尿 路 感 染 天津中医学院第二附属医院 付滨

概 念 简称尿感 , 是指尿路内有大量微生物繁殖 炎症 , 可分为上尿路感染 ( 主要是肾孟肾炎 ) 和下尿路感染 ( 主要是膀胧炎 ), 侵入尿路均可引起尿感 , 但以细菌性尿感最为常见 , 这是本章主要介绍的内容。 常见病 , 其发病率约占总人口的 2% 。

病 因 任何细菌入侵尿路均可引起尿感 , 最常见的是革兰阴性杆菌 , 其中大肠杆菌 约占80%-90% 病 因 任何细菌入侵尿路均可引起尿感 , 最常见的是革兰阴性杆菌 , 其中大肠杆菌 约占80%-90% 无症状细菌尿、非复杂性尿路感染或首次发生的尿感常为大肠杆菌所致。 而住院期间发生的、复杂性 、反复再发的、尿路器械检查后发生的尿感 , 则多为粪链球菌、变形杆菌、克雷白杆菌和 绿脓杆菌引起 , 其中绿脓杆菌常见于尿路器械检查后 长期留置导尿管之后、肾移植以及身体抵抗力极差的患者偶见厌氧菌感染

Community-Acquired UTI E.coli S.epi & gm - enterics Enterococcus Proteus S.saprophyticus K.pneumoniae

Nosocomial UTI catheter associated Short Term Long Term E.coli Enterobacter E.coli Proteus Enterococcus Candida Proteus Providencia S.aureus Morganella Pseudomonas Pseudomonas

发病机制 感染途径 上行感染 血行感染 淋巴道感染 易感因素 尿路梗阻 膀胧输尿管返流及其他尿路畸形和结构异常 器械的使用 代谢因素 其他 机体抗病能力 细菌的致病力

致病性是细菌种的特征之一，具有质的概念，如鼠疫细菌引起鼠疫，结核杆菌引起结核。致病性强弱程度以毒力(Virulence)表示，是量的概念。各种细菌的毒力不同，并可因宿主种类及环境条件不同而发生变化。同一种细菌也有强毒、弱毒与无毒菌株之分。 构成病原菌毒力的主要因素是侵袭力和毒素。

K荚膜抗原 O菌体抗原 H边毛抗原

甘露糖受体

This patient was in a car accident and was paralyzed below the waist This patient was in a car accident and was paralyzed below the waist. He also had an indwelling catheter in the urinary bladder

This urinary bladder appears trabeculated This urinary bladder appears trabeculated. Explain the term "trabeculation." Do you see the reason for trabeculation and cystitis in this case?

Pseudomembranous cystitis developing in a patient with urinary bladder cancer treated with cytotoxic drugs.

Acute pyelonephritis Pathophysiology Ascending bacterial infection (P-fimbriated E. coli) of ureter results in dilation and obstruction that causes subsequent inflammation of the kidney Direct reflux of bacteria into kidney Hematogenous spread of bacteria

Histopathology  Prulent exudate consisting of neutrophils and debris are present in the renal tubules.  Note the tubular destruction and abscess (bottom half), and normal looking tubules (top half).

                                                                   Fig 1. Acute pyelonephritis is diagnosed by intratubular aggregations of polymorphonuclear neutrophils (PMNs). There may be surrounding interstitial inflammation with a mixture of PMNs, lymphocytes, and plasma cells, but the predominant inflammation is within the tubules. (Jones' Silver Stain, original magnification X200).

Fig 2. More extensive intratubular polymorphonuclear neutrophils (PMNs) are present in this case of acute pyelonephritis. The PMNs are easily recognizable by their multilobed irregular nuclei. There is associated tubular degeneration and necrosis, but only minimal interstitial changes. (Jones' Silver Stain, original magnification X200).

Chronic pyelonephritis Pathophysiology Infection of the urinary tract. Normally, valves in the ureter close during urination to prevent urine from being simultaneously forced back into the kidneys. With valve failure, infected urine squirts upwards, and infects the kidney. Repeated attacks cause chronic pyelonephritis. Kidney stones may also cause this disorder.

Chronic pyelonephritis Histopathology  Note the thyroidization, i.e., many dilated tubules with hyaline casts. Patchy presence of inflammatory cells.

临床表现 膀胱炎 急性肾盂肾炎 慢性肾盂肾炎

临床表现 膀胱炎： 主要表现为膀胱刺激症 , 即尿频、尿急、尿痛 。 白细胞尿 , 偶可有血尿，甚至肉 眼血尿。

临床表现 膀胱炎 急性膀胱炎：仅有膀胱刺激征 频发膀胱炎： 复发 重新感染

临床表现 急性肾盂肾炎 泌尿系统：膀胱刺激症、腰痛和 / 或下腹部痛、肋脊角及输尿管点压痛、肾区压痛叩击痛 全身感染：寒战、发热、头痛、恶心、呕吐、食欲不振等 , 常伴有血白细胞计数升高和血 沉增快

临床表现 慢性肾盂肾炎 少数可间歇发生症状性肾盂肾炎 但更为常见的是间歇性无症状细菌尿和间 歇性尿急、尿频等下尿路感染症状

International classification of vesicoureteral reflux International classification of vesicoureteral reflux. Grade I, ureter only; Grade II, ureter, pelvis, calyces; no dilatation, normal calyceal fornices; Grade 111, mild or moderate dilatation and/or tortuosity of ureter, and mild or moderate dilatation of the pelvis, but no or slight blunting of the fornices; Grade IV, moderate dilatation and/or tortuosity of ureter, and mild dilatation of renal pelvis and calyces; complete obliteration of sharp angle of fornices, but maintenance of papillary impressions in majority of calyces; Grade V, gross dilatation and tortuosity of ureter; gross dilatation of renal pelvis and calyces, papillary impressions are no longer visible in majority of calyces. (Adapted from International Reflux Committee: Medical versus surgical treatment of primary vesicoureteral reflux. Pediatrics 67:392, 1981; with permission.)

Chronic pyelonephritis Acute pyelonephritis Chronic pyelonephritis Symptoms  High fever Shaking chills Nausea Vomiting Diarrhea Symptoms  Seldom causes symptoms until the condition is well-established. Increased urination Nausea Itching skin

并发症 肾乳头坏死 肾周围脓肿 革兰阴性杆菌败血症 败血症是指细菌进入血循环，并在其中生长繁殖、产生毒素而引起的全身性严重感染。临床表现为发热、严重毒血症状、皮疹瘀点、肝脾肿大和白细胞数增高等。革兰阳性球菌败血症易发生迁徙病灶；革兰阴性杆菌败血症易合并感染性休克。当败血症伴有多发性脓肿时称为脓毒败血症。

实验室及其他检查 血常规 急性肾盂肾炎时 , 血白细胞可轻或中度增加 , 中性白细胞常增多 尿常规 尿色在含脓、血较多时呈混浊。尿沉渣镜检白细胞> 5 个 /HP, 可有红细胞 , 少数出现肉眼血尿 尿细菌学:常取清洁中段尿培养及进行药敏试验 其他实验室检查 慢性肾孟肾炎可出现肾小管功能减退 , 晚期血尿素氮及血肌酶升高 影像学

诊断 急性膀胱炎 尿路刺激症及尿白细胞增多,尿细菌培养阳性 急性肾盂肾炎 根据全身、局部症状和体征，血、尿常规白细胞增多，尿细菌培养阳性 慢性肾盂肾炎 尿感反复发作史，尿检白细胞增多，尿浓缩功能下降，尿细菌培养阳性，影像学检查一侧肾脏缩小，肾盂形状异常

复杂 性UTI 常发生于尿路存在解剖或功能异常的患者，包括泌尿系统本身的疾病如肾脏结石、前列腺增 生等，也包括留置导尿管等。这类感染的致病菌多为耐药菌株，较难治愈，对肾功能造成长 时间损害的危险性也明显增加

鉴别诊断 全身性感染疾病 肾结核：肾结核膀胱刺激症多明显，晨尿结核杆菌培养阳性，尿沉渣可找到抗酸杆菌 尿道综合征 仅有膀胱刺激征，而无脓尿及细菌尿，多于中年妇女，尿频较排尿不适更突出，有长期使用抗生素而无效的病史

Chronic pyelonephritis and hydronephrosis Chronic pyelonephritis and hydronephrosis. Note asymmetrical involvement of kidneys. Both kidneys are involved but one is more severely involved with marked atrophy and the parenchyma and features of end stage renal disease.

Pyelonephritis

治疗 治疗原则 : 积极彻底进行抗菌治疗 , 消除诱发因素 , 防止复发 。 一般治疗：卧床休息，多饮水，给与足够的热量及维生素 抗菌治疗 祛除诱因 对尿路感染尤其是慢性肾盂肾炎 , 首先应积极寻找易感因素并尽力祛除

抗菌治疗 急性膀胱炎 对无复杂因素存在的急性膀胱炎，常用单剂抗生素治疗。如复方新诺明 、氟哌酸，对有多次发作者，可给予治疗 3 天 急性肾盂肾炎 尿标本采集后应立即进行治疗，一般首选革兰阴性杆菌有效的抗生素，以后应参照药敏报告用药 慢性肾孟肾炎 急性发作时，治疗同急性肾孟肾炎。反复发作者，应根据病情和参考药敏试验结果制定治疗方案

预防 女性应注意月经期、妊娠期、性生活时的会阴部清洁。积极治疗阴道炎、宫颈炎等 女婴应注意会阴及尿布卫生 男性应积极治疗前列腺炎，避免或减少导尿和尿路器械检查