Prevention of

Urinary Tract
Diseases
Isabelita M. Samaniego MD
Session Objectives
 1. To describe the present health status of
kidney problem in the Philippines.
 2.To review the common types of kidney
diseases.
 3. To describe the national objectives for
the control and prevention of kidney
diseases.
Situationer
 6,500 yearly deaths in the country
secondary to various kidney diseases
 Renal Diseases threaten to be one of the
leading causes of death
 Health consequence of chronic kidney
disease is renal failure
 DOH reported that there are about 6,000
new cases of ESRD a year
Situationer
 ESRD –causes are as follows:
 Chronic glomerulonephritis (CGN) is the
most common (47 percent )
 Chronic pyelonephritis (17 percent),
diabetes mellitus (13 percent), and
hypertensive nephrosclerosis (5 percent)
(Kidney center of the Philippines, Medical
City 1975-1981
Situationer
 Dialysis patients:
b) Chronic glomerulonephritis (39 percent)
c) Diabetes mellitus (22 percent)
d) Hypertension (14 percent) (RDR,1998).
 Other conditions that cause Chronic renal failure
f) vasculitis,
g) interstitial nephritis
h) genetic and congenital disorders
i) polycystic kidney disease.
Situationer
 ESRD affects persons of all ages
 Chronic glomerulonephritis (CGN) usually
affects children, adolescent and young
adults in their reproductive years
 One primary reason for CGN progression
is failure to diagnose the disease in its
early stage
Situationer
 Three interventions have been effective
in defined populations:
b) Increase case finding and treatment for
CGN
c) Good glycemic control (for patient with
diabetes mellitus)
d) Optimum blood pressure control
Situationer
 Interventions to slow down the ESRD
 Simple urinalysis can detect symptoms of
urinary tract infection in asymptomatic
individuals
Acute Uncomplicated Cystitis in
Women
 Definition: Growth of > 100 colony- forming units ( cfu)/
ml of mid stream urine in non pregnant women ( 18-50
yrs old)
 Symptoms Presented:
c) Dysuria
d) Frequency
e) Urgency
f) Gross hematuria
g) Hypogastric pain
h) Without symptoms of vaginitis , pyelonephritis or risk
factors for subacute pyelonephritis or complicated UTI
( Grade A)
Risk Factors for subacute
pyelonephritis or complicated UTI
 Hospital Acquired Infection
 Indwelling Catheter
 Recent UTI
 Recent urinary tract instrumentation ( 2 weeks)
 Functional or anatomic abnormality of the
urinary tract
 Recent antimicrobial use ( 2 weeks)
 Symptoms > 7 days at presentation
 DM
 Immunosuppresion
Treatment & Duration
 3 day course of the ff:
 TMP/SMX 160/800
 Nitrofurantoin 100 mg QID
 Norfloxacin 200 mg BID
 Cirpofloxacin 250 mg BID
 Ofloxacin 200 mg BID
 Co amoxyclav 375 mg TID
Acute uncomplicated
Pyelonephritis
 Definition : Fever , chills flank pains,
costovertebral angle tenderness , nausea,
vomiting, with or without symptoms of
lower urinary tract infection in an
otherwise healthy female with no clinical
or historical evidence or functional or
anatomic urologic abnormalities
Acute uncomplicated
Pyelonephritis
 Definition :
 Laboratory: pyuria> 5wbc/ hpf in a
centrifuge urine
Acute uncomplicated
Pyelonephritis
 Etiologic diagnosis:
 Gram stain ( grade C)
 Quantitative C/s ( grade C)
Acute uncomplicated
Pyelonephritis
Treatment:
Indications for admission:
 Inability to maintain oral hydration or medication
 Concern about compliance
 Uncertainty about the diagnosis
 Severe illness with high grade fever
 Severe pain
 Marked debility
 Signs of sepsis
 Acute uncomplicated
Pyelonephritis
Characteristic Pathogens Clinical Situation Empiric treatment

E. Coli Mild to moderate illness, Oral: Quinolones,

Proteus Mirabilis no nausea, vomiting- TMP/SMX/ Co amox- 14
OPD days
K Pneumonia

S. Saprophyticus Severe illness- Parenteral –

hospitalization Aminoglycoside,
quinolones, 3rd gen
cephalosporine for 2
days then shift to oral for
14 days
Asymptomatic Bacteriuria
 Definition : a) presence of > 100,000 cfu/
ml of one or more pathogen on two
consecutive midstream urine specimens
 B) absence of symptoms attributable to
UTI
Asymptomatic Bacteriuria
 Risk Groups:
 Elderly esp. women
 Women with DM
 Individuals with long term indwelling
catheters
 GUT abnormalities
 Renal transplant
Treatment for Asymptomatic
Bacteriuria
 Persistent bacteriuria after catheter
removal
 Patients who will undergo instrumentation
 DM
 Abnormal Urinary tract
UTI in pregnancy
 Asymptomatic Bacteriuria :

 A) > 100,000 cfu/ ml with 1 or more

organism in two consecutive mid stream
urine
 B) Absence of symptoms of UTI
UTI in pregnancy
 SCREENING:
 All pregnant women must be screened
 Urinalysis – mid stream
 Urine culture / sensitivity
Acute Cystitis in Pregnancy
 Definition: urinary frequency, urgency ,
dysuria , bacteriuria ,gross hematuria but
no fever, CVA tenderness
 Pyuria of 8 or more pus cells in the urine
Treatment for UTI in Pregnant
women
Safe Caution Contraindicated
Cephalosporin Aminoglycoside Tetracycline
Co amoxyclav TMP/SMX Quinolone
Ampicillin TMP/ sulfa –
sulbactam third trimester
Recurrent UTI
 Episodes of acute uncomplicated UTI
documented by urine culture occurring
more than 2x a year in a non pregnant
woman with no urinary tract abnormality
Treatment of Individual
Episodes of UTI
 Grade A: Tx with Co amoxyclav,
Cefradine, ciprofloxacin, - 7 days
 Grade C = 3 day treatment with antibiotics
for simple uncomplicated cystitis.
 Intermittent self administered therapy- 4
tablets of TMP/SMX = single dose as soon
as the symptoms appear.
Recommended Prophylaxis

Medications Recommended Recommended

dose for dose for Post
continuous coital
Prophylaxis Prophylaxis
Nitrofurantoin- 100 mg HS -----
Norfloxacin 200 mg HS 200 mg HS
TMP/smx 40/200mg HS 40/200mg HS
Ciprofloxacin 125 mg/HS 125 mg/HS
Ofloxacin 100 mg
Screening Recommendation
 Gross hematuria during UTI episodes
 Obstructive symptoms
 Persistent infections
 Infections with urea splitting microbes
 History of pyelonephritis
 Suggestive or urolithiasis
 Childhood UTI
 Elevated Creatinine
Choice of Screening Procedure
 KUB UTZ & plain abdomen
 Referral to specialist
Prophylaxis for Menopausal
Women
 Use of estriol cream intravaginal 2x HS for
2 weeks then 2x weekly for 8 months
Grade A
Complicated UTI
 Definition- significant bacteriuria in a
setting of functional & anatomic
abnormalities in the urinary tract.
Types of Complicated UTI
 Catheter Associated
 UTI in diabetics
 Long Term > 1 week
 Renal transplantation
 Anatomic abnormalities
 UTI in AIDS
 Neutropenic patients
Antibiotic Regimen
 Oral  Dose
 Cirpofloxacin  250 mg BID 14 d
 Nofloxacin  400 mg BID 14 d
 Ofloxacin  200 mg BID 14 d
 TMP/SMX  160/800 BID 10 days
Antibiotic Regimen
 Parenteral  Dose
 1 gm q 6 hrs IV gentamicin 3 gm/ kg
 Amoicillin /day OD IV
 Ceftazidime  1-2 gms q 8 hrs IV
 Ceftraiaxone  1-2 gms q 8 hrs IV
 Cirpofloxacine
 200-400 gms IV q 12 hrs
 Imipenem-cilastin  250-500 mg q 6-8 hrs Iv
 Ofloxacin  200-400 mgs Q 12 hrs IV
UTI in Males
 Definition : Uncomplicated in Young Males
First episode of symptomatic lower UTI in a
male (15-40 yrs of age) otherwise healthy
sexually active no clinical or historical
evidence of structural or functional
abnormality.
Diagnosis: significant pyuria=> 10 WBC/
mm3 or 5 wbc /HPF
Diagnostic Work up
 Urinalysis /urine culture
 Imaging proedures
Treatment
 TMX/SMX-
 Fluroquinolone
 Choice of antibiotic is based on sensitivity
patterns
Prostatitis
 Acute
 Definition: febrile illness with abrupt onset
ofn chills, low back & perinial pain ,
generalized malaise and prostration,
irritative voiding symptoms, dysuria,
nosturia & frequency 7 urgency. Rectal
examination – marked tenderness if the
prostate .
Prostatitis
 Chronic
 Definition:varying degrees of irritative
voiding & pain perceived in various sites ,
suprapubic, perineal, low back, scrotal,
penile & inner thighs.
Diagnosis
 Expressed prostatic secretions ( EPS)-
> 10 wbc/ hpf presence of lipid laden
macrophages is more prostate specific .
 Triple voided urine test- quantitative
bacterial colony count of ( EPS) & the next
5-10 ml of urine significantly exceed those
of the Urethral & bladder and should be 1
log.
Treatment
 Acute: TMP/ SMX=( 160/800 mg)
 Fluoroquinolone start while waiting
for the result of C/S
 TX = 30 days to prevent chronicity
 Seriously ill= hospitalized – parenteral
ampicillin – aminoglycoside or
fluoroquinolone
 Refer to urologist
Treatment
 Chronic :TMP/ SMX=( 160/800 mg)
 Fluoroquinolone
 Given for 2-3 months to prevent chronicity
 Recalcitrant cases- radical TURP
 Hot sitz bath
 Antiinflammatory agents
 Prostatic massage
 Long term low dose suppressive therapy =
TMP/SMX 80/400 mg once daily
Prevention of Catheter
Associated UTI
 Personnel:
 Only persons trained in correct aseptic
technique of catheter insertion 7 care
should handle urinary catheter
 Hand washing should be dome
immediately before & after insertion
Prevention of Catheter
Associated UTI
 The catheter
 Limit catheter use to carefully selected patients
 Should be inserted using aseptic technique &
sterile equipment
 Maintain a sterile , closed catheter system at all
times
 Urine specimen should be obtained aseptically
without opening the catheter junction.
 Maintain unobstructed & adequate urine outflow
at all times.
Prevention of Catheter
Associated UTI
 The catheter
 Do not change catheters at arbitrary fixed
intervals
 Remove catheter as soon as possible
Prevention of Catheter
Associated UTI
 Method to prevent endogenous infection –Daily
meatal care is not recommended
 Method to prevent exogenous infection
 Irrigation of the bladder with antimicrobial agents
is not useful
 Instillation of disinfectants into the bag & the use
of antireflux valves & vents are not helpful
 Segregate infected from uninfected catheterized
patients.
Bacteriologic monitoring and treatment of
asymptomatic bacteriuria to prevent
complications . 2nd prevention
 Regular bacteriologic monitoring of catheterized
patients is not recommended
 Use of systemic antibiotic prophylaxis in
catheterized patient is discouraged.
 Patients at high risk of complications of catheter-
associated bacteriuria , such as renal transplant
& granulocytopenic patients may benefit from
antibiotic prophylaxis.
Goal

 Reduction of Morbidity and Mortality From

Kidney Diseases
Health Status Objectives
• Reduce the occurrence of kidney diseases
and incidence rate of ESRD to 3,000
cases a year. ( baseline 6, 500 yearly
deaths secondary to various kidney
diseases, 1998 DOH)
Risk Reduction Objectives
• Increase awareness and practice of preventing renal
diseases which includes:
b) Adequate water intake,
c) Balanced diet
d) Personal hygiene
e) moderate exercise
f) BP check-up
g) complete immunization
h) management of throat and skin infections
i) regular urinalysis) among high risk groups to 80
percent.
Risk Reduction Objective
• Increase awareness of the signs and
symptoms of kidney disease (e.g. edema,
high BP) to 75 percent.
• Increase the proportion of school children,
adolescent and young adults routinely
screened for urinary tract infections,
diabetes and kidney disease to 75
percent.
Risk Reduction Objective
• Increase the proportion of diabetic patients who
receive annual screening tests for
microalbuminuria to 70 percent
• those who receive adequate treatment with
ACE-inhibitors and low protein diet for the
prevention and control of nephropathy to 50
percent. (Baseline: less than 10 percent are
screened for microalbuminuria in 1998: baseline
data on adequate treatment is established in
2000)
Risk Reduction Objective
 Increase the proportion of hypertensive
individuals screened at the time of initial
evaluation for the presence of renal disease
(proteinuria, creatinine, BUN) to 80 percent.
 Increase the proportion of patients with chronic
renal disease with optimum blood pressure
control of <130/85 to more than 50 percent and
yearly monitoring of renal function (proteinuria,
hematuria, and serum creatinine) to 60 percent.
Risk Reduction Objective
• Reduce the prevalence of ESRD due to
chronic glomerulonephritis to 32 percent
(baseline 47 percent), chronic
pyelonephritis to 11 percent (baseline 17
percent), diabetes nephropathy to 9
percent (baseline 13 percent) and
hypertensive nephrosclerosis to 2 percent
(baseline 5 percent) through increased
screening, early detection and treatment.
Service and protection
Objectives
• Increase early referral of abnormality
urinary findings to nephrologists for early
and adequate management and
monitoring to 50 percent.
• Improve access and median waiting time
for renal transplantation.
Service and protection
Objectives
• Increase organ donation for renal
transplantation to 300 donors a year ( Baseline 7
donors in 1993, NKTI)
• Increase the proportion of primary care
providers who routinely counsel their patients
about the effects of chronic health conditions
(CGN, diabetes, hypertension) on the
development and progression of renal disease
to 75 percent.
Service and protection
Objectives
• Upgrade the capabilities of regional
hospitals and facilities that cater to kidney
patients for primary, secondary and
tertiary care to 90 percent.
Summary
 1. Described the present health status of
kidney problem in the Philippines.
 2.Reviewed the common types of kidney
diseases.
 3.Described the national objectives for the
control and prevention of kidney diseases.