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Infe cções do Trato Urinário

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Serviço de Urologia Hospital das Clínicas – HC – UFG

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Infe cções do Trato Urinário

  1. 1. Infe cções do Trato Urinário Serviço de Urologia Hospital das Clínicas – HC – UFG Rodrigo Pastor – R1 Goiânia, 05 de Abril de 2011
  2. 2. Introdução <ul><li>ITU correspondem a um amplo espectro de doenças, desde bacteriúria até infecção renal grave com sepse </li></ul><ul><li>7 milhões de consultas / ano </li></ul><ul><li>1 milhão de visitas à sala de emergência / ano </li></ul>Campbell’s Urology – 9th Edition; vol. 1; p. 223.
  3. 3. Epidemiologia <ul><li>Atinge todas as faixas etárias </li></ul><ul><li>Mais comum no sexo feminino </li></ul><ul><ul><li>30 : 1 em jovens </li></ul></ul><ul><ul><li>2 : 1 em idosos </li></ul></ul>Campbell’s Urology – 9th Edition; vol. 1; p. 224.
  4. 4. Epidemiologia Campbell’s Urology – 9th Edition; vol. 1; p. 226.
  5. 5. Etiopatogenia <ul><li>Bactérias Gram negativas da flora intestinal </li></ul><ul><li>Patogenicidade da bactéria </li></ul><ul><li>X </li></ul><ul><li>Fatores de defesa do hospedeiro </li></ul>
  6. 6. Etiopatogenia Campbell’s Urology – 9th Edition; vol. 1; p. 229.
  7. 7. Etiopatogenia pili tipo1: Cistite “ P” pili: Pielonefrite Campbell’s Urology – 9th Edition; vol. 1; p. 230.
  8. 8. Etiopatogenia <ul><li>Fatores de defesa do hospedeiro: </li></ul><ul><li>Flora da região periuretral </li></ul><ul><li>Urina diluída, com ↑ osmolaridade e ↓ pH </li></ul><ul><li>Esvaziamento vesical normal </li></ul><ul><li>Resposta imune adequada </li></ul>Campbell’s Urology – 9th Edition; vol. 1; p. 236.
  9. 9. Localização anatômica Campbell’s Urology – 9th Edition; vol. 1; p. 241. Number and Sex Bladder Only Unilateral Renal Bacteriuria Bilateral Renal Bacteriuria 95 females 38 (40%) 27 (28%) 30 (32%) 26 males 16 (62%) 6 (26%) 4 (15%) 121 combined 54 (45%) 33 (27%) 34 (28%)
  10. 10. Cistite Aguda
  11. 11. Cistite Aguda <ul><li>Infecção bacteriana restrita à bexiga </li></ul><ul><li>Patógenos mais comuns: </li></ul><ul><ul><li>E. coli – 70 a 95% </li></ul></ul><ul><ul><li>S. Saprophyticus – 5 a 10% </li></ul></ul><ul><ul><li>Proteus(cálculos) </li></ul></ul><ul><ul><li>Klebisiella </li></ul></ul>Campbell’s Urology – 9th Edition; vol. 1; p. 254 e 255.
  12. 12. Cistite Aguda <ul><li>Quadro clínico </li></ul><ul><ul><li>Disúria </li></ul></ul><ul><ul><li>Polaciúria </li></ul></ul><ul><ul><li>Urgência </li></ul></ul><ul><ul><li>Dor suprapúbica </li></ul></ul><ul><ul><li>Hematúria </li></ul></ul>Campbell’s Urology – 9th Edition; vol. 1; p. 255.
  13. 13. Cistite Aguda <ul><li>Critérios de ITU complicada : </li></ul><ul><li>Sexo masculino </li></ul><ul><li>Idosos </li></ul><ul><li>Infecção hospitalar </li></ul><ul><li>SVD </li></ul><ul><li>Gravidez </li></ul><ul><li>Manipulação recente do TGU </li></ul>Guidelines on urological infections – EAU 2009.
  14. 14. Cistite Aguda <ul><li>Critérios de ITU complicada : </li></ul><ul><li>Anormalidade anatômica ou funcional do TGU </li></ul><ul><li>Uso recente de ATB </li></ul><ul><li>Sintomas há mais de 7 dias </li></ul><ul><li>Diabetes Melitus </li></ul><ul><li>Imunodepressão </li></ul>Guidelines on urological infections – EAU 2009.
  15. 15. Cistite Aguda <ul><li>Diagnóstico </li></ul><ul><li>- Clínico </li></ul><ul><li>- EAS </li></ul><ul><li>- Urocultura </li></ul>
  16. 16. Cistite Aguda Tratamento Guidelines on urological infections – EAU 2009.
  17. 17. Cistite Aguda Tratamento (recorrência) Guidelines on urological infections – EAU 2009.
  18. 18. Cistite Aguda Tratamento Campbell’s Urology – 9th Edition; vol. 1; p. 255.
  19. 19. Pielonefrite Aguda
  20. 20. Pielonefrite Aguda <ul><li>Inflamação do rim e pelve renal </li></ul><ul><li>Diagnóstico clínico </li></ul><ul><ul><li>Febre </li></ul></ul><ul><ul><li>Calafrios </li></ul></ul><ul><ul><li>Dor em flanco </li></ul></ul><ul><li>Disúria, polaciúria e urgência podem estar presentes </li></ul>Campbell’s Urology – 9th Edition; vol. 1; p. 265.
  21. 21. Pielonefrite Aguda <ul><li>Urinálise </li></ul><ul><ul><li>Leucocitúria </li></ul></ul><ul><ul><li>Hematúria </li></ul></ul><ul><ul><li>Cilindros leucocitários </li></ul></ul><ul><li>Urocultura (+) em 80% dos casos </li></ul><ul><li>Hemocultura (+) em 25% dos casos </li></ul>Campbell’s Urology – 9th Edition; vol. 1; p. 265 e 267.
  22. 22. Pielonefrite Aguda <ul><li>Bacteriologia </li></ul><ul><ul><li>E.Coli – 80% dos casos (P pili) </li></ul></ul><ul><ul><li>Proteus </li></ul></ul><ul><ul><li>Klebisiella </li></ul></ul><ul><ul><li>Pseudomonas </li></ul></ul><ul><ul><li>Serratia </li></ul></ul><ul><ul><li>Enterobacter </li></ul></ul><ul><ul><li>Citrobacter </li></ul></ul><ul><ul><li>S. epidermidis; S. aureus </li></ul></ul><ul><ul><li>E. faecalis </li></ul></ul>Campbell’s Urology – 9th Edition; vol. 1; p. 269.
  23. 23. Pielonefrite Aguda Campbell’s Urology – 9th Edition; vol. 1; p. 266.
  24. 24. Pielonefrite Aguda Campbell’s Urology – 9th Edition; vol. 1; p. 266.
  25. 25. Pielonefrite Aguda Campbell’s Urology – 9th Edition; vol. 1; p. 269.
  26. 26. Pielonefrite Aguda Campbell’s Urology – 9th Edition; vol. 1; p. 269.
  27. 27. Pielonefrite Aguda Campbell’s Urology – 9th Edition; vol. 1; p. 270.
  28. 28. Pielonefrite Aguda Guidelines on urological infections – EAU 2009.
  29. 29. Nefrite Focal <ul><li>Infecção restrita a um único lobo renal ou múltiplos lobos (multifocal) </li></ul><ul><li>Forma incomum e grave de infecção renal (fase inicial de abscesso renal ? ) </li></ul><ul><li>Associação com diabetes – 50% </li></ul>Campbell’s Urology – 9th Edition; vol. 1; p. 271.
  30. 30. Nefrite Focal <ul><li>Quadro clínico semelhente à pielonefrite, com maior gravidade (sepse) </li></ul><ul><li>Bacteremia em 50% dos casos </li></ul>Campbell’s Urology – 9th Edition; vol. 1; p. 271.
  31. 31. Nefrite Focal Campbell’s Urology – 9th Edition; vol. 1; p. 272.
  32. 32. Nefrite Focal Campbell’s Urology – 9th Edition; vol. 1; p. 272.
  33. 33. Nefrite Focal Campbell’s Urology – 9th Edition; vol. 1; p. 272.
  34. 34. Nefrite Focal <ul><li>Tratamento </li></ul><ul><li>Antibiótico IV por 07 dias + VO por 07 dias </li></ul><ul><li>Exames de imagem para descartar uropatia obstrutiva, abscesso renal ou perirrenal </li></ul>Campbell’s Urology – 9th Edition; vol. 1; p. 271.
  35. 35. Pielonefrite Enfisematosa <ul><li>Infecção aguda necrotizante parenquimatosa e perirrenal </li></ul><ul><li>Complicação de pielonefrite aguda ? </li></ul><ul><li>Causada por uropatógenos formadores de gás </li></ul><ul><ul><li>E. coli </li></ul></ul><ul><ul><li>Klebisiella </li></ul></ul><ul><ul><li>Proteus </li></ul></ul>Campbell’s Urology – 9th Edition; vol. 1; p. 271 e 272.
  36. 36. Pielonefrite Enfisematosa <ul><li>Patogênese pouco compreendida </li></ul><ul><li>Maior incidência em pacientes diabéticos </li></ul><ul><li>Outros fatores: </li></ul><ul><ul><li>Hidronefrose associada a nefrolitíase </li></ul></ul><ul><ul><li>IRC </li></ul></ul>Campbell’s Urology – 9th Edition; vol. 1; p. 271 e 272.
  37. 37. Pielonefrite Enfisematosa <ul><li>Tríade clássica de pielonefrite </li></ul><ul><ul><li>Febre </li></ul></ul><ul><ul><li>Calafrios </li></ul></ul><ul><ul><li>Dor em flanco </li></ul></ul><ul><li>Pneumatúria em casos de invasão para sistema coletor </li></ul>Campbell’s Urology – 9th Edition; vol. 1; p. 271 e 272.
  38. 38. Pielonefrite Enfisematosa Campbell’s Urology – 9th Edition; vol. 1; p. 273.
  39. 39. Pielonefrite Enfisematosa Campbell’s Urology – 9th Edition; vol. 1; p. 274.
  40. 40. Pielonefrite Enfisematosa <ul><li>Tratamento </li></ul><ul><li>É considerada emergência cirúrgica </li></ul><ul><ul><li>Nefrectomia </li></ul></ul><ul><li>Pode-se tentar tratamento clínico em casos de rim funcionante, não obstruído e sem sepse </li></ul><ul><ul><li>ATB + reposição volêmica </li></ul></ul><ul><ul><li>Maioria dos casos evolui para nefrectomia </li></ul></ul>Campbell’s Urology – 9th Edition; vol. 1; p. 273.
  41. 41. Abscesso Renal <ul><li>Coleção de material purulento confinado ao parênquima renal </li></ul><ul><li>Inoculação hematogênica </li></ul><ul><ul><li>Gram + ( Staphylococci ) </li></ul></ul><ul><ul><li>Formação no córtex renal </li></ul></ul><ul><li>Infecção ascendente </li></ul><ul><ul><li>Gram – ( E. coli ) </li></ul></ul><ul><ul><li>Formação na junção córtico-medular </li></ul></ul>Campbell’s Urology – 9th Edition; vol. 1; p. 273 e 274.
  42. 42. Abscesso Renal Campbell’s Urology – 9th Edition; vol. 1; p. 275.
  43. 43. Abscesso Renal Campbell’s Urology – 9th Edition; vol. 1; p. 275.
  44. 44. Abscesso Renal Campbell’s Urology – 9th Edition; vol. 1; p. 275.
  45. 45. Abscesso Renal Campbell’s Urology – 9th Edition; vol. 1; p. 275.
  46. 46. Abscesso Perinefrético Campbell’s Urology – 9th Edition; vol. 1; p. 277.
  47. 47. Abscesso Perinefrético Campbell’s Urology – 9th Edition; vol. 1; p. 278.
  48. 48. Abscesso Renal <ul><li>Tratamento </li></ul><ul><li>Abscessos < 3 cm </li></ul><ul><ul><li>ATB de amplo espectro direcionado à etiologia </li></ul></ul><ul><li>Abscessos > 3 cm, imunodeprimidos ou falha do tratamento clínico </li></ul><ul><ul><li>Drenagem percutânea </li></ul></ul>Campbell’s Urology – 9th Edition; vol. 1; p. 275 e 276.
  49. 49. Hidronefrose Infectada e Pionefrose <ul><li>Hidronefrose infectada </li></ul><ul><li>Infecção em rim hidronefrótico </li></ul><ul><li>Pionefrose </li></ul><ul><li>Hidronefrose infectada associada a destruição do parênquima e perda acentuada da função renal </li></ul>Campbell’s Urology – 9th Edition; vol. 1; p. 276.
  50. 50. Hidronefrose Infectada e Pionefrose <ul><li>Quadro clínico </li></ul><ul><ul><li>Queda do estado geral </li></ul></ul><ul><ul><li>Febre, calafrios, dor em flanco </li></ul></ul><ul><li>Bacteriúria pode não estar presente em casos de obstrução completa </li></ul>Campbell’s Urology – 9th Edition; vol. 1; p. 276.
  51. 51. Hidronefrose Infectada e Pionefrose Campbell’s Urology – 9th Edition; vol. 1; p. 276.
  52. 52. Hidronefrose Infectada e Pionefrose Campbell’s Urology – 9th Edition; vol. 1; p. 277.
  53. 53. Hidronefrose Infectada e Pionefrose <ul><li>Tratamento </li></ul><ul><li>Antibioticoterapia </li></ul><ul><li>Drenagem da pelve renal </li></ul><ul><ul><li>Duplo J – Pacientes em fase inicial sem sepse </li></ul></ul><ul><ul><li>Nefrostomia </li></ul></ul><ul><li>Tratamento posterior da causa da obstrução </li></ul>Campbell’s Urology – 9th Edition; vol. 1; p. 276.
  54. 54. Pielonefrite Xantogranulomatosa <ul><li>Infecção renal crônica, grave e incomum </li></ul><ul><li>Associada a rim hidronefrótico e não funcionante secundário a nefrolitíase </li></ul><ul><li>Unilateral na maioria dos casos </li></ul><ul><li>feminino </li></ul><ul><li>Acúmulo de macrófagos ricos em gordura </li></ul>Campbell’s Urology – 9th Edition; vol. 1; p. 281.
  55. 55. Pielonefrite Xantogranulomatosa Campbell’s Urology – 9th Edition; vol. 1; p. 282.
  56. 56. Pielonefrite Xantogranulomatosa Campbell’s Urology – 9th Edition; vol. 1; p. 283.
  57. 57. Pielonefrite Xantogranulomatosa <ul><li>Tratamento </li></ul><ul><li>Nefrectomia quando não é possível a distinção com carcinoma de células renais </li></ul><ul><li>Nefrectomia parcial em casos de certeza diagnóstica </li></ul>Campbell’s Urology – 9th Edition; vol. 1; p. 283.
  58. 58. OBRIGADO

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