. tuberculosis has replaced acid-fast staining as the ideal method of diagnos
The steps of UPEC pathogenesis include (6)
The steps of UPEC pathogenesis include (1) UPEC colonization of the periurethral and vaginal tissue as well as the urethra; (2) ascending infection into the bladder lumen and within the urine; (3) adherence to the surface urothelium and interaction with the bladder epithelial cell defense mechanism; (4) biofilm elaboration; (5) invasion and replication by forming bladder Intracellular Bacterial Communities (IBCs), in which quiescent intracellular reservoirs (QIRs) can form and stay dormant in the underlying urothelium; (6) and, in some cases, renal colonization and host tissue damage with high risk for sepsis
___ are commonly expressed on nonpathogenic and pathogenic E. coli
Type 1 pili are commonly expressed on nonpathogenic and pathogenic E. coli
some bacteria grown in a broth medium express pili, whereas the same strain grown on the same medium in a solid state will cease production of pili. This is called
phase variation
Natural Defenses of the Urinary Tract (3)
Periurethral and Urethral Region
Urine
Bladder
Uromodulin (Tamm-Horsfall protein), a kidney-derived mannosylated protein that is present in an extraordinarily high concentration in the urine (>100 mg/mL), may play a defensive role by saturating all the mannose-binding sites of the type 1 pili, thus potentially blocking bacterial binding to the uroplakin receptors of the urothelium
___, a kidney-derived mannosylated protein that is present in an extraordinarily high concentration in the urine (>100 mg/mL), may play a defensive role by saturating all the mannose-binding sites of the type 1 pili, thus potentially blocking bacterial binding to the uroplakin receptors of the urothelium
The early diagnosis of RPN is important to improve prognosis and reduce morbidity. In addition to chronic infection, patients with ___ may have an increased incidence of urothelial tumors; routine urinary cytologic examinations may be helpful to diagnose these tumors early
The early diagnosis of RPN is important to improve prognosis and reduce morbidity. In addition to chronic infection, patients with analgesic abuse–associated papillary necrosis may have an increased incidence of urothelial tumors; routine urinary cytologic examinations may be helpful to diagnose these tumors early
Renal PAPILLARY NECROSIS: __ and ___ can minimize a decline in renal function. A patient who suffers from an acute ureteral obstruction caused by a sloughed papilla and who has a concomitant UTI has a urologic emergency. In this case, immediate removal of the obstructing papilla by ___ or____ of the kidney by ureteral catheter or percutaneous nephrostomy is necessary
adequate antimicrobial therapy to control infection and early recognition and treatment of ureteral obstruction caused by sloughed necrotic tissue can minimize a decline in renal function. A patient who suffers from an acute ureteral obstruction caused by a sloughed papilla and who has a concomitant UTI has a urologic emergency. In this case, immediate removal of the obstructing papilla by stone basket or acute drainage of the kidney by ureteral catheter or percutaneous nephrostomy is necessary
UTIs are fivefold more prevalent in ___than in control subjects The pathologic bacteria include higher rates of ___ and ___ in HIV positive patients.
UTIs are fivefold more prevalent in HIV-positive individuals than in control subjects (Schonwald et al., 1999). The pathologic bacteria include higher rates of Acinetobacter and Salmonella species in HIVpositive patients.
Of all patients with bacteriuria, no group compares in severity and morbidity with those who have ___
Of all patients with bacteriuria, no group compares in severity and morbidity with those who have SCI.
painless gross hematuria, or microhematuria
in the absence of a positive culture, should always raise the suspicion for___ , and a ___ must be initiated.
painless gross hematuria, or microhematuria
in the absence of a positive culture, should always raise the suspicion for urologic malignancy, and a hematuria evaluation must be initiated.
Before sample collection in circumcised men, the glans should
be cleansed with a ___. For those uncircumcised, the foreskin should be ___ and the glans cleansed with the ___ before specimen collection. A ___specimen should be obtained by collecting it in a sterile cup.
Before sample collection in circumcised men, the glans should
be cleansed with a 2% castile soap towelette. For those uncircumcised, the foreskin should be retracted and the glans cleansed with the towelette before specimen collection. A midstream specimen should be obtained by collecting it in a sterile cup.
Situations in which a catheterized sample should be considered include when the voided sample shows clear evidence of ___ (i.e., many ___), a patient has a___, the patient is unable to provide an adequate clean-catch sample, or the patient cannot provide any sample at all.
Situations in which a catheterized sample should be considered include when the voided sample shows clear evidence of contamination (i.e., many squamous epithelial cells), a patient has a pessary, the patient is unable to provide an adequate clean-catch sample, or the patient cannot provide any sample at all. Although
Leukocyte esterase is produced by the ____. Its presence is an indication of ___, but not ___specifically. the presence of WBCs and therefore leukocyte esterase is uncommon/not uncommon in women with vaginal contamination. Nitrites are present when bacteria reduce ___, via ___ activity. ALL /NOT ALL bacteria produce nitrites.
Leukocyte esterase is produced by the breakdown of WBCs in the urine. Its presence is an indication of pyuria, but not bacteria specifically. As mentioned previously, the presence of WBCs and therefore leukocyte esterase is not uncommon in women with vaginal contamination. Nitrites are present when bacteria reduce dietary nitrates, via bacterial nitrate reductase activity. Not all bacteria produce nitrites, though, so the absence of nitrites does not mean bacteria are not present
Other conditions known to cause pyuria include aside from UTI: (4)
GU tuberculosis, urolithiasis, injury to the urothelium (including chlamydial urethritis), and interstitial nephriti
a standard urine culture may be negative. In this scenario a culture should be sent specifically looking for ___ organisms such as__ or __
a standard urine culture may be negative. In this scenario a culture should be sent specifically looking for atypical organisms such as Ureaplasma urealyticum or Mycoplasma hominis.
The term asymptomatic bacteriuria is appropriately used when
a person has no signs or symptoms of a UTI, yet bacteria are identified in a noncontaminated urine sample. In women, the term asymptomatic bacteriuria is used when the ___ is identified in quantitative counts of greater than or equal to ____ in ___ voided samples that are obtained in a fashion that ___.
In men, ___ voided sample that identifies one bacterial species in quantitative counts greater than or equal to___ CFUs is necessary to use the term asymptomatic bacteriuria appropriately
The term asymptomatic bacteriuria is appropriately used when
a person has no signs or symptoms of a UTI, yet bacteria are identified in a noncontaminated urine sample. In women, the term asymptomatic bacteriuria is used when the same bacteria is identified in quantitative counts of greater than or equal to 100,000 CFUs in two consecutive voided samples that are obtained in a fashion that minimizes contamination. In men, only one cleancatch voided sample that identifies one bacterial species in quantitative counts greater than or equal to 100,000 CFUs is necessary to use the term asymptomatic bacteriuria appropriately
guidelines clearly stipulate that, in the majority of patients, asymptomatic bacteriuria SHOULD/ should not be treated. it should always be treated in __ and in patients who are undergoing procedures in which ___ is anticipated
Should not, pregnant, transmucosal bleeding
Nitrofurantoin can cause___and ___, such as pulmonary fibrosis, when used chronically. Nitrofurantoin should also be avoided in patients with suspicion of or known ___ deficiency because it can lead to hemolytic anemia. It had always been recommended that nitrofurantoin be avoided in patients with chronic renal insufficiency, defined as a CrCl less than 30 mL/min, because of lack of efficacy from poor renal concentrating ability
Nitrofurantoin can cause GI upset and rare pulmonary issues, such as pulmonary fibrosis, when used chronically. Nitrofurantoin should also be avoided in patients with suspicion of or known glucose6-phosphate dehydrogenase (G6PD) deficiency because it can lead to hemolytic anemia. It had always been recommended that nitrofurantoin be avoided in patients with chronic renal insufficiency, defined as a CrCl less than 30 mL/min, because of lack of efficacy from poor renal concentrating ability
Fosfomycin, an oral bactericidal antimicrobial agent similar to phosphonic acid in chemical structure, is active against most uropathogens. Its major benefit is ___, as well as its efficacy against the majority of __ and ___. Further, it has been shown to be effective as a single-dose agent when used as an empirical treatment for __-. It is an excellent oral option for MDR bacteria that would otherwise necessitate treatment with intravenous antibiotics
Fosfomycin, an oral bactericidal antimicrobial agent similar to phosphonic acid in chemical structure, is active against most uropathogens. Its major benefit is its limited cross-resistance between most other common antibacterial agents, as well as its efficacy against the majority of gram-negative organisms and vancomycin-resistant Enterococcus (VRE). Further, it has been shown to be effective as a single-dose agent when used as an empirical treatment for uncomplicated cystitis. It is an excellent oral option for MDR bacteria that would otherwise necessitate treatment with intravenous antibiotics
Woman with acute uncomplicated cystitis • Absence of fever, flank pain, or other suspicion for pyelonephritis • Able to take oral medication, next step in management
Approximately 90% of women are asymptomatic ___ after initiating antimicrobial therapy A follow-up visit or culture is required/not required in women who are asymptomatic after therapy. Further urologic evaluation is unnecessary in women who respond to therapy . However, UTIs in most men should be considered complicated until proven otherwise
Approximately 90% of women are asymptomatic within 72 hours after initiating antimicrobial therapy (Fihn et al., 1985). A follow-up visit or culture is not required in women who are asymptomatic after therapy. Further urologic evaluation is unnecessary in women who respond to therapy (Abarbanel et al., 2003; Lipsky, 1989). However, UTIs in most men should be considered complicated until proven otherwise
unresolved urinary tract infection causes: (4)
SUMMARIZED ANSWER: ANTIMICROBIALS ARE NOT EFFECTIVE TO BEGIN WITH
DEVELOPMENT OF RESISTANCE IN PREVIOUSLY SUSCEPTIBLE SPECIES
PRESENCE OF UNSUSPECTED PATHOGEN
REINTRODUCTION OF NEW SPECIES WHILE UNDERGOING THERAPY for the 1st speceis being treated
Most commonly, the bacteria are resistant to the antimicrobial agent selected to treat the infection. Typically, the patient has received the antimicrobial therapy in the recent past and developed bowel colonization with resistant bacteria.
The second most common cause is development of resistance in a previously susceptible population of bacteria during the course of treatment of UTIs. This problem occurs in approximately 5% of the patients receiving antimicrobial therapy. It is easy to recognize clinically because the culture on therapy shows that the previous susceptible population has been replaced by resistant bacteria of the same species. It can be shown that resistant organisms were actually present before contact with the initial antimicrobial agent, but they were present in such low numbers that it was impossible to detect by in vitro susceptibility studies before therapy. When the antimicrobial concentration in the urine is insufficient to kill all the bacteria present, the more resistant forms will emerge. This characteristically is seen in patients who are underdosed or who are poorly compliant and hence have inadequate dose regimens. The third cause is the presence of an unsuspected, second pathogen that was present initially and is resistant to the antimicrobial therapy chosen. Treatment of the dominant organism unmasks the presence of the second strain.
The fourth cause is rapid reintroduction of a new resistant species while the patient is undergoing initial therapy. Rapid reinfection that mimics unresolved bacteriuria should alert the clinician to the possibility of an enterovesical fistula.
A recurrent UTI is defined as ___or
___
A recurrent UTI is defined as two UTIs in a 6-month period or
three or more UTIs in a 12-month period
risk factors for recurrent UTI
Significant risk factors for recurrence in women (6)
Significant risk factors for recurrence in women include sexual activity, a new sexual partner within the past year, menopause, spermicidal use, family history of UTI in a first-degree female relative, and recent antimicrobial use
In patients with emptying symptoms or a distended bladder on physical examination, documentation of a ___
In patients with emptying symptoms or a distended bladder on physical examination, documentation of a postvoid residual is critical
Cranberry products for UTI prophylaxis have been investigated for years in the scientific and lay press. One of the active ingredients in cranberry is the ___, which prevents the ___ from adhering to uroepithelial cells
Cranberry products for UTI prophylaxis have been investigated for years in the scientific and lay press. One of the active ingredients in cranberry is the polyphenol type A proanthocyanidin (PAC), which prevents the P fimbriae of E. coli from adhering to uroepithelial cells
decreased estrogen levels contribute to the transformation to __ and __, which creates a more hospitable environment for bacteria to thrive.
decreased estrogen levels contribute to the transformation to atrophic vaginal epithelium and increased vaginal pH, which creates a more hospitable environment for bacteria to thrive. Indeed, the lack of estrogen causes marked changes in the vaginal microflora, including a loss of lactobacilli and increased colonization by E. coli
vaginal estrogen is effective in preventing recurrent UTIs in postmenopausal women. The beneficial effect from vaginal estrogen use can take at ___ weeks to manifest
vaginal estrogen is effective in preventing recurrent UTIs in postmenopausal women. The beneficial effect from vaginal estrogen use can take at least 12 weeks to manifest
the relationship between laboratory findings
and the presence of ___ often is poor. Bacteriuria and pyuria, the hallmarks of UTI, are/are not predictive of renal infection.
patients with significant renal infection may have sterile urine if the _ or __.
the relationship between laboratory findings
and the presence of renal infection often is poor. Bacteriuria and pyuria, the hallmarks of UTI, are not predictive of renal infection. Conversely, patients with significant renal infection may have sterile urine if the ureter draining the kidney is obstructed or the infection is outside of the collecting system
UA of acute pyelenophritis.
the relationship between laboratory findings
and the presence of renal infection is __. Bacteriuria and pyuria, the hallmarks of UTI, are not/are predictive of renal infection. Conversely, patients with significant renal infection may have sterile urine if the ureter draining the kidney is __ or __
the relationship between laboratory findings
and the presence of renal infection often is poor. Bacteriuria and pyuria, the hallmarks of UTI, are not predictive of renal infection. Conversely, patients with significant renal infection may have sterile urine if the ureter draining the kidney is obstructed or the infection is outside of the collecting system
opd pyeloneph tx: __ is an appropriate first-line therapy in patients not requiring hospitalization where the prevalence of uropathogen resistance to quinolones in the community does not exceed __
Oral ciprofloxacin (500 mg twice daily) for 7 days is an appropriate first-line therapy in patients not requiring hospitalization where the prevalence of uropathogen resistance to quinolones in the community does not exceed 10%
pyelonephritis: solitary obstructed kidney causes acute renal failure; antimicrobial agents are dosed based on the GFR. Any substantial obstruction must be relieved expediently by the safest and simplest means, such as __ or __
solitary obstructed kidney causes acute renal failure; antimicrobial agents are dosed based on the GFR. Any substantial obstruction must be relieved expediently by the safest and simplest means, such as ureteral stent or percutaneous nephrostomy tube placement
Emphysematous pyelonephritis is a urologic emergency characterized by an ___l and __ infection caused by ___ uropathogens.
usually occurs in patients with __,
Emphysematous pyelonephritis is a urologic emergency characterized by an acute necrotizing parenchymal and perirenal infection caused by gas-forming uropathogens. The pathogenesis is poorly understood. Because the condition usually occurs in patients with diabetes, it has been postulated that the high tissue glucose levels provide the substrate for microorganisms such as E. coli, which are able to produce carbon dioxide by the fermentation of sugar
diagnosis of emphysematous pyelonephritis is established radiographically. ____ that is distributed in the parenchyma may appear on ___ as __ over the involved kidney
he diagnosis is established radiographically. Tissue gas that is distributed in the parenchyma may appear on abdominal radiographs as mottled gas shadows over the involved kidney
Empmysetous pyelonephritis: Obstruction is demonstrated in approximately ___. A ___ should be performed to assess the degree of renal function impairment in the involved kidney and the status of the contralateral kidney.
Obstruction is demonstrated in approximately 25% of the cases. A nuclear renal scan should be performed to assess the degree of renal function impairment in the involved kidney and the status of the contralateral kidney.
renal abscess: A thorough history may reveal a ___ before the onset of urinary tract symptoms or symptoms consistent with UTI or pyelonephritis in the weeks prior The infection may have occurred ___
A thorough history may reveal a gram-positive source of infection 1 to 8 weeks before the onset of urinary tract symptoms or symptoms consistent with UTI or pyelonephritis in the weeks prior (Hung et al., 2007). The infection may have occurred in any area of the body. Multiple skin carbuncles and IV drug abuse introduce grampositive organisms into the bloodstream. Other common sites are the mouth, lungs, and bladder
although the classic treatment for an abscess has been ___, there is good evidence that use of IV antimicrobial agents and careful observation of a small abscess less than ___ in a clinically stable patient is appropriate.
Antibiotics, if begun early enough in the course of the process, may obviate surgical procedures
lthough the classic treatment for an abscess has been percutaneous or open incision and drainage, there is good evidence that use of IV antimicrobial agents and careful observation of a small abscess less than 3 cm or even 5 cm in a clinically stable patient is appropriate. Antibiotics, if begun early enough in the course of the process, may obviate surgical procedures
_____ is bacterial infection in a hydronephrotic kidney. The term ___ refers to infected hydronephrosis associated with ___ of the parenchyma of the kidney, in which there is ___
Tx:
Once the diagnosis of pyonephrosis is made, the treatment is initiated with appropriate__ and __
Infected hydronephrosis is bacterial infection in a hydronephrotic kidney. The term pyonephrosis refers to infected hydronephrosis associated with suppurative destruction of the parenchyma of the kidney, in which there is total or nearly total loss of renal function
Once the diagnosis of pyonephrosis is made, the treatment is initiated with appropriate antimicrobial drugs and drainage of the infected pelvis
__ extends beyond the renal capsule but is contained by Gerota fascia and usually results from rupture of an acute cortical abscess into the perinephric space, extravasated infected urine from obstruction, or from hematogenous seeding from sites of infection
A perinephric abscess extends beyond the renal capsule but is contained by Gerota fascia and usually results from rupture of an acute cortical abscess into the perinephric space, extravasated infected urine from obstruction, or from hematogenous seeding from sites of infection
Xanthogranulomatous pyelonephritis (XGP) is a rare, severe, chronic renal infection typically resulting in diffuse renal destruction. Most cases are \_\_\_ and result in a \_\_ associated with \_\_\_\_ secondary to \_\_\_. XGP is characterized by accumulation of \_\_\_\_ . It begins within the pelvis and calyces and subsequently extends into and destroys renal parenchymal and adjacent tissues. It has been known to imitate almost every other inflammatory disease of the kidney, as well as renal cell carcinoma, on radiographic examination
Xanthogranulomatous pyelonephritis (XGP) is a rare, severe, chronic renal infection typically resulting in diffuse renal destruction. Most cases are **unilateral** and result in a **nonfunctioning, enlarged kidney**associated with**obstructive uropathy secondary to nephrolithiasis**. XGP is characterized by**=---** It begins within the pelvis and calyces and subsequently extends into and destroys renal parenchymal and adjacent tissues. It has been known to imitate almost every other inflammatory disease of the kidney, as well as renal cell carcinoma, on radiographic examination
The primary factors involved in the pathogenesis of XGP are:
he primary factors involved in the pathogenesis of XGP are nephrolithiasis, obstruction, and infection
_ to be the most common organism involved with XGP
Proteus to be the most common organism involved with XGP (
XGP has been associated with:
XGP has been associated with renal cell carcinoma, papillary transitional cell carcinoma of the pelvis or bladder, and infiltrating squamous cell carcinoma of the pelvis
Malacoplakia, from the Greek word meaning “soft plaque,” is an unusual inflammatory disease originally described to affect the bladder but has been found to affect the GU and GI tracts, skin, lungs, bones, and mesenteric lymph nodes
It is hypothesized that bacteria or bacterial fragments form
the nidus for the calcium phosphate crystals that laminate the ___. Most investigations into the pathogenesis of this disease support theories that a defect in intraphagosomal bacterial digestion accounts for the unusual immunologic response that causes malacoplakia.
___ from the Greek word meaning “soft plaque,” is an unusual inflammatory disease originally described to affect the bladder but has been found to affect the GU and GI tracts, skin, lungs, bones, and mesenteric lymph nodes
It is hypothesized that bacteria or bacterial fragments form
the nidus for the calcium phosphate crystals that laminate the Michaelis-Gutmann bodies. Most investigations into the pathogenesis of this disease support theories that a defect in intraphagosomal bacterial digestion accounts for the unusual immunologic response that causes malacoplakia.
identift A, B, C
(A) Cut surface demonstrates extensive cortical and upper medullary replacement by multifocal, confluent, tumorlike masses.
(B) Cortical surface exhibits multiple, firm, plaquelike lesions.
(C) Hallmark of malacoplakia is demonstration of the Michaelis-Gutmann body (arrows), which represents incompletely destroyed bacteria surrounded by lipoprotein membrane (hematoxylin)
Multifocal malacoplakia on excretory urography typically is seen as ___
Multifocal malacoplakia on excretory urography typically is seen as enlarged kidneys with multiple filling defects
fournier’s gangrene: Predisposing factors include diabetes mellitus, local trauma, paraphimosis, periurethral extravasation of urine, perirectal or perianal infections, and surgery such as circumcision or herniorrhaphy. In cases originating in the genitalia, specifically as a result of urethral obstruction, the infecting bacteria probably pass through___ and spread along the ____ of the scrotum and penis, ____of the perineum, and ___ of the anterior abdominal wall
Predisposing factors include diabetes mellitus, local trauma, paraphimosis, periurethral extravasation of urine, perirectal or perianal infections, and surgery such as circumcision or herniorrhaphy. In cases originating in the genitalia, specifically as a result of urethral obstruction, the infecting bacteria probably pass through Buck fascia of the penis and spread along the Dartos fascia of the scrotum and penis, Colles fascia of the perineum, and Scarpa fascia of the anterior abdominal wall
fournier’s gangrene: Because __ is often an early finding, a plain film of the abdomen may be helpful in identifying air. Scrotal ultrasonography is also useful in this regard
Because crepitus (subcutaneous gas) is often an early finding, a plain film of the abdomen may be helpful in identifying air. Scrotal ultrasonography is also useful in this regard
Periurethral abscess is frequently a sequela of __, __ and ___ ___ is also associated with periurethral abscess formation
Periurethral abscess is frequently a sequela of gonorrhea, urethral stricture disease, or urethral catheterization. Frequent instrumentation is also associated with periurethral abscess formation
characteristics of sepsis spectrum
It is not surprising that untreated bacteriuria in the __- is accompanied by a substantial increase in the incidence of acute pyelonephritis because half of these women have upper tract bacteriuria
It is not surprising that untreated bacteriuria in the first trimester is accompanied by a substantial increase in the incidence of acute pyelonephritis because half of these women have upper tract bacteriuria
pregnancy:
This hydroureter has been attributed to the muscle-relaxing effects of ___ during pregnancy and to ___ by the enlarging uterus at the pelvic brim
This hydroureter has been attributed to the muscle-relaxing effects of increased progesterone during pregnancy and to mechanical obstruction of the ureters by the enlarging uterus at the pelvic brim
Cunnington’s review suggests that ascending GU tract infections may contribute to up to 50% of premature deliveries, especially when they occur before ___
Cunnington’s review suggests that ascending GU tract infections may contribute to up to 50% of premature deliveries, especially when they occur before 30 weeks’ gestation
oral antibiotic for pregnant women, what to avoid
CDC define a CAUTI as a ____To be diagnosed with a CAUTI, patients must have one symptom of a UTI (5) and a ___.
CDC define a CAUTI as a UTI after placement of an indwelling urinary catheter for more than 2 days (Centers for Disease Control and Prevention: Urinary Tract Infection, 2015). To be diagnosed with a CAUTI, patients must have one symptom of a UTI (suprapubic tenderness, CVA tenderness, urinary frequency/ urgency/dysuria, or fever >100.4°F) and a urine culture with a single organism more than 100,000 CFU/mL.
The development of bacteriuria in the presence of an indwelling catheter is inevitable and occurs at an incidence of approximately ___ per day of catheterization. Sterile and clean intermittent catheterization has been associated with rates of bacteriuria ranging from ___ per catheterization
The development of bacteriuria in the presence of an indwelling catheter is inevitable and occurs at an incidence of approximately 10% per day of catheterization. Sterile and clean intermittent catheterization has been associated with rates of bacteriuria ranging from 1% to 3% per catheterization
CAUTI: The catheter-meatal junction should be cleaned daily with ___, but antimicrobial agents should be avoided because they lead to colonization with resistant pathogens, such as___
The catheter-meatal junction should be cleaned daily with water, but antimicrobial agents should be avoided because they lead to colonization with resistant pathogens, such as Pseudomonas.
UTI and SCI: Although never rigorously compared with indwelling urethral catheterization, CIC has been shown to decrease lower urinary tract complications by maintaining __ and by reducing the ___ (Stover et al., 1989). CIC also appears to reduce complications associated with an indwelling catheter, such as (5)
Although never rigorously compared with indwelling urethral catheterization, CIC has been shown to decrease lower urinary tract complications by maintaining low intravesical pressure and by reducing the incidence of stones (Stover et al., 1989). CIC also appears to reduce complications associated with an indwelling catheter, such as UTI, fever, bacteremia, and local infections such as epididymitis and prostatitis
cauti: Urinalysis will show bacteriuria and pyuria. Pyuria is not diagnostic of infections because it may occur from the __
Urinalysis will show bacteriuria and pyuria. Pyuria is not diagnostic of infections because it may occur from the irritative effects of the catheter.
SCI px on catheters: Chronic infection and inflammation of the bladder mucosa could be the __ in these patient, __ produced in infected urine have also been implicated
Chronic infection and inflammation of the bladder mucosa could be the carcinogenic stimulus in these patients (Pyrah et al., 1955). Nitrosamines produced in infected urine have also been implicated
When used as Antimicrobial Prophylaxis, vancomycin and fluoroquinolones should be initiated within ___ the procedure. Single-dose AP is most appropriate in the majority of uncomplicated urologic surgery.
When used as AP, vancomycin and fluoroquinolones should be initiated within 120 minutes of the procedure. Single-dose AP is most appropriate in the majority of uncomplicated urologic surgery.
The most common cause for infection after transrectal prostate biopsy is __
The most common cause for infection after transrectal prostate biopsy is fluoroquinolone-resistant E. coli
screening before TRUS-Bx and targeted prophylaxis should be considered as a thoughtful, predictable___ to empirical prophylaxis. That being said, there are a number of issues related to the actual process of targeted prophylaxis including: (5)
Thus screening before TRUS-Bx and targeted prophylaxis should be considered as a thoughtful, predictable alternative to empirical prophylaxis. That being said, there are a number of issues related to the actual process of targeted prophylaxis including costs, time of extra visits, special culture media, and lab requirements
wound classfication of 1. Opening into urinary tract, as in nephrectomy, cystectomy, prostatectomy, endoscopic procedures.
- PCNL
- Clean-contaminated ( class 2)
- contaminated (class 3)
A 45-year-old woman is found to have a raised bladder lesion on cystoscopy. The biopsy shown in Fig. 55.3 reveals malakoplakia. The next step in management is: a. intravesical bacille Calmette-Guérin. b. fulguration of the lesions. c. intravesical mitomycin C. d. treat with a sulfonamide for several months. e. a 3-day course of ciprofloxacin.
d. Treat with a sulfonamide for several months. Fig. 55.3A shows von Hansemann histiocytes, and Fig. 55.3B demonstrates the Michaelis-Gutmann bodies, both of which are characteristic of malakoplakia. It is thought to be infectious in origin, and therefore the treatment is an extended course of an antibiotic that achieves a high intracellular concentration.
A 68-year-old diabetic woman presents to the emergency room with the chief complaint of abdominal pain. CT scan findings of her pelvis are shown in Fig. 55.7. The next step in her management is:
a. inpatient antibiotics, Foley catheter placement, and glucose management b. collection of a urine sample and discharge home with empiric antibiotic coverage c. emergent exploration and surgical debridement with placement of a suprapubic tube d. obtain an ultrasound to assess the upper urinary tract e. reassurance
a. Inpatient antibiotics, Foley catheter placement, and glucose management. The figure is an example of emphysematous pyelonephritis. The majority (90%) of these patients are treated with medical therapy alone, which consists of antibiotics (often parenteral), bladder drainage, and treatment of comorbid conditions such as poorly controlled diabetes. The need for surgical intervention is rare and is reserved for those cases that respond poorly to initial medical management or severe necrotizing infections.
