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Asymptomatic Bacteriuria

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SESSION 7 Suggested out line for notes Asymptomatic Bacteriuria occurs in about 5% of woman and is important in pregnancy where, untreated, 20-30% of cases will develop acute pyelonephritis. Bacteriuria in pregnancy is also associated with premature birth, low birth weight and increased perinatal mortality. It is therefore important that all women have their urine cultured early in pregnancy. Those with positive cultures must be treated (with a safe and effective agent such as nitrofurantoin or a cephalosporin) and follow-up cultures obtained to ensure clearance. In catheterised patients the incidence of UTI is about 1-5% per catheterisation and about 50% at 4-7 days post catheterisation with modern closed systems. The potential entry points for infection are: a. urethral meatus around catheter b. junction between catheter and connection tube c. sample port d. reflux from bag to tubing e. drainage outlet UTIs in catheterised patients should only be treated if patients have systemic features. Whenever possible the catheter should be removed before treatment. Where indicated, use antibiotics determined by susceptibility testing. Do not use prophylaxis in catheterised patients as this generally leads to the emergence of resistance. A catheter/catheterisation policy should address the basic issues, including the following points to reduce catheter- associated UTIs: i. Only catheterise when absolutely necessary ii. Remove catheter as soon as possible iii. Use intermittent rather than continuous catheterisation iv. Insert catheter with good aseptic technique v. Use closed sterile drainage system vi. Ensure urine drains by gravity to avoid reflux Bacteriuria is more common in both children and the elderly. The prevalence of UTI in infants is about 1-2%, (higher in pre-term babies) being more common in boys during the first three months and thereafter more common in girls. In pre-school children the prevalence of bacteriuria in girls is about 4.5% and 0.5% in boys. Many of these infections will be symptomatic but some will be clinically silent. ...read more.


Increased deposition of basement membrane between the sub-epithelial deposits gives the appearance of spikes on silver staining under light microscopy. There is little proliferation but mesangial sclerosis may occur in advanced cases. All glomeruli are involved uniformly. Focal and segmental glomerulonephritis: this is characterised by sclerosis of some but not all glomeruli. Only a portion of the glomerular tuft is abnormal. In early cases predominantly juxtamedullary glomeruli are involved. 3. Proteinuria should be considered abnormal in a 35 year old patient, although in young adults and children proteinuria in association with a febrile illness or postural proteinuria (proteinuria only present when standing) are possible more benign diagnoses. Investigations should include assessment of renal function, with measurement of plasma urea and creatinine and creatinine clearances. Quantification of 24 hour protein excretion should be performed. Immunological tests, including autoantibodies, ANCA, Complement levels, plasma and urinary protein electrophoresis (to exclude multiple myeloma, which would be unusual in a patient of this age) are indicated. An MSU should be checked, although urinary tract infection is an unlikely cause of isolated proteinuria. Renal imaging should be performed and, if the kidneys are normal, consideration given to performing a renal biopsy to establish a definitive histological diagnosis. Most nephrologists would perform a renal biopsy if the proteinuria was significant (> 1 gram/24 hours) or if the proteinuria was associated with haematuria or abnormal renal function. 4. Tissue fluid is regulated by a series of forces known as Starling forces. At the proximal (arteriolar) end of the capillary fluid moves from the vascular space into the interstitium under hydrostatic pressure. Towards the end of the capillary, fluid returns from the intestitial space into the capillaries under the influence of the oncotic pressure within the capillary. Plasma proteins, particularly albumin, are the main factors responsible for the oncotic pressure. In proteinuric states, where the proteinuria is sufficient to lower plasma albumin, the oncotic pressure within the capillaries would be reduced; thus the driving force to return fluid from the interstitial space into the capillaries is reduced and oedema will result (this is the nephrotic syndrome). ...read more.


Use of ACE inhibitors in these conditions effectively dilate the efferent arteriole and cause glomerular filtration rates to fall. Under pathological conditions renal blood flow is maintained by vasodilation induced by vasodilatory prostaglandins. The use of non-steroidal anti-flammatory drugs (inhibitors of cyclo-oxygenase) in such patients will therefore cause relative renal vasoconstriction and a fall in renal blood flow and glomerular filtration rate. Thus these drugs should be used cautiously in patients with chronic renal failure, as they are likely to precipitate a decline in renal function. In addition an idiosyncratic 'allergic reaction' is seen in a small percentage of patients given non-steroidal anti-inflammatory drugs producing an interstitial nephritis and acute renal failure. This is rare and often associated with a peripheral eosinophilia. Gentamicin is a potential tubular toxin and given in excess amounts will cause acute tubular necrosis. It is principally excreted by the kidney and therefore may accumulate in patients with renal impairment. It is essential when using Gentamicin that drug levels are measured frequently (peak and trough) to ensure appropriate does are given and toxicity is avoided. Toxicity may also be compounded by the co-administration of loop diuretics which concentrate Gentamicin within the tubular cells. 6. A fractional excretion of sodium of 2% is high but can be normal. It is compatible with all of the listed diagnosis other than pre-renal failure in which the fractional excretion should be low (less than 1%). Fractional excretion of sodium may be high in normal individuals who consume large amounts of sodium. It is high in patients with acute tubular necrosis where the tubules are no longer able to absorb sodium and the filtered load is also declining due to a falling GFR. Such patients will usually be oliguric Patients undergoing an osmotic diuresis, such as those with uncontrolled diabetes or patients receiving loop diuretics, will also have a high fractional excretion of sodium. Clinical evaluation of the patient is essential to distinguish these possibilities. In addition, urinary output and serum creatinine are required. ...read more.

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