Download MBBS Urology Presentations 12 Urinary Tract Infection Lecture Notes

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Introduction
Terminology
Classification of UTI
Epidemiology
Etiology

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Pathogenesis
Risk factors
Clinical presentation
Diagnosis
Treatment

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Conclusion


Introduction

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? Symptomatic presence of

micro organisms within

the urinary tract

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i.e., kidney, ureters,

bladder and urethra.

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? Associated with

inflammation of

urinary tract.

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Anatomy

vThe upper urinary tract,

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composed of the kidneys,

renal pelvis, and ureters.

v the lower urinary tract

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that consists of the

urinary bladder and the

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urethra.

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v Upper urinary tract infections affect the ureters

(ureteritis) or the renal parenchyma (pyelonephritis).

v Lower urinary tract infections may affect the urethra

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(urethritis), the bladder (cystitis), or the prostate in

males (prostatitis).

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UTI - Terminology

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v Significant bacteriuria: presence of at least 105

bacteria/ml of urine.

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v Asymptomatic bacteriuria : bacteriuria with No symptoms.

v Uncomplicated: UTI without underlying renal or

neurologic disease.

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v Complicated: UTI with underlying structural, medical or

neurologic disease.

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v Recurrent : > 3 symptomatic UTIs within 12 months

following clinical therapy.

v Reinfection: recurrent UTI caused by a different pathogen

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at any time
v Relapse: recurrent UTI caused by same species

causing original UTI within 2 wks after therapy.

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v Urethritis: infection of anterior urethral tract

v Cystitis: infection to urinary bladder

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v Acute pyelonephritis: infection of one/both kidneys;

sometimes lower tract also.

v Chronic pyelonephritis: particular type of pathology of

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kidney; may/may not be due to infection.

vPyuria

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? the presence of 10 WBC/cumm in a urine specimen,

? 1-5 white cel s per high-power field of uncentrifuged

urine,

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? or a urinary dipstick test that is positive for leukocyte

esterase.

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vSterile pyuria

- the persistent finding of white cel s in the urine in the

absence of bacteria.

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UTI

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Upper

Lower

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?Acute pyelonephritis

?Cystitis

?Chronic pyelonephri tis

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?Prostatitis

?Interstitial pyelonephritis

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?Urethritis

?Renal abscess

?Perirenal abscess

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?Both upper & lower UTI are further divided into

complicated and uncomplicated.

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Epidemiology

Seen in al age groups
Infants up to 6 months ? 2/1000
More common in boys than girls

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Women ? at greater risk than men; prevalence 40-50% in

women and 0.04% in men.

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10% women have recurrent UTI in their life
7 million new cases of lower UTI / year
1 million hospitalizations / year

Incidence of UTI increases in old age; 10% of men and 20%

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of women are infected.
Criteria for Classification of Urinary Tract Infections by

Clinical Syndrome

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Etiology

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Acute uncomplicated UTI: Infection in a structural y and

neurological y normal urinary tract.

? 80% by Escherichia coli

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? 20% by :
Gram negative enteric bacteria ? Klebsiel a
Gram positive cocci ? Streptococcus faecalis
Staphylococcus saprophyticus

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? S.saprophyticus ? restricted to infections in young sexual y

active women.
Complicated UTI : Infection in a urinary tract

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with functional or structural abnormalities

Proteus

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Pseudomonas

Klebsiel a

Enterobacter

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Flores-Mireles AL, Walker JN, Caparon M, Hultgren SJ. Urinary tract infections: epidemiology, mechanisms of infection and treatment

options. Nature reviews microbiology. 2015 May;13(5):269.

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Flores-Mireles AL, Walker JN, Caparon M, Hultgren SJ. Urinary tract infections: epidemiology, mechanisms of infection and treatment

options. Nature reviews microbiology. 2015 May;13(5):269.

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Resident microflora of urinary tract

vCoagulase-negative staphylococci (excluding

Staphylococcus saprophyticus)

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vViridans and nonhemolytic streptococci Lactobacil i

(adult females)

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vDiphtheroids (Corynebacterium spp.)
vNonpathogenic (saprobic) Neisseria spp. (adult women)
v Anaerobic cocci
vPropionibacterium spp. (adult patients)
vCommensal Mycobacterium spp.

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vCommensal Mycoplasma spp.
vYeasts (pregnant, adult females)

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Hospital Acquired UTI (HAUTI)
? 80 % because of indwel ing catheters.

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? Organisms responsible are :
E.coli
Klebsiel a
Proteus
Staphylococci

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Pseudomonas
Enterococci
Candida

Catheter Associated UTI (CAUTI)

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? 10-30% of catheterized patients developed bacteriuria.

? After hospitalization, patient become colonized with bacteria

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endemic to the institution, often gram negative aerobic and

facultative bacil i carrying resistance markers.

Pathogenesis

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? 4 routes of bacterial entry to urinary tract.

1. Ascending infection

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2. Descending infection (Blood borne spread)

3. Lymphatogenous spread

4. Direct extension from other organs

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ASCENDING INFECTION

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? Most common route.

? Organisms ascend through urethra into
bladder.

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DESCENDING INFECTION

Caused by hematogenous route
Common organisms:
staphylococcus aureus,

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mycobacterium tuberculosis,
salmonel a sp,
leptospira,
yeast (candida albicans),
rickettsia

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? LYMPHATOGENOUS SPREAD

Men- Through rectal and colonic lymphatic vessels

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to prostate and bladder.

Women- Through periuterine lymphatics to urinary
tract.

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? DIRECT EXTENSION FROM OTHER ORGANS

Pelvic inflammatory diseases
Genito-urinary tract fistulas

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BACTERIAL VIRULENCE FACTORS

UTI

HOST BEHAVIOR HOST CHARACTERISTICS

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UTI ? RISK FACTORS

1. Aging:

diabetes mel itus

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urine retention

impaired immune system

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2. Females:

shorter urethra

sexual intercourse contraceptives

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incomplete bladder emptying with age

3. Males: prostatic hypertrophy

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bacterial prostatis age

Risk factors for complicated UTI

? Functional/structural abnormalities of urinary tract

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? Recent urinary tract instrumentation
? Recent antimicrobial use
? Diabetes mellitus
? Immunosuppression
? Pregnancy

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? Hospital acquired infection
UTI-CLINICAL PRESENTATION

? Clinical manifestations depending on site of infection

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? Clinical manifestations depending on age of patient

Clinical manifestations depending on site of

infection

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? Urethritis:

Discomfort in voiding
Dysuria

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Urgency
frequency
? Cystitis:

dysuria, urgency and frequent urination t

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Pelvic discomfort
Abdominal pain
Pyuria

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? Hemorrhagic cystitis:

Visible blood in urine.
Irritating voiding symptoms

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? Pyelonephritis:

Invasive nature
Suprapubic tenderness
Fever and chills

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White blood cell casts in urine
Back pain
Nausea and vomiting

Complications include sepsis, septic shock and death.

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Clinical manifestations depending on age

? infants :

Failure to thrive

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Fever

Apathy

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Diarrhoea

? Children:

Dysuria, urgency, frequency

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Haematuria

Acute abdominal pain

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Vomiting

? Adults:

Lower UTI- frequency, urgency, dysuria,

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haematuria

Upper UTI- fever, rigor and loin pain and symptoms

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of lower UTI.

? Elderly patients:

Mostly asymptomatic

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Not diagnostic as the symptoms are common with

age.
DIAGNOSIS

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macroscopy

microscopy

UTI

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Culture

&Antibiotic

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sensitivity

Imaging

Specimen Col ection

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Male

MSU

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Female

During

CSU

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cystoscopy

Specimen

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Children,

collection-

Suprapubic aspirate

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infants, older

Urine

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women

TB of urinary tract

EMU

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(3 specimen)

Urethritis,

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Initial flow

prostatitis

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Clean-Catch Midstream Urine

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Catheter specimen of Urine

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Suprapubic Bladder Aspiration

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vGold standard for obtaining urine

specimens for culture in children

under 2 years.

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vSuprapubic aspirate is a simple,

safe, rapid and effective procedure.

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vThe use of ultrasound increases the

success of the procedure.

vAny growth of pathogenic bacteria

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in an SPA specimen is significant.

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In Infants

vSuprapubic aspiration

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vNon-invasive-

vBy tapping just above the pubis

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with 2 fingers at 1h after feed,

v1tap/sec for 1 min, then 1min

interval .

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For infants - the `Quick-wee' method can be

considered to increase the voiding and success

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rate of a `clean-catch' urine

This method uses gentle cutaneous suprapubic

stimulation with gauze soaked in cold 0.9%

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saline to trigger faster voiding.

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UTI- URINALYSIS

1. Appearance of the sample- colour of specimen

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whether clear or turbid

2. Microscopic examination of urine as wet preparation to

detect ?

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WBCs
RBCs
Yeast
Casts/Crystals
Bacteria

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Trophozoites-trichomonas vaginalis
Egg
Epithelial cells
3. Gram Stain: Should be done when bacteria or pus cel s are seen in wet

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mount.

Laboratory findings

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Normal Findings

Abnormal findings

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? pH - 4.6 ? 8.0

?pH ? Alkaline(increases)

? Appearance- clear

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? Color ? pale to amber

?Appearance ? cloudy

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yellow

? Color - deep amber

? Odor ? aromatic

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? Blood ? none

? Odor ? foul smel ing

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? Leukocyte esterase ? none ?Blood ? maybe present

?Leukocyte esterase - present

? WBC- absent

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?WBC- present

? Bacteria- absent

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?Bacteria- present
BIOCHEMICAL TESTS

a) Protein- Proteinuria is found in most bacterial urinary tract

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infections.
b) Nitrite- detected by Greiss Test or nitrite reagent strip test. This

test is positive with infection by E.coli, Klebsiel a, Proteus and

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negative with infection caused by Enterococcus faecalis,

Staphylococcus, Candida, Pseudomonas sp.
c) Leukocyte esterase enzyme test which detects the presence of

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pus cells (pyuria).

False negative results occur when urine contains boric acid as

preservative.

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Urine culture :

Not a rapid diagnostic tool

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>105 bacteria /ml

Differential leukocyte count-

Urine culture

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increased neutrophils


GENERAL INTERPRETATIVE GUIDELINES FOR URINE

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CULTURES

EXAMINE AND REPORT THE CULTURES

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If colonies are < 103 CFU/ml ? No significant Growth

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? If >103 and < 105 CFU/ml --- No Significance

Significant
? Patients on antimicrobials,

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? Female patients with urethritis,
? Symptomatic males,
? Presence of pus cells and absence of epithelial cells,
? Sample collected by suprapubic aspiration and
? from freshly inserted urinary catheter,

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? Single type of growth from non-contaminated sample .
Clinical correlation is very important.

Organism identification

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>105 CFU/ml --- Significant Bacteriuria



Organism identification

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Diagnostic tests for adults with

recurrent UTI
? INDICATIONS:
? H/O Calculus

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? H/O surgery
? Polycystic kidneys
? Potential ureteral obstruction
? Neuropathic bladder
? Unusual infecting organism

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? Poor response to treatment
? Diabetes mellitus

? IVP/CT SCAN

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? Voiding cystourethrography

? Cystoscopy

? Manual pelvic and

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Digital Rectal examination
UTI

urinalysis

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Urine microscopy and culture

Further investigation

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Adult female

Male

pyelonephritis Children

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Lower UTI

Any UTI

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Complicated

Any UTI

Treat without

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Blood

further

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Ultrasound

cultures

cystourethro

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investigation

cystoscopy

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CT scan

graphy

Check renal

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UTI - management

? Symptomatic UTI- antibiotic therapy

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? Asymptomatic UTI- no treatment required except in

special situations.

? Non- specific therapy:

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? more water intake.

? Maintaining acidity of urine by fluids like canberry

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juice.
Anti-microbial therapy

? Goals of therapy:

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Elimination of infection
Relief of acute symptoms
Prevention of recurrence and long term

complications

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? Decision to hospitalize ?

? Treatment considerations ?

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? Ideal antibiotic for UTI :

Adequate coverage over E.coli
Concentration in urine
Duration of therapy

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Low resistance
Cost
Low adverse effect profile
Principles of anti microbial therapy

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? Levels of antibiotic in urine but not in blood

? Blood levels of antibiotic ? important in pyleonephritis

? Penicillins and cephalosporins ? drugs of choice for UTI

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with renal failure.

Treatment duration

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? Single dose therapy

? 3 day course

? 7 day course

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? 10 ? 14 day course
Single dose therapy

o Trimethoprim- sulfamethaxole

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? Amoxicillin- clavulnate 500mg

? Ciprofloxacin 500mg

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? Norfloxacin 400mg

? For uncomplicated UTI

? Not for patients with

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1. past history of complicated UTI
2. history of antibiotic resistance
3. history of relapse with single dose

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? advantages: compliance, cost, less side effects, less

resistance

? Disadvantages: increased recurrence or relapse

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3 day therapy

? Efficacy same as 7 day therapy with less adverse

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effects

? Drugs used include

1. quinolines

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2. TMP-SMZ
3. betalactam antibiotics

? Extended release ciprofloxacin 500mg for

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uncomplicated UTI 1000mg for complicated UTI


7 day therapy

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? Used less for uncomplicated UTI
? Useful in

1. recurrent cases

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2. pregnancy
3. UTI with other risk factors

14 day therapy

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? For complicated UTI
? High risk of mortality and morbidity

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Pathogen specific treatment

Pathogen

Treatment options

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Escherichia coli

Ceftriaxone 50mg/kg

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i.v

/I.M Qday

Pseudomonas

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Gentamycin 6-7.5mg /kg

aeroginosa

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i.v Q8hr / Qday

Klebsiel a sps

Enterobacter sps Proteus

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Ceftadizine 100-

sps

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150mg/kg/day i.v Q8hr

Enterococcus sps

Ampicil in 100-

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200mg/kg/day Q6hr

Acute pyelonephritis

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? Parenteral antibiotics

? Cefuroxime ? 750mg i.v. Q8h Gentamycin - 80-120g

i.v. Q12h Ciprofloxacin ? 200mg i.v. Q12h

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? 10-14 days treatment

? Ceftazimide, imipenam, ciprofloxacin ? for hospital

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acquired pyelonephritis
Asymptomatic bacteriuria

? Children ? treatment same as symptomatic bacteriuria

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? Adults ?

treatment required in cases of

a. pregnancy

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b. patient with obstructive structural abnormalities

Bacteriuria in pregnancy

? To prevent risk of pyelonephritis

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? 7 day course with following antibiotics

Cephalaxin
Nitrofurantoin

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Amoxicil in

? Therapy continued at regular intervals of

pregnancy.

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Relapsing UTI

? 7-10 day course
? If fails ? 2week course / 6week course

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? Structural abnormalities corrected by surgery
? 6week course ?

a. children
b. adults with continuous symptoms

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c. high risk of renal damage

Prophylaxis for urinary tract infection

Given when:

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? Women of child bearing age have recurrent cystitis.

? Catheterization or instrumentation inflicting trauma to

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the lining of the urinary tract is performed; bacteremia

frequently occurs and injured lining is especial y

susceptible.

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? Indwel ing catheters are placed.

? Uncorrectable abnormalities of the urinary tract are

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present.

? Inoperable prostate enlargement or other chronic

obstruction causes urinary stasis.

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The most frequently used drugs for prophylaxis of lower

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UTI are:
? Cotrimoxazole 480 mg*
? Nitrofurantoin 100 mg*
? Norfloxacin 400 mg*

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? Cephalexin 250 mg*
* Al drugs are given once daily at bed time.

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Surgical treatment

v Surgical removal of renal calculi,

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bladder calculi

v Treatment of anatomic obstruction

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b) Ureteroplasty

c) Reimplatation of ureters if VUR

present

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Conclusion

Urinary tract infections are the 2nd most common

bacterial infections.

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Women are the most infected subjects in the

population.

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Development of resistance to antibiotics by the

bacteria result in problems during the treatment

and lead to relapse or recurrence.

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Recent advances such as development of

immunologicals like intranasal vaccines may result

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in life time cure of the infection