KEYWORDS: ..성인에서 요로감염은 여성이 남성보다 25~30배 정도 많고, 일생동안 전체여 자의 20%에서 요로감염을 경험한다. ..UTIs are the most common bacterial infection in the elderly, and are a common source of bacteremia. 원인균 Escherichia coli Staphylococcus saprophyticus Proteus mirabilis Klebsiella pneumoniae Enterococcus species Pseudomonas aeruginosa i. Obstruction : bladder outlet obstruction, uterine prolapse, stones, tumor, congenital abnormalities ii. Foreign body : catheter, stent iii. Postvoid residual greater than 100mL : neurologic disease, medications iv. Vesicoureteral reflux v. Recent invasive urologic procedure vi. Renal transplants vii. Azotemia viii. Ileal loop ix. Immunosuppression x. Diabetes mellitus Acute urinary tract infection in adults (Acute cystitis, pyelonephritis) 471 The Root of ambulatory care xi. Pregnancy xii. Nosocomial infection ▶ 초음파/요로조영술/CT Lower UTI : Cystitis 1. Dysuria 2. Frequency 3. Nocturia 4. Suprapubic pain 5. Hematuria 6. Malodorous urine 7. Incontinence Upper UTI : Pyelonephritis 1. Flank pain 2. Fever, Chills 3. Nausea and vomiting, Abdominal tenderness 4. Mental changes, Tachycardia, Tachypnea (in the elderly) ..단순 하부 요로감염에서도 연관통에 의해 flank pain & CVA tenderness가 있 을 수 있다. Lower UTI : Cystitis 1. Suprapubic tenderness Upper UTI : Pyelonephritis 1. Flank tenderness : CVA tenderness 2. Fever 3. Tachypnea 4. Tachycardia 5. Mental status change ( elderly ) 6. Nausea and Vomiting Key symptoms Key signs Key tests Differential diagnosis Key treatments Acute urinary tract infection in adults (Acute cystitis, pyelonephritis) 1. Urine microscopy : microscopic or gross hematuria may be observed in UTI but not specific. 2. Pyuria : > 10 WBC/ml in uncentrifuged urine 3. White cell casts : indicate pyelonephritis. 4. Clean-catch midstream urine culture : In the absence of a positive culture (< 100 uropathogens/mL), suggests infection by Chlamydia trachomatis or Neisseria gonorrhoeae or tuberculosis. 5. Blood culture : in toxic or elderly patients with signs of upper UTI - 15~30% of patients with acute pyelonephritis may be bacteremic with positive cultures. Elderly patients, DM, and individuals with urinary tract obstruction appear to have an increased risk of bacteremia. 6. Biochemical screening test : glucose oxidase, catalase, nitrite reduction, leukocyte esterase tests Lower UTI 1. Urethritis : in females caused by C.trachomatis, N.gonorrhoeae, H.simplex 2. Vaginitis : Candida albicans, Trichomonas vaginalis, bacterial vaginosis Upper UTI 1. Diverticulitis 2. Appendicitis 3. Pneumonia 4. Intestinal obstruction 5. Nephrolithiasis -Acute cystitis : uncomplicated 1. 1st line agents ..Septrin.. 400/80mg 1T, 2T bid×3days (×7~10days in Male) ..Norfloxacin.. 200mg 1T, 2T bid×3days (2T bid×7days in Male) ..Ciprobay.. 250mg 1T, 1T bid×3days (2T bid×7days in Male ) 473 The Root of ambulatory care 1. Recurrent urinary tract infection ( > 2회/ year) ..Septrin.. 400/80mg 1T, 2T bid×3days <저용량장기 예방 요법> ..Septrin.. 400/80mg 1T, 1/2T qd for 6months - 성교와 무관할때 ..Septrin.. 400/80mg 1T, 1/2T postcoital - 성교관련시 성교 후 2시간 이내 ..Septrin.. - SMX/TMP ..Ciprobay..- Ciprofloxacin ..1주일이상 증상 지속, 최근 요로감염증의 병력이 있거나, 피임방법으로 diaphragm을 사용하는 환자, 당뇨환자, 65세 이상, 임산부에서는 7-10일간 치 료함 - 치료 후에도 증상이 지속되거나 2주 이내 재발시, 균배양 검사 후 양성 이면 감염원, 위험인자를 교정하며 2주일 이상 사용해야 한다. ..어린이 및 50세 이상 남자에서의 재발성 요로감염시 요로계 이상에 대한 검 사를 해야 한다. ..재발성 요로감염시 충분한 수분섭취, 성관계 후 배뇨, 적절한 휴식이 예방에 도움이 된다. - Acute Pyelonephritis : uncomplicated 1. Parenteral - 보통 2-3일 투여하며 해열 후 oral agent로 교체 ..Rocephin.. 1g vial 1g qd ..Ciprobay.. 200mg/100ml btl 400mg q 12hrs IV over 1hr 2. Oral agents ..Septrin.. 400/80mg 1T, 2T bid×14days ..Ciprobay.. 250mg 1T, 2T bid×14days ..Rocephin..- Ceftriaxone Key treatments Acute urinary tract infection in adults (Acute cystitis, pyelonephritis) ..총항생제 치료 기간은 경구, 비경구 포함하여 2주, 만일 2주 치료로 완치되지 않으면 6주 치료를 고려해야 한다. ..항생제 치료 후 48-72시간이 지나도 호전이 없는 경우, 요로폐쇄, 신농양, 급 성 국소성 세균성 감염, 신주위 농양을 배제하기 위해 신장 초음파 실시해야 한다. (필요시 IVP, CT) ▶ Asymptomatic bacteriuria - Definition : 105 CFU/mL or more of the same organism in two separate clean-catch urine specimens in the absence of urinary tract infection. - Prevalence : Nonpregnant women younger than 65years ; 3~6% Pregnant women ; 3~15% Elderly women ; 50% - Treatment indication : 1) Pregnant women (치료하지 않으면 preterem labor나 low birth weight infants등을 야기할 수 있는 pyelonephritis 발생 위험이 20~40%나 된다.) First line drug → Nitrofurantoin 5~7mg/kg/day and give q 6h for 7days, cephalosporins, amoxicillin Second line drug → TMP-SMZ, amoxicillin-clavulanate Follow up : repeat urine culture 1 to 2 weeks after therapy, and repeat urine culture every 4 to 6weeks for the remainder of the pregnancy. 2) Patients with renal transplants 3) Patients who are about to undergo genitourinary tract procedures Cf) No benefit is gained from treatment, including the treatment of elderly, catheterized, diabetic patients. ▶ Urinary tract infection in children - Prevalence : 5% (female children), 1~2% (male children) ; In the neonatal age group there is a male predominance, whereas female predominance occurs afterward. - Etiology : E.coli (80%), Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas aeruginosa, Enterobacter species, Staphylococcus aureus, Streptococcus viridans, Enterococcus species, Candida albicans - Symptoms : Fever/Vomiting/Dysuria/Frequency/Flank pain/Enuresis (In pediatric 475 The Root of ambulatory care patients, symptoms are not specific and are seldom localized to the urinary tract.) - Signs : Abdominal tenderness/Fever/Suprapubic tenderness/Toxic appearance/ Lethargy/Costovertebral tenderness - Tests : Urine culture ( >105 colonies from a mid-stream clean-catch urine/ > 103 colonies from an intermittent catheterization/any number of colonies from a suprapubic bladder aspiration) ; one positive culture associated with symptoms or two concurrent positive cultures in an asymptomatic child indicate UTI. - Treatment : TMP/SMX 8~10mg(trimethoprim)/kg/day q12h (Septrin.. syrup 1ml/kg/day # 2) for 7~10days - Prophylaxis : 1) Younger than 5years with vesicoureteral reflux 2) Those in whom conservative management has failded to prevent recurrent urinary tract infection → TMP/SMX 2~3mg(trimethoprim)/kg/day (Septrin.. syrup 0.2~0.3ml/kg/day) - Urologic examination : 1) Children with systemic illness 2) Any child less than 5 years of age 3) Any male children 4) Female children over 5years of age with recurrent UTI → Renal ultrasonography/Cystography (VCUG:voiding cystourethrogram/DMSA : Dimercaptosuccinic acid renal nuclear scan) 참고 문헌 Steven K. Swedlund : Acute Urinary Tract Infection in Adults, in Saunders Manual of Medical Practice, 2nd ed, Robert E. Rakel(ed). Philadelphia, Saunders, 2000, P 725-727 Syed M. Ahmed : Acute Urinary Tract Infection in Children, in Saunders Manual of Medical Practice, 2nd ed, Robert E. Rakel(ed). Philadelphia, Saunders, 2000, P 728-731 권혁중 : 요로감염, in 가정의학 임상편. 서울, 계측문화사, 2002, P 1392-1402 Florian M.E. Wagenlehner, M.D., Ph.D., Kurt G. Nayef El-Daher, M.D., Ph.D. : Pyelonephritis, in Conn's Current Therapy 2004, Robert E.Rakel(ed), Edward T. Bope(ed_). Philadelphia, Saunders, 2004, P 732- 734 Patricia D. Brown, M.D., Jack D. Sobel, M.D. : Urinary Tract Infection in Women, in Conn's Current Therapy 2004, Robert E.Rakel(ed), Edward T. Bope(ed_). Philadelphia, Saunders, 2004, P 711-714 오창석(ed) : 급성 방광염, 급성 신우신염, in Complete Guide To Practical Based Prescription Medicine. 서울, 한우리, 2005, P 292-293, P 300-301 Robert Orenstein, D.O., Edward S. Wong, M.D. : Urinary Tract Infections in Adults. A journal of the American Family Physicains 1999 ; 59(5) : 1225-1238