MANEJO ACTUALIZADO DE LAS INFECCIONES URINARIAS

Presentación del tema: "MANEJO ACTUALIZADO DE LAS INFECCIONES URINARIAS"— Transcripción de la presentación:

1 MANEJO ACTUALIZADO DE LAS INFECCIONES URINARIAS
Laura Sánchez. Sección de Nefrología. MANEJO ACTUALIZADO DE LAS INFECCIONES URINARIAS When a patient has a leak after bariatric surgery we can say that we are in front of one of the most severe complications. These leaks usually occurr at he upper end of the staple line below te EG junction, near the previous Hiss angle. Size of leaks is variable but they are ussualy small. But size is not directly proportional to the severity of this complication. We have seen small leaks producing a gastro-bronchial fistula and on the contrary big leaks with a easier resolution. All leaks are risky and if unproperly treated can lead to life-threatening situations and long-term morbidity and mortality

2 DEFINICIÓN Es una de las infecciones bacterianas más frecuentes, sobre todo en sexo femenino. 50% de mujeres tendrán ITU a lo largo de su vida Infección urinaria es la colonización y multiplicación de cualquier microorganismo, habitualmente bacterias, en el aparato urinario: Cistitis Uretritis Prostatitis Pielonefritis Why do leaks occur almost always at the same place? We have always defended narrow sleeves in order to reach better weight loss. Etiology of leaks are isquemic or mechanical. In SG vessel of the lesser curvature are preserved, so mechanical causes are more probable. It may due to an increase intragastric pressure, in a narrow and long cavity (> 35 cm. in length), with low compliance and probable immediate stasis after surgery. To date few manometric studies are available after SG. 2

3 DEFINICIÓN Bacteriuria: presencia de bacterias en orina.
Bacteriuria significativa: ≥ UFC/ml en 2 cultivos consecutivos por micción espontánea en mujeres (1 cultivo en hombres), > 1000 UFC/ml por sondaje o cualquier cantidad por punción suprapúbica. Bacteriuria asintomática: bacteriuria significativa sin síntomas. Cistitis: síndrome miccional y piuria. Piuria: ≥ 10 leucocitos/campo en orina centrifugada. Why do leaks occur almost always at the same place? We have always defended narrow sleeves in order to reach better weight loss. Etiology of leaks are isquemic or mechanical. In SG vessel of the lesser curvature are preserved, so mechanical causes are more probable. It may due to an increase intragastric pressure, in a narrow and long cavity (> 35 cm. in length), with low compliance and probable immediate stasis after surgery. To date few manometric studies are available after SG. 3

4 MUESTRA DE ORINA Ideal la de primera hora de la mañana a mitad del chorro (es más concentrada y las bacterias se han multiplicado durante la noche). El resto del día la orina es más diluida y puede disminuir la cuenta de colonias. Sospecha de prostatitis: analizar las últimas gotas de orina tras masaje prostático. Enviar de forma inmediata o meter en nevera a 4ºC (si no, la bacteria sigue proliferando y aumenta la cuenta bacteriana). Why do leaks occur almost always at the same place? We have always defended narrow sleeves in order to reach better weight loss. Etiology of leaks are isquemic or mechanical. In SG vessel of the lesser curvature are preserved, so mechanical causes are more probable. It may due to an increase intragastric pressure, in a narrow and long cavity (> 35 cm. in length), with low compliance and probable immediate stasis after surgery. To date few manometric studies are available after SG. 4

5 MUESTRA DE ORINA La ITU sin piuria es inusual.
La piuria asintomática sin bacteriuria puede ser por: leucocitos vaginales, nefritis intersticial, nefrolitiasis, tumor uroepitelial. La piuria sin bacteriuria y con síndrome miccional: Chlamydia, ureaplasma urealyticum o tuberculosis. Nitritos positivos: indican la existencia de Enterobacterias que convierten los nitratos de la orina a nitritos (un test + suele reflejar ≥ UFC/ml de Enterobacterias). Leucoesterasa: detecta piuria. Why do leaks occur almost always at the same place? We have always defended narrow sleeves in order to reach better weight loss. Etiology of leaks are isquemic or mechanical. In SG vessel of the lesser curvature are preserved, so mechanical causes are more probable. It may due to an increase intragastric pressure, in a narrow and long cavity (> 35 cm. in length), with low compliance and probable immediate stasis after surgery. To date few manometric studies are available after SG. 5

6 BACTERIURIA ASINTOMÁTICA
Se debe hacer despistaje y tratamiento en: Embarazo Antes de procedimiento urológico Tras 48 horas de retirada de sonda vesical en mujeres Niños con alteraciones del tracto urinario No hacer despistaje y tratamiento: Mujeres diabéticas (5 veces más ITU) Ancianos institucionalizados Portadores de sonda vesical Pacientes con daño medular Trasplantados e inmunodeprimidos Why do leaks occur almost always at the same place? We have always defended narrow sleeves in order to reach better weight loss. Etiology of leaks are isquemic or mechanical. In SG vessel of the lesser curvature are preserved, so mechanical causes are more probable. It may due to an increase intragastric pressure, in a narrow and long cavity (> 35 cm. in length), with low compliance and probable immediate stasis after surgery. To date few manometric studies are available after SG. 6

7 BACTERIURIA ASINTOMÁTICA
Se produce por ascenso de bacterias uretrales a vejiga procedentes del área periuetral, vagina e intestino. Es más frecuente en mujeres y su prevalencia aumenta con la edad. Es más frecuente en gestantes (2-9%), sondadas (50%), diabéticas (8-17%) e institucionalizadas (15-50%). El estreñimiento predispone a la bacteriuria. Las mujeres con BA no tinen aumento de mortalidad ni deterioro de la función renal. Why do leaks occur almost always at the same place? We have always defended narrow sleeves in order to reach better weight loss. Etiology of leaks are isquemic or mechanical. In SG vessel of the lesser curvature are preserved, so mechanical causes are more probable. It may due to an increase intragastric pressure, in a narrow and long cavity (> 35 cm. in length), with low compliance and probable immediate stasis after surgery. To date few manometric studies are available after SG. 7

8 BACTERIURIA ASINTOMÁTICA
Germen: Escherichia coli (80-90%). Alteraciones del tracto urinario, cuerpos extraños o antimicrobianos repetidos: Pseudomona aeruginosa, enterococo, estafilococo coagulasa negativo o estafilococo saprofítico (mujeres). La prevalencia de BA aumenta con la edad, actividad sexual, espermicidas y diafragmas Su tratamiento se asocia a un incremento en la frecuencia de infección sintomática post-antimicrobiano en premenopaúsicas, diabéticas, ancianos, parapléjicos, sondados e inmunodeprimidos (HIV). Why do leaks occur almost always at the same place? We have always defended narrow sleeves in order to reach better weight loss. Etiology of leaks are isquemic or mechanical. In SG vessel of the lesser curvature are preserved, so mechanical causes are more probable. It may due to an increase intragastric pressure, in a narrow and long cavity (> 35 cm. in length), with low compliance and probable immediate stasis after surgery. To date few manometric studies are available after SG. 8

9 CISTITIS AGUDA EN MUJERES
El coito es el factor de riesgo más importante en la cistitis no complicada. Disuria, frecuencia miccional, urgencia miccional, dolor suprapúbico, hematuria. La uretritis y vaginitis también causan disuria pero no frecuencia y urgencia miccional (flujo vaginal, prurito, dispareunia) Practicamente siempre hay piuria. La hematuria no predice complicación. La hematuria descarta uretritis o vaginitis. Why do leaks occur almost always at the same place? We have always defended narrow sleeves in order to reach better weight loss. Etiology of leaks are isquemic or mechanical. In SG vessel of the lesser curvature are preserved, so mechanical causes are more probable. It may due to an increase intragastric pressure, in a narrow and long cavity (> 35 cm. in length), with low compliance and probable immediate stasis after surgery. To date few manometric studies are available after SG. 9

10 CISTITIS AGUDA EN MUJERES
De elección: Septrin forte: días (igual efectividad) De segunda elección: quinolona 3-7 días o nitrofurantoina 100 mg/12 h 5 días (creciente resistencia a quinolonas) Amoxicilina-clavulánico no es eficaz 3 días. Dosis única de fosfomicina menos efectiva que ciprofloxacino o Septrin Se desaconseja la hidratación porque diluye la orina y puede reducir la concentración urinaria de antimicrobianos NO hacer cultivo post-tratamiento en mujer asintomática (no se trata la BA) Why do leaks occur almost always at the same place? We have always defended narrow sleeves in order to reach better weight loss. Etiology of leaks are isquemic or mechanical. In SG vessel of the lesser curvature are preserved, so mechanical causes are more probable. It may due to an increase intragastric pressure, in a narrow and long cavity (> 35 cm. in length), with low compliance and probable immediate stasis after surgery. To date few manometric studies are available after SG. 10

11 ITU. RECURRENTE EN MUJERES
NO predisponen a HTA o nefropatía. Frecuente en mujeres con tracto urinario normal. Son uropatógenos de la flora rectal. Es más frecuente la reinfección (tras 2 semanas de completar el tratamiento) que la recidiva. No se asocia con micción pre-postcoital, aseo personal, tampones, contraceptivos orales o uso de pantis. Se asocia a incontinencia, cistocele o residuo postmiccional. Why do leaks occur almost always at the same place? We have always defended narrow sleeves in order to reach better weight loss. Etiology of leaks are isquemic or mechanical. In SG vessel of the lesser curvature are preserved, so mechanical causes are more probable. It may due to an increase intragastric pressure, in a narrow and long cavity (> 35 cm. in length), with low compliance and probable immediate stasis after surgery. To date few manometric studies are available after SG. 11

12 ITU. RECURRENTE EN MUJERES
We have been trying to prevent the existence of a leak since the moment of the construction of the sleeve gastrectomy. Postoperatively, if Methylene blue and/or Gastrografin tests demonstate a leak we have several alternatives: If they are found during the early postoperative course, reoperation and surgical management with sutures, eventual resection and reconstruction of anastomosis may be effective. But in many cases, inflammatory changes are present in the surrounding tissues and leakage may recur. Operative treatment is the mainstay for patients with signs of sepsis and haemodinamic instability. RNY as a remedial operation in this conditions may be a good option. It means the conversion of a LSG into a modified GBP. On the other hand, stable patients with minimal clinical signs or patients that develop fistulas during the late postoperative course, may be managed conservatively with proper drainage, total parenteral nutrition or distal enteral feeding, and antibiotics. Enteral feeding must be initiated early during the treatment as nutrition is important for leak closure. Others have suggested the use of fibrin sealant applied endoscopically to close the fistula and also the use of percutaneous microcoil embolization via the fistula tract (Target Vascular Boston Scientific). Nevertheless, not all fistulas will close with this type of therapy. The placement of CSES can temporally bypass the site of leakage and allow the patients to maintain enteral nutrition until complete closure of the leak. Patients can be discharged from hospital tolerating soft-food and normal diets. If stents fail or the leak is persistent surgical reparation should be planned. RNY is our preferred option, and TG should be an alternative if leak relapses.

13 ITU. RECURRENTE EN MUJERES
ESTRATEGIAS DE PREVENCIÓN: NO usar espermicidas, sobre todo asociados a diafragmas. Vaciar la vejiga tras el coito (no demostrado). Zumo de arándanos (300 ml diarios o cápsulas): inhibe la adherencia de uropatógenos a células uroepiteliales. Crema de estrógenos vaginal en postmenopaúsicas: aumenta los lactobacilos y reduce la colonización vaginal de E. coli (menor incidencia de ITU). Why do leaks occur almost always at the same place? We have always defended narrow sleeves in order to reach better weight loss. Etiology of leaks are isquemic or mechanical. In SG vessel of the lesser curvature are preserved, so mechanical causes are more probable. It may due to an increase intragastric pressure, in a narrow and long cavity (> 35 cm. in length), with low compliance and probable immediate stasis after surgery. To date few manometric studies are available after SG. 13

14 ITU. RECURRENTE EN MUJERES
PROFILAXIS (muy efectiva 95%): Indicación: ≥ 2 ITU sintomáticas en 6 meses o ≥ 3 en 1 año. Se debe erradicar la ITU previa con cultivo negativo tras 1-2 semanas del tratamiento. Tipos: Continua 6-12 meses. Septrin 0-0-1, nitrofurantoina 50 mg en dosis única nocturna. Postcoital. Septrin, nitrofurantoina 50 mg, cefalexina 250 mg, quinolonas (norfloxacina 200 mg). Why do leaks occur almost always at the same place? We have always defended narrow sleeves in order to reach better weight loss. Etiology of leaks are isquemic or mechanical. In SG vessel of the lesser curvature are preserved, so mechanical causes are more probable. It may due to an increase intragastric pressure, in a narrow and long cavity (> 35 cm. in length), with low compliance and probable immediate stasis after surgery. To date few manometric studies are available after SG. 14

15 EMBARAZO BACTERIURIA ASINTOMÁTICA: 2-9%, sobre todo multíparas
la dilatación ureteral del embarazo, facilita el ascenso de bacterias de vejiga a riñón (>40% de BA progresa a pielonefritis)  riesgo: nacimiento prematuro, bajo peso, mortalidad perinatal Screening semanas. Re-screening solo en mujeres de riesgo Tratar cualquier cultivo positivo, repetir tras 1 semana y mensualmente hasta el parto Why do leaks occur almost always at the same place? We have always defended narrow sleeves in order to reach better weight loss. Etiology of leaks are isquemic or mechanical. In SG vessel of the lesser curvature are preserved, so mechanical causes are more probable. It may due to an increase intragastric pressure, in a narrow and long cavity (> 35 cm. in length), with low compliance and probable immediate stasis after surgery. To date few manometric studies are available after SG. 15

16 EMBARAZO BACTERIURIA ASINTOMÁTICA: Recomendado:
Nitrofurantoína 100 mg/12 h 5-7 días (Furantoina 50 mg ®) Cefpodoxima 100 mg/12 h 3-7 d (Otreon 100 ®) Amoxicilina-clavulánico 500 mg/12 h 3-7 d Fosfomicina 3 gramos dosis única (Monurol ® ) Profilaxis: cuando hay BA persistente tras ≥ 2 ciclos de tratamiento: Nitrofurantína mg at bedtime Cefalexina mg at bedtime Why do leaks occur almost always at the same place? We have always defended narrow sleeves in order to reach better weight loss. Etiology of leaks are isquemic or mechanical. In SG vessel of the lesser curvature are preserved, so mechanical causes are more probable. It may due to an increase intragastric pressure, in a narrow and long cavity (> 35 cm. in length), with low compliance and probable immediate stasis after surgery. To date few manometric studies are available after SG. 16

17 EMBARAZO CISTITIS AGUDA: Tratamiento igual que en BA.
Se puede dar trimetoprim-sulfametoxazol en el 2º trimestre (Septrin 160/800 forte ®). Evitar quinolonas. Profilaxis: si hay ITU recurrente. en diabetes se hace profilaxis tras la 1ª ITU del embarazo. en historia de ITU recurrente pre-embarazo, se recomienda profilaxis. Why do leaks occur almost always at the same place? We have always defended narrow sleeves in order to reach better weight loss. Etiology of leaks are isquemic or mechanical. In SG vessel of the lesser curvature are preserved, so mechanical causes are more probable. It may due to an increase intragastric pressure, in a narrow and long cavity (> 35 cm. in length), with low compliance and probable immediate stasis after surgery. To date few manometric studies are available after SG. 17

18 EMBARAZO PIELONEFRITIS AGUDA: La mayoría en el segundo trimestre.
Hospitalización. Antibióticos iv. hasta 24 horas afebril. Ceftriaxona o ampicilina más gentamicina días. No usar quinolonas. Pielonefritis recurrente. Ocurre en 6-8% de los embarazos. Se ha de hacer profilaxis con nitrofurantoína o cefalexina. Why do leaks occur almost always at the same place? We have always defended narrow sleeves in order to reach better weight loss. Etiology of leaks are isquemic or mechanical. In SG vessel of the lesser curvature are preserved, so mechanical causes are more probable. It may due to an increase intragastric pressure, in a narrow and long cavity (> 35 cm. in length), with low compliance and probable immediate stasis after surgery. To date few manometric studies are available after SG. 18

19 SONDA VESICAL La bacteria puede entrar en vejiga por vía extraluminal (exudado uretral) o intraluminal (drenaje o bolsa de orina). En sondaje permanente: 100% de ITU. Retirar la sonda lo antes posible. Insertar con técnica estéril y evitar tracción. Ducharse con agua y jabón. Desinfectantes y lubricantes uretrales antibacterianos NO previenen la ITU. Irrigación antimicrobiana de la vejiga NO previene ITU y puede crear resistencias. Why do leaks occur almost always at the same place? We have always defended narrow sleeves in order to reach better weight loss. Etiology of leaks are isquemic or mechanical. In SG vessel of the lesser curvature are preserved, so mechanical causes are more probable. It may due to an increase intragastric pressure, in a narrow and long cavity (> 35 cm. in length), with low compliance and probable immediate stasis after surgery. To date few manometric studies are available after SG. 19

20 SONDA VESICAL NO está indicada la profilaxis antibiótica.
Sacar el cultivo del catéter pero no de la bolsa de drenaje. NO screening ni tratamiento de la BA en sondados excepto en embarazadas o antes de procedimiento urológico. Siempre que haya fiebre, sacar urino y hemocultivos (no da signos típicos de ITU). Las bacteriurias suelen ser polimicrobianas. Profilaxis previa al recambio de sonda SOLO en inmunodeprimidos y pacientes con riesgo de endocarditis. Why do leaks occur almost always at the same place? We have always defended narrow sleeves in order to reach better weight loss. Etiology of leaks are isquemic or mechanical. In SG vessel of the lesser curvature are preserved, so mechanical causes are more probable. It may due to an increase intragastric pressure, in a narrow and long cavity (> 35 cm. in length), with low compliance and probable immediate stasis after surgery. To date few manometric studies are available after SG. 20

21 SONDA VESICAL Es una infección complicada y se trata días con cefotaxima iv o ceftriaxona o ciprofloxacino o levofloxacino. Sospecha de Pseudomona: ceftazidima o cefepime. Enterococo: ampicilina o vancomicina. Mejor sondaje intermitente que prolongado (menos BA y ITU sintomática). En ITU en sondaje prolongado: antibiótico y cambio de sonda. Why do leaks occur almost always at the same place? We have always defended narrow sleeves in order to reach better weight loss. Etiology of leaks are isquemic or mechanical. In SG vessel of the lesser curvature are preserved, so mechanical causes are more probable. It may due to an increase intragastric pressure, in a narrow and long cavity (> 35 cm. in length), with low compliance and probable immediate stasis after surgery. To date few manometric studies are available after SG. 21

22 ITU. EN EL HOMBRE CAUSAS DE BAJA INCIDENCIA DE ITU.:
atmósfera periuretral más seca mayor longitud de la uretra sustancias antibacterianas en fluído prostático TIPOS DE ITU: Complicadas: en recién nacido (Proteus por colonización del prepucio en primer año), niño y ancianos (alteraciones urológicas) No complicadas (15-50 a): sexo anal, coito con mujer con ITU o ausencia de circuncisión Why do leaks occur almost always at the same place? We have always defended narrow sleeves in order to reach better weight loss. Etiology of leaks are isquemic or mechanical. In SG vessel of the lesser curvature are preserved, so mechanical causes are more probable. It may due to an increase intragastric pressure, in a narrow and long cavity (> 35 cm. in length), with low compliance and probable immediate stasis after surgery. To date few manometric studies are available after SG. 22

23 ITU. EN EL HOMBRE SE TRATA LA BACTERIURIA ASINTOMÁTICA
antes de RTU prostática antes de procedimientos urológicos DIAGNÓSTICO DIFERENCIAL: Prostatitis crónica, sobre todo en ITU recurrente (foco prostático de E. coli, otras enterobact, enterococo fecalis o Chlamydia) Uretritis, sobre todo si hay úlceras en pene o exudación uretral CUALQUIER HOMBRE CON CISTITIS SIN FACTORES DE RIESGO, DEBE ESTUDIARSE. Why do leaks occur almost always at the same place? We have always defended narrow sleeves in order to reach better weight loss. Etiology of leaks are isquemic or mechanical. In SG vessel of the lesser curvature are preserved, so mechanical causes are more probable. It may due to an increase intragastric pressure, in a narrow and long cavity (> 35 cm. in length), with low compliance and probable immediate stasis after surgery. To date few manometric studies are available after SG. 23

24 ITU. EN EL HOMBRE TRATAMIENTO CISTITIS NO COMPLICADA:
Quinolonas o Septrin 7 días (no 3 días) No usar nitrofurantoína o betalactámicos (ineficaces en prostatitis oculta) TRATAMIENTO CISTITIS COMPLICADA: ciprofloxacino 500 mg/12 h o levofloxacino mg/24 h 7-14 días No usar moxifloxacino (menor nivel en vía urinaria) SI NO HAY MEJORÍA CLÍNICA EN HORAS, REPETIR EL URINOCULTIVO. Why do leaks occur almost always at the same place? We have always defended narrow sleeves in order to reach better weight loss. Etiology of leaks are isquemic or mechanical. In SG vessel of the lesser curvature are preserved, so mechanical causes are more probable. It may due to an increase intragastric pressure, in a narrow and long cavity (> 35 cm. in length), with low compliance and probable immediate stasis after surgery. To date few manometric studies are available after SG. 24

25 ITU. EN POLIQUISTOSIS A.D.
Lo más frecuente son los quistes infectados y la pielonefritis aguda, que pueden afectar a riñones no funcionantes. En pielonefritis aguda puede haber cilindros leucocitarios y el urinocultivo suele ser +. Hay dolor lumbar difuso. En los quistes infectados el sedimento suele ser normal y el urinocultivo suele ser -. Hay dolor a la exploración en un área concreta. Los hemocultivos suelen ser positivos. Piuria sin ITU en 45% de las PQR. Why do leaks occur almost always at the same place? We have always defended narrow sleeves in order to reach better weight loss. Etiology of leaks are isquemic or mechanical. In SG vessel of the lesser curvature are preserved, so mechanical causes are more probable. It may due to an increase intragastric pressure, in a narrow and long cavity (> 35 cm. in length), with low compliance and probable immediate stasis after surgery. To date few manometric studies are available after SG. 25

26 ITU. EN POLIQUISTOSIS A.D.
TAC o RM: cambios en quiste similares en infección o hemorragia. Si dolor lumbar: DD pielonefritis, infección de quiste renal o hemorragia intraquística. Ausencia de fiebre: hemorragia intraquística o aumento de tamaño del quiste (la hemorragia puede dar fiebre transitoria y leucocitosis). Why do leaks occur almost always at the same place? We have always defended narrow sleeves in order to reach better weight loss. Etiology of leaks are isquemic or mechanical. In SG vessel of the lesser curvature are preserved, so mechanical causes are more probable. It may due to an increase intragastric pressure, in a narrow and long cavity (> 35 cm. in length), with low compliance and probable immediate stasis after surgery. To date few manometric studies are available after SG. 26

27 ITU. EN POLIQUISTOSIS A.D.
Quinolonas, trimetoprim-sulfametoxazol o cloranfenicol consiguen concentraciones terapeúticas en los quistes (aminoglucósidos y penicilina no penetran en quiste). Elección: ciprofloxacino iv. PNF aguda: días. Quiste infectado: 4-6 semanas, y si recaen 2-3 meses. A veces se ha de asociar drenaje del quiste. Why do leaks occur almost always at the same place? We have always defended narrow sleeves in order to reach better weight loss. Etiology of leaks are isquemic or mechanical. In SG vessel of the lesser curvature are preserved, so mechanical causes are more probable. It may due to an increase intragastric pressure, in a narrow and long cavity (> 35 cm. in length), with low compliance and probable immediate stasis after surgery. To date few manometric studies are available after SG. 27

28 INFECCIONES POR HONGOS
La candiduria es frecuente en hospitalizados (drenaje urinario, antibióticos, diabetes, patología del tracto urinario o tumores malignos). La mayoría son contaminación y no infección. Los infectados pueden tener síndrome miccional o estar asintomáticos. La candiduria puede ser fuente de candidemia en obstrucción o en procedimientos sobre el tracto urinario. Why do leaks occur almost always at the same place? We have always defended narrow sleeves in order to reach better weight loss. Etiology of leaks are isquemic or mechanical. In SG vessel of the lesser curvature are preserved, so mechanical causes are more probable. It may due to an increase intragastric pressure, in a narrow and long cavity (> 35 cm. in length), with low compliance and probable immediate stasis after surgery. To date few manometric studies are available after SG. 28

29 INFECCIONES POR HONGOS
El riñón es el órgano más afectado en infección sistémica por Cándida (bilateral y con microabscesos en córtex y médula). No suele afectar la función renal. Puede haber necrosis papilar: la papila es un nido para la formación de un bezoar (bola de hongo). Puede haber infarto renal embólico en endocarditis por Cándida. Puede haber absceso perinéfrico. Why do leaks occur almost always at the same place? We have always defended narrow sleeves in order to reach better weight loss. Etiology of leaks are isquemic or mechanical. In SG vessel of the lesser curvature are preserved, so mechanical causes are more probable. It may due to an increase intragastric pressure, in a narrow and long cavity (> 35 cm. in length), with low compliance and probable immediate stasis after surgery. To date few manometric studies are available after SG. 29

30 INFECCIONES POR HONGOS
TTO. CANDIDURIA ASINTOMÁTICA: En neutropenia, neonatos de bajo peso o manipulación del tracto urinario (fluconazol mg varios días antes y después). Trasplante: no es indicación absoluta de tto. TTO. CANDIDURIA SINTOMÁTICA: Fluconazol 200 mg/día ( días en PNF) Anfotericina B iv. en resistencia a fluconazol (1-7 días en cistitis y 14 días en PNF) NO irrigación de vejiga con anfotericina B (efecto transitorio) NO formulación lipídica de anfotericina B (no adecuada concentración en orina) Flucitosina, asociada a anfotericina B en resistencia a fluconazol Why do leaks occur almost always at the same place? We have always defended narrow sleeves in order to reach better weight loss. Etiology of leaks are isquemic or mechanical. In SG vessel of the lesser curvature are preserved, so mechanical causes are more probable. It may due to an increase intragastric pressure, in a narrow and long cavity (> 35 cm. in length), with low compliance and probable immediate stasis after surgery. To date few manometric studies are available after SG. 30