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Bacterial Urinary Tract Infections

Author(s):
Osborne C.A. and
Lulich J. P.
In: Mechanisms of Disease in Small Animal Surgery (3rd Edition) by Bojrab M.J. and Monnet E.
Updated:
JUL 28, 2014
Languages:
  • EN
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    In context of surgery, conceptual understanding of alterations in interactions between host defenses and pathogenic microbes that result in bacterial urinary tract infections (UTI) are important for at least two reasons. First, many surgical procedures designed to correct noninfectious disorders of the urinary tract may partially or totally interfere with local host defenses that normally prevent or impair development of UTI. Second, surgical correction of abnormalities that affect host defense mechanisms may be a prerequisite to preventing recurrent or persistent bacterial UTI.

    Why is it Important to Recognize that Bacterial Urinary Tract Infection is not a Primary Diagnostic Entity?

    Although the urinary tract communicates with an external environment loaded with bacteria and other potentially pathogenic agents, most of it is normally sterile and all of it is normally resistant to infection. As with all systems of the body, resistance to urinary tract infection is dependent on the interaction of several host defense mechanisms [1]. The pathogenesis of UTIs is related to the relationship between the virulence of uropathogenic infectious agents (analogous to seeds) and the functional status of host defense mechanisms (analogous to soil; Table 65-1). Growth of bacteria (seeds) usually will not occur unless abnormalities of host defenses (suitable soil) are present. Therefore, in context of diagnosis, prognosis, and therapy, a bacterial urinary tract infection (UTI) may be viewed as a secondary (or complicating) rather than a primary (or definitive) diagnostic entity.

    Table 65-1. Natural and Acquired Urinary Tract Defenses against Bacterial Infection

    1. Normal Micturition
    1. Adequate urine volume
    2. Frequent voiding
    3. Complete voiding
    1. Anatomic Structures
    1. Urethral high-pressure zones
    2. Surface characteristics of urethral urothelium
    3. Urethral peristalsis
    4. Prostatic secretions (antibacterial fraction and immunoglobulins)
    5. Normal length of urethra
    6. Ureterovesical flap valves
    7. Ureteral peristalsis
    8. Glomerular mesangial cells?
    9. Extensive renal blood supply and flow
    1. Mucosal Defense Barriers
    1. Local antibody production
    2. Surface layer (hydrophilic glycosaminoglycans)
    3. Intrinsic mucosal cell antimicrobial properties
    4. Exfoliation of cells
    5. Commensal microbes (normal flora) of distal urethra and distal genital tract that interfere with infection by uropathogens
    1. Antimicrobial Properties of Urine
    1. Extremes (high or low) of urine pH
    2. Hyperosmolality (highly concentrated urine)
    3. High concentration of urea
    4. Organic acids
    5. Small molecular weight carbohydrates
    6. Tamm-Horsfall mucoprotein
    7. Leukocyte esterase-like substances (cats)?
    1. Systemic Immunocompetence
    1. Cell-mediated immunity
    2. Humoral-mediated immunity

    CAVEAT - In addition to focusing on antimicrobial treatment of bacterial pathogens (which are usually secondary causes of urinary tract disease), it is also important to consider detection and treatment of abnormalities in host defenses that allow bacteria to colonize and invade tissues of the urinary tract (Table 65-1 and Table 65-2). If UTIs are managed inappropriately, one or more sequelae may occur (Table 65-3). Early detection followed by proper treatment and follow-up evaluation will minimize the occurrence and severity of these sequelae.

    Table 65-2. Some Predisposing Causes of Complicated UTI

    1. Interference with Normal Micturition
    1. Mechanical obstruction to outflow
    1. Uroliths, neoplasms and strictures (especially of urethra)
    2. Herniated urinary bladder
    3. Prostatic cysts, abscesses, or neoplasms
    1. Incomplete emptying of excretory pathway
    1. Damaged innervation
    1. Vertebral fractures, luxations, subluxations, anomalies
    2. Neoplasia
    3. Reflex dyssynergia
    1. Anatomic defects
    1. Diverticula of urethra, bladder, ureters, and renal pelves.
    2. Vesicoureteral reflux
    1. Anatomic Defects
    1. Congenital or inherited
    1. Urethral anomalies
    2. Ectopic ureters
    3. Persistent urachal diverticula
    4. Vulvar abnormalities predisposing to perivulvar dermatitis
    1. Acquired
    1. Diseases of the urinary tract, especially lower portions
    2. Urethrostomy and other surgical diversion procedures
    1. Alteration of Urothelium
    1. Trauma
    1. Catheterization and other instrumentation
    2. Urolithiasis
    1. Metaplasia
    1. Administration of estrogens
    2. Estrogen-producing Sertoli cell neoplasms
    1. Neoplasia
    2. Urinary excretion of cytotoxic drugs such as cyclophosphamide
    3. Alteration of normal flora of distal urethra, prepuce, and vagina
    1. Alterations in the Volume, Frequency, or Composition of Urine
    1. Decreased urine volume
    1. Negative water balance
    2. Primary oliguric renal failure
    1. Voluntary or involuntary retention
    2. Glycosuria
    3. Formation of dilute urine
    1. Impaired Immunocompetence
    1. Diseases
    1. Congenital immunodeficiency?
    2. Acquired
    1. Hyperadrenocorticism?
    2. Uremia
    1. Corticosteroids; immunosuppressant drugs

    Table 65-3. Potential Sequela to Untreated or Improperly Treated Bacterial Urinary Tract Infections

    1. Lower urinary tract dysfunction (acute or chronic)
    1. Dysuria, pollakiuria
    2. "Urge" incontinence
    3. Damage to the detrusor muscle
    4. Damage to the urethra
    1. Prostatitis (acute or chronic)
    2. Struvite urolithiasis and its sequelae
    3. Infertility
    4. Renal dysfunction (acute or chronic)
    1. Pyelonephritis
    2. Renal failure
    3. Septicemia (especially in patients with concomitant obstruction to urine outflow)
    1. Anemia of chronic inflammation
    2. Lumbosacral discospondylitis

    What Diagnostic Classification will Facilitate Treatment of Bacterial Utis?

    Bacterial UTI encompass a wide variety of clinical entities whose common denominator is microbial invasion of any of its components. Urinary tract infections may be classified on the basis of 1) anatomic location (i.e., kidney, ureter, bladder, and/or urethra), 2) etiology (Escherichia coli, Staphylococcus intermedius, etc.), 3) complexity (uncomplicated or complicated), and/or 4) response to therapy (persistent, relapse, reinfection, or superinfection) [1-3].

    Anatomic localization of infections within the urinary tract should be considered because it may influence the prognosis; type, dosage, and dose interval of antimicrobial agent selected; and duration of therapy. Classification of UTIs based on complexity is also of prognostic and therapeutic significance because it allows differentiation of uncomplicated (or simple) urinary tract infections from complicated urinary tract infections (Table 65-1 and Table 65-2).

    Uncomplicated UTI

    An uncomplicated UTI is defined as an infection in which an underlying structural, neurologic, immunologic, or functional abnormality cannot be identified. Although useful, this classification may be misleading in that it implies that bacterial infection is the primary rather than a secondary abnormality. However, most bacteria survive and multiply only when host defenses are compromised. Many simple UTIs encompass transient and potentially reversible defects in the patient's innate defense mechanisms, even though the underlying cause may escape detection. Others occur when normal host defenses are overwhelmed by virulent uropathogens. For example, nosocomial UTI could occur as a result of improper transurethral catheterization in a hospital intensive care unit harboring resistant uropathogens. Uncomplicated UTIs might also be caused by replacement of the normal microbial flora (so-called good bacteria) of the distal urethra and genital tract with uropathogenic microbes that have emerged as a consequence of prior treatment of the patient with antibiotics. Uncomplicated UTIs are usually associated with a better prognosis for recovery.

    Complicated UTI

    Complicated UTIs occur as a result of bacterial invasion of the urinary system secondary to an identifiable disease that interferes with one or more defense mechanisms (Table 65-2) [1,2,4]. A relationship exists between the severity of host defense abnormality and the frequency and severity of UTI. In general, the abnormality in host defenses must be corrected or removed if secondary bacterial infection is to be completely eradicated and prevented from recurring. Failure or inability to do so is a common cause of persistent or recurrent UTI (relapse or reinfection).

    CAVEAT -Differentiation of uncomplicated from complicated UTIs and anatomic localization of UTI require appropriate diagnostic evaluation, which may include transrectal palpation of the genitourinary tract, ultrasonography, survey and contrast radiography, cystoscopy, and aspiration, punch, or surgical biopsy.

    Why is it Important to Differentiate UTIs According to whether they are Persistent, Relapses, Reinfections, or Superinfections?

    Relapses

    Recurrent bacterial UTIs that occur following withdrawal of therapy may be classified as relapses or reinfections (Table 65-4). Relapses (i.e., relapse of a persistent pathogen) are defined as recurrences of clinical signs caused by the same species (and serologic strain) of microbe. In this situation, remission of clinical signs and eradication of bacteria from the urine are not associated with eradication of pathogenic bacteria from tissues of the urinary tract. Although viable bacteria remain sequestered in sites inaccessible to bacteriocidal concentrations of antimicrobics, results of the culture of urine samples obtained by cystocentesis during antimicrobic therapy are likely to be negative if the drug is eliminated in high concentration in urine. Relapses of clinical signs usually occur within several days to a few weeks after interruption of antimicrobic therapy. The bacteria may become more resistant to antimicrobial agents than prior to therapy. The pathogenesis of relapsing UTI likely involves failure to completely eliminate pathogenic bacteria before antimicrobic therapy is withdrawn. Relapses represent antimicrobial treatment failures associated with one or more causes, and affect both male and female dogs throughout their lifespan (Table 65-5). Relapses have the potential to cause significant morbidity if mismanaged (Table 65-3).

    Table 65-4. Examples of Patterns of Bacteriuria Detected by Sequential Urine Cultures Performed to Monitor Response to Antimicrobial Treatment of UTI

    Time and Status of Culture of Urine for Bacteria

    Prior to Treatment

    3 to 5 Days after Initiating Treatment

    3 to 5 Days Before Finishing Treatment

    7 to 14 Days After Treatment Discontinued

    More Than 2 Weeks After Treatment Discontinued

    Interpretations

    Positive

    Positive

    Does not apply

    Does not apply

    Does not apply

    Persistent UTI;
    Treatment failure

    Positive

    Negative

    Negative

    Positive for same microbe

    Does not apply

    Relapse
    (
    Table 65-5)

    Positive

    Negative

    Negative

    Negative

    Negative

    Cure

    Positive

    Negative

    Negative

    Negative

    Positive for different microbe

    Reinfection
    (
    Table 65-6)

    Table 65-5. Checklist of Potential Causes of Recurrent UTIs Owing to Relapses

    Use of Ineffective Drugs

    1. Mixed infections with more than one type of pathogen in which all pathogens were not eradicated by antimicrobial therapy
    2. Bacteria are resistant to drug selected
    3. Antimicrobic does not attain therapeutic concentration in urine
    4. Antimicrobic does not achieve therapeutic concentrations at infection sites (especially kidneys, prostate gland, and infection-induced uroliths)
    5. Patient does not absorb a portion or all of an orally administered drug because of ingesta, gastrointestinal dysfunction, or interaction with other drugs
    6. Initiation of therapy at an advanced state in the course of the disease
    7. Acquired drug-resistant bacteria, including L-forms
    8. Host factors detrimental to drug efficacy

    Ineffective Use of Drugs

    1. Use of improper antimicrobial susceptibility tests and/or misinterpretation of results
    2. Prescription of antimicrobics for an insufficient period to eradicate uropathogens
    3. Failure to prescribe a proper dosage and/or maintenance interval for an antimicrobic that would otherwise be effective
    4. Lack of compliance characterized by failure or inability of owners to give the prescribed dosage of antimicrobic at the proper maintenance intervals and for sufficient a duration
    5. Inappropriate use of combination of drugs that interfere

    Reinfections

    Reinfections are defined as recurrent UTI caused by one or more different pathogens (Table 65-4). In this situation, bacteria have been eradicated from urine and surrounding tissue, but persistent dysfunction of one or more host defense mechanisms predisposes to reinfection with different uropathogens (Table 65-2 and Table 65-6). If superficial damage to tissues of the urinary tract induced by bacteria by the initial infection have time to heal, recurrence of clinical manifestations of reinfections often occur at a longer interval following cessation of therapy than relapses. Reinfections appear to be more common in female dogs and young to middle-aged cats with lower urinary tract disease.

    Table 65-6. Checklist of Potential causes of Recurrent UTIs owing to Reinfections

    1. Invalid culture results caused by:
    1. Contamination of specimen during collection, transport, storage, or handling
    2. Improper technique of bacterial culture of urine
    1. Continued dysfunction of host defense mechanisms (Table 65-1 and Table 65-2)
    2. Failure or inability to recognize and eliminate predisposing causes
    3. Iatrogenic infection, especially associated with transurethral catheterization
    4. Sequelae to surgical techniques that have impaired host defense function, especially urethrostomies and urine diversion procedures
    5. Spontaneous reinfection

    Superinfections

    Superinfections are defined as infections with one or more additional pathogens during the course of antimicrobial therapy [1]. They are most likely to occur in association with in-dwelling transurethral catheters; as a sequela to urinary diversion techniques (i.e., antepubic urethrostomy, tube cystostomy, percutaneous nephropyelostomy); and because of anatomic abnormalities that promote ascending migration of bacteria into the urinary tract.

    CAVEAT -The therapeutic plan for relapses often differs from the therapeutic plan for reinfections. Therefore, it is important to compare results of bacterial culture of urine obtained prior to initiation of therapy to bacterial cultures of urine obtained during and/or after withdrawal of therapy.

    Why is Diagnostic Urine Culture the Gold Standard of Diagnosis of Bacterial UTI?

    Because UTI encompasses a spectrum of underlying abnormalities in host defense mechanisms in addition to bacterial pathogens, diagnostic and therapeutic requirements vary from case to case. No pathognomonic history, physical examination, radiographic, or ultrasonographic findings are associated with bacterial UTI.

    In addition to bacterial infection, many diverse noninfectious disease processes, including neoplasia and urolithiasis, result in inflammatory lesions of the urinary tract characterized by exudation of RBC, WBC, and protein into urine. The resultant hematuria, pyuria, and proteinuria suggest inflammatory urinary tract disease, but do not indicate its cause or location within the urinary tract. Diagnosis of bacterial UTI solely on the basis of urinalysis and detection of inflammatory cells in urine sediment will result in over-diagnosis. Therefore, it is essential to distinguish between inflammation and infection related to urinary tract disease. Although detection of bacteria in fresh urine sediment should prompt consideration of UTI, it should be verified by urine culture. Non-bacterial "look-alikes" in urine sediment are often confused with bacteria [4].

    Quantitative urine culture is considered to be the gold standard for diagnosis of bacterial UTI [8]. In addition to facilitating differentiation of bacterial contaminants from bacterial pathogens, accurate identification of specific bacterial species aids in selection of antimicrobial drugs. Also recall that recurrent UTIs owing to relapses cannot be distinguished from recurrent UTIs owing to reinfections without comparison of pretreatment bacterial culture results to follow-up culture results.

    CAVEAT -Failure to perform bacterial urine cultures or failure to correctly interpret the results of urine cultures may lead not only to diagnostic errors but therapeutic failures as well. Although detection of bacteria in properly collected urine samples is highly indicative of bacterial UTI, further information is required to confirm and localize the site(s) of infection.

    How should Urine Samples be collected for Diagnostic Culture?

    We prefer to collect urine samples for bacterial culture by cystocentesis to eliminate problems of differentiating contaminants from pathogens [3]. Detection of bacteria, even in low numbers, in urine aseptically collected by cystocentesis is indicative of UTI. However, false positive results may occur if the needle penetrates a loop of intestine during cystocentesis, or if the sample is contaminated during transfer to culture media. For this reason, quantitative urine culture is routinely recommended, even for samples collected by cystocentesis. Urine culture results should be interpreted in context of other clinical findings (Table 65-7) [5].

    CAVEAT -Catheter-induced UTIs (nosocomial infections) are common in patients with urinary tract diseases, and could even result in iatrogenic pyelonephritis, renal failure, and septicemia. Therefore, transurethral catheterization of patients at increased risk for UTI should be evaluated in context of risks and benefits.

    Table 65-7. Checklist of Factors Influencing Interpretation of Qualitative Bacterial Cultures of Urine

    • Method of urine collection?
    • Time lapse between urine collection and bacterial culture?
    • Method of preservation if urine is not cultured within 30 minutes?
    • Pure or mixed culture of bacteria?
      1 isolate       in about 75% of UTI
      2 isolates     in only 20% of UTI
      3 isolates     in only 5% of UTI
    • Magnitude of inflammatory response (if any) detected by urinalysis?
    • Light microscopic detection of bacteria in uncontaminated fresh unspun urine?

    How should Urine Samples be Preserved Prior to Culture?

    If diagnostic bacterial cultures are to be performed, urine should be collected for culture before antibacterial therapy is initiated. If the patient is currently being treated with an antimicrobic, it should be discontinued for approximately 3 to 5 days prior to diagnostic urine culture in order to minimize inhibition of in vivo and in vitro bacterial growth.

    Because urine may be a good culture medium at room temperature (bacterial counts may double every 20 to 45 minutes), it should be cultured within 15 to 30 minutes from the time of collection [6]. Another indication for culture of fresh urine samples is that destruction of some fastidious bacteria may be detectable within an hour of collection. If for any reason culture of freshly collected urine samples is not possible, the samples should be kept in a sealed sterile container and immediately refrigerated following collection. Refrigerated samples may be stored for 6 to 12 hours without significant additional growth of bacteria [6]. However, it is emphasized that fastidious organisms may be killed in the urine environment if refrigeration storage time is prolonged.

    Alternatively, commercially manufactured collection tubes combined with refrigeration may be used to preserve samples for up to 72 hours. Commercially manufactured urine culture and susceptibility test kits are also available (IndicatoRx, Idexx Laboratories, Westbrook, Maine).

    CAVEAT -Transport of urine specimens to a commercial microbiology laboratory results in increased time between urine collection and aerobic culture and, therefore, adds a potential source of error, especially if the samples are not properly preserved. Freezing urine samples may also destroy bacteria.

    Why are Quantitative Bacterial Urine Cultures a Standard of Practice in the Management of Utis?

    The gold standard for diagnosis of UTI is isolation of bacteria in a properly collected urine sample. However, the presence of bacteria in urine per se is not synonymous with UTI because urine may be contaminated with bacteria as it flows through the urethra, and after it is removed from the patient, but before it is cultured. Quantitative urine culture includes determination of the number of bacteria (colony-forming units) per milliliter of urine in addition to isolation and identification of bacteria. Because it facilitates differentiation of bacteria that have contaminated the urine sample from bacteria that are likely to be causing UTI, quantitative culture is the preferred method of diagnostic culture for urine samples obtained by any collection method.

    The concept of significant bacteriuria was introduced to aid differentiation between harmless bacterial contaminants of urine and pathogenic bacteria causing infectious disease of the urinary system [1,2,7]. A high bacterial count in a properly collected and cultured urine sample indicates the high probability of UTI (Table 65-8). Small numbers of bacteria obtained from untreated patients usually indicate contamination.

    The lower limit of numbers of bacteria isolated from feline urine that indicate infection (so-called cutoff values) has not been precisely determined. However, it is usually less than that in dogs because feline urine appears to be less conducive to bacterial growth than urine of dogs (Table 65-8) [8].

    CAVEAT -When interpreting bacterial cultures, several variables should be considered (Table 65-7). In up to 20% of canine patients, bacterial UTI may be present with less than 10,000 colony-forming units per milliliter of urine [2]. In this circumstance, samples collected by catheterization or during voiding might erroneously be interpreted as contaminants (Table 65-8). This observation emphasizes the importance of cystocentesis as the preferred method of collection for diagnostic urine culture.

    Table 65-8. Interpretation-Quantitative Urine Cultures in Dogs and Cats*

    Collection Method

    Significant

    Suspicious

    Contaminant

     

    Dog

    Cat

    Dog

    Cat

    Dog

    Cat

    Cystocentesis

    ≥ 1000†

    ≥ 1000

    100 to 1000

    100 to 1000

    ≤ 100

    ≤ 100

    Catheterization

    ≥ 10,000

    ≥ 1000

    1000 to 10,000

    100 to 1,000

    ≤ 1000

    ≤ 100

    Voided midstream

    ≥ 100,000‡

    ≥ 10,000

    10,000 to 90,000

    1000 to 10,000

    ≤ 10,000

    ≤ 1000

    *The data represent generalities. On occasion, bacterial UTI may be detected in dogs and cats with the fewer numbers of organisms (i.e., false negative results).

    † Numbers represent colony-forming units of bacteria per milliliter of urine.

    ‡Caution: Contamination of midstream samples may result in colony counts of 10,000/ml or higher in some cats, and especially female dogs (i.e., false positive results). Therefore, they should not be used for routine diagnostic culture of urine.

    How can Routine Quantitative Aerobic Cultures of Urine be Adapted to a Primary Care Veterinary Practice?

    Many veterinarians do not routinely perform urine cultures because of the time and expertise required to specifically identify bacteria. However, all individuals can recognize lack of growth of bacteria on culture plates. Therefore, we recommend that veterinarians quantitatively culture urine on microbiology plates (such as blood agar and MacConkey agar) utilizing calibrated microbiologic loops [9]. If no growth occurs after incubation of the culture plates at 37° for approximately 24 hours, or if only small numbers of bacteria grow (contaminants), further efforts to identify bacterial species is unnecessary, and treatment with an antimicrobial drug is usually not warranted (Table 65-8). If significant numbers of bacteria (colony-forming units) are isolated, the microbiologic plates, or swab cultures from the plates, can then be sent to commercial laboratories for species identification and antimicrobial susceptibility tests. Therapy with an appropriate antimicrobial drug (refer to next section on empirical choices of antimicrobics) may be initiated pending results from the commercial laboratory.

    We routinely use calibrated bacteriologic inoculating loops (available from Veterinary Lab Supply, 120 S. 1st Ave., Winterset Iowa 50237) or microliter mechanical pipettes that deliver exactly 0.01 or 0.001 milliliters of urine to culture plates. To facilitate culture, urine is streaked over the surface of agar plates with the inoculating loops by conventional methods. The plates are placed in an incubator upside down at 37°C for 18 to 24 hours, and then examined for bacterial growth. Blood agar will support growth of most aerobic organisms encountered in patients with UTI. MacConkey agar provides information that aids in tentative identification of bacteria and prevents "swarming" of microbes.

    This strategy of in-hospital bacterial culture of urine not only fosters appropriate diagnosis and therapy, it is also financially sound. The fee normally paid to the diagnostic laboratory for a sterile urine culture can be rightfully earned by the veterinary hospital. This strategy also enhances use of urine cultures to monitor the effectiveness of therapy (so-called "test of effectiveness").

    CAVEAT -Before culture, urine should not be kept at room temperature or frozen. Also, urine should not be placed in enrichment broth immediately following collection to enhance bacterial growth, as this will invalidate the results of quantitative culture.

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    References

    1. Osborne CA. Bacterial Infections of the Canine and Feline Urinary Tract: Cause, Cure, and Control. In: Disease Mechanisms in Small Animal Surgery. Bojrab MJ (ed). Philadelphia: Lea & Febiger, 1993, p. 426. - Available from amazon.com -

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    How to reference this publication (Harvard system)?

    Osborne, C. A. and Lulich, J. P. (2014) “Bacterial Urinary Tract Infections”, Mechanisms of Disease in Small Animal Surgery (3rd Edition). Available at: https://www.ivis.org/library/mechanisms-of-disease-small-animal-surgery-3rd-ed/bacterial-urinary-tract-infections (Accessed: 30 March 2023).

    Affiliation of the authors at the time of publication

    Veterinary Clinical Sciences Department, College of Veterinary Medicine, University of Minnesota, St. Paul, MN, USA.

    Author(s)

    • Osborne C.A.

      DVM PhD Dipl ACVIM
      Veterinary Clinical Sciences Department, College of Veterinary Medicine, University of Minnesota
      Read more about this author
    • Lulich

      Lulich J. P.

      DVM, PhD, DACVIM
      Minnesota Urolith Center, College of Veterinary Medicine, University of Minnesota
      Read more about this author

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      Dirofilariosis Felina: abordaje clínico y situación actual en España - Argos Nº241 Supl., Septiembre 2022

      In: Argos
      SEP 30, 2022
    • Chapter

      Carpus, Metacarpus, and Phalanges

      In: Current Techniques in Small Animal Surgery (5th Edition)
      SEP 26, 2022
    • Chapter

      Radius and Ulna

      In: Current Techniques in Small Animal Surgery (5th Edition)
      SEP 16, 2022
    • Chapter

      Humerus and Elbow Joint

      In: Current Techniques in Small Animal Surgery (5th Edition)
      SEP 10, 2022
    • Chapter

      Scapula and Shoulder Joint

      In: Current Techniques in Small Animal Surgery (5th Edition)
      SEP 05, 2022
    • Chapter

      Bone Grafts and Implants

      In: Current Techniques in Small Animal Surgery (5th Edition)
      SEP 03, 2022
    • Chapter

      External Skeletal Fixation

      In: Current Techniques in Small Animal Surgery (5th Edition)
      AUG 28, 2022
    • Chapter

      Fixation with Screws and Bone Plates

      In: Current Techniques in Small Animal Surgery (5th Edition)
      AUG 15, 2022
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    This book and many other titles are available from Teton Newmedia, your premier source for Veterinary Medicine books. To better serve you, the Teton NewMedia titles are now also available through CRC Press. Teton NewMedia is committed to providing alternative, interactive content including print, CD-ROM, web-based applications and eBooks.

      

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    Teton NewMedia
    PO Box 4833
    Jackson, WY 83001
    307.734.0441
    Email: sales@tetonnm.com

    ISBN-10
    1591610389
    ISBN-13
    978-1591610380
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