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URINARY TRACT INFECTION

Contents

Introduction
Terminology
Classification of UTI
Epidemiology
Etiology
Pathogenesis
Risk factors
Clinical presentation
Diagnosis
Treatment
Conclusion


Introduction

? Symptomatic presence of

micro organisms within

the urinary tract

i.e., kidney, ureters,

bladder and urethra.

? Associated with

inflammation of

urinary tract.

Anatomy

vThe upper urinary tract,

composed of the kidneys,

renal pelvis, and ureters.

v the lower urinary tract

that consists of the

urinary bladder and the

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

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

males (prostatitis).

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UTI - Terminology

v Significant bacteriuria: presence of at least 105

bacteria/ml of urine.

v Asymptomatic bacteriuria : bacteriuria with No symptoms.

v Uncomplicated: UTI without underlying renal or

neurologic disease.

v Complicated: UTI with underlying structural, medical or

neurologic disease.

v Recurrent : > 3 symptomatic UTIs within 12 months

following clinical therapy.

v Reinfection: recurrent UTI caused by a different pathogen

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

causing original UTI within 2 wks after therapy.

v Urethritis: infection of anterior urethral tract

v Cystitis: infection to urinary bladder

v Acute pyelonephritis: infection of one/both kidneys;

sometimes lower tract also.

v Chronic pyelonephritis: particular type of pathology of

kidney; may/may not be due to infection.

vPyuria

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

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

urine,

? or a urinary dipstick test that is positive for leukocyte

esterase.

vSterile pyuria

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

absence of bacteria.

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UTI

Upper

Lower

?Acute pyelonephritis

?Cystitis

?Chronic pyelonephri tis

?Prostatitis

?Interstitial pyelonephritis

?Urethritis

?Renal abscess

?Perirenal abscess

?Both upper & lower UTI are further divided into

complicated and uncomplicated.

Epidemiology

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

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

women and 0.04% in men.

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%

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

Clinical Syndrome

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Etiology

Acute uncomplicated UTI: Infection in a structural y and

neurological y normal urinary tract.

? 80% by Escherichia coli

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

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

active women.
Complicated UTI : Infection in a urinary tract

with functional or structural abnormalities

Proteus

Pseudomonas

Klebsiel a

Enterobacter

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.

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.


Resident microflora of urinary tract

vCoagulase-negative staphylococci (excluding

Staphylococcus saprophyticus)

vViridans and nonhemolytic streptococci Lactobacil i

(adult females)

vDiphtheroids (Corynebacterium spp.)
vNonpathogenic (saprobic) Neisseria spp. (adult women)
v Anaerobic cocci
vPropionibacterium spp. (adult patients)
vCommensal Mycobacterium spp.
vCommensal Mycoplasma spp.
vYeasts (pregnant, adult females)

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

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

Catheter Associated UTI (CAUTI)

? 10-30% of catheterized patients developed bacteriuria.

? After hospitalization, patient become colonized with bacteria

endemic to the institution, often gram negative aerobic and

facultative bacil i carrying resistance markers.

Pathogenesis

? 4 routes of bacterial entry to urinary tract.

1. Ascending infection

2. Descending infection (Blood borne spread)

3. Lymphatogenous spread

4. Direct extension from other organs


ASCENDING INFECTION


? Most common route.

? Organisms ascend through urethra into
bladder.

DESCENDING INFECTION

Caused by hematogenous route
Common organisms:
staphylococcus aureus,
mycobacterium tuberculosis,
salmonel a sp,
leptospira,
yeast (candida albicans),
rickettsia


? LYMPHATOGENOUS SPREAD

Men- Through rectal and colonic lymphatic vessels
to prostate and bladder.

Women- Through periuterine lymphatics to urinary
tract.

? DIRECT EXTENSION FROM OTHER ORGANS

Pelvic inflammatory diseases
Genito-urinary tract fistulas

BACTERIAL VIRULENCE FACTORS

UTI

HOST BEHAVIOR HOST CHARACTERISTICS
UTI ? RISK FACTORS

1. Aging:

diabetes mel itus

urine retention

impaired immune system

2. Females:

shorter urethra

sexual intercourse contraceptives

incomplete bladder emptying with age

3. Males: prostatic hypertrophy

bacterial prostatis age

Risk factors for complicated UTI

? Functional/structural abnormalities of urinary tract
? Recent urinary tract instrumentation
? Recent antimicrobial use
? Diabetes mellitus
? Immunosuppression
? Pregnancy
? Hospital acquired infection
UTI-CLINICAL PRESENTATION

? Clinical manifestations depending on site of infection

? Clinical manifestations depending on age of patient

Clinical manifestations depending on site of

infection

? Urethritis:

Discomfort in voiding
Dysuria
Urgency
frequency
? Cystitis:

dysuria, urgency and frequent urination t

Pelvic discomfort
Abdominal pain
Pyuria

? Hemorrhagic cystitis:

Visible blood in urine.
Irritating voiding symptoms

? Pyelonephritis:

Invasive nature
Suprapubic tenderness
Fever and chills
White blood cell casts in urine
Back pain
Nausea and vomiting

Complications include sepsis, septic shock and death.
Clinical manifestations depending on age

? infants :

Failure to thrive

Fever

Apathy

Diarrhoea

? Children:

Dysuria, urgency, frequency

Haematuria

Acute abdominal pain

Vomiting

? Adults:

Lower UTI- frequency, urgency, dysuria,

haematuria

Upper UTI- fever, rigor and loin pain and symptoms

of lower UTI.

? Elderly patients:

Mostly asymptomatic
Not diagnostic as the symptoms are common with

age.
DIAGNOSIS

macroscopy

microscopy

UTI

Culture

&Antibiotic

sensitivity

Imaging

Specimen Col ection

Male

MSU

Female

During

CSU

cystoscopy

Specimen

Children,

collection-

Suprapubic aspirate

infants, older

Urine

women

TB of urinary tract

EMU

(3 specimen)

Urethritis,

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

vGold standard for obtaining urine

specimens for culture in children

under 2 years.

vSuprapubic aspirate is a simple,

safe, rapid and effective procedure.

vThe use of ultrasound increases the

success of the procedure.

vAny growth of pathogenic bacteria

in an SPA specimen is significant.

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In Infants

vSuprapubic aspiration

vNon-invasive-

vBy tapping just above the pubis

with 2 fingers at 1h after feed,

v1tap/sec for 1 min, then 1min

interval .

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

considered to increase the voiding and success

rate of a `clean-catch' urine

This method uses gentle cutaneous suprapubic

stimulation with gauze soaked in cold 0.9%

saline to trigger faster voiding.

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UTI- URINALYSIS

1. Appearance of the sample- colour of specimen

whether clear or turbid

2. Microscopic examination of urine as wet preparation to

detect ?
WBCs
RBCs
Yeast
Casts/Crystals
Bacteria
Trophozoites-trichomonas vaginalis
Egg
Epithelial cells
3. Gram Stain: Should be done when bacteria or pus cel s are seen in wet

mount.

Laboratory findings



Normal Findings

Abnormal findings

? pH - 4.6 ? 8.0

?pH ? Alkaline(increases)

? Appearance- clear

? Color ? pale to amber

?Appearance ? cloudy

yellow

? Color - deep amber

? Odor ? aromatic

? Blood ? none

? Odor ? foul smel ing

? Leukocyte esterase ? none ?Blood ? maybe present

?Leukocyte esterase - present

? WBC- absent

?WBC- present

? Bacteria- absent

?Bacteria- present
BIOCHEMICAL TESTS

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

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

negative with infection caused by Enterococcus faecalis,

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

pus cells (pyuria).

False negative results occur when urine contains boric acid as

preservative.

Urine culture :

Not a rapid diagnostic tool

>105 bacteria /ml

Differential leukocyte count-

Urine culture

increased neutrophils


GENERAL INTERPRETATIVE GUIDELINES FOR URINE

CULTURES

EXAMINE AND REPORT THE CULTURES

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





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

Significant
? Patients on antimicrobials,
? 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,
? Single type of growth from non-contaminated sample .
Clinical correlation is very important.

Organism identification

>105 CFU/ml --- Significant Bacteriuria



Organism identification
Diagnostic tests for adults with

recurrent UTI
? INDICATIONS:
? H/O Calculus
? H/O surgery
? Polycystic kidneys
? Potential ureteral obstruction
? Neuropathic bladder
? Unusual infecting organism
? Poor response to treatment
? Diabetes mellitus

? IVP/CT SCAN

? Voiding cystourethrography

? Cystoscopy

? Manual pelvic and

Digital Rectal examination
UTI

urinalysis

Urine microscopy and culture

Further investigation

Adult female

Male

pyelonephritis Children

Lower UTI

Any UTI

Complicated

Any UTI

Treat without

Blood

further

Ultrasound

cultures

cystourethro

investigation

cystoscopy

CT scan

graphy

Check renal

UTI - management

? Symptomatic UTI- antibiotic therapy

? Asymptomatic UTI- no treatment required except in

special situations.

? Non- specific therapy:

? more water intake.

? Maintaining acidity of urine by fluids like canberry

juice.
Anti-microbial therapy

? Goals of therapy:

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

complications

? Decision to hospitalize ??

? Treatment considerations ??

? Ideal antibiotic for UTI :

Adequate coverage over E.coli
Concentration in urine
Duration of therapy
Low resistance
Cost
Low adverse effect profile
Principles of anti microbial therapy

? Levels of antibiotic in urine but not in blood

? Blood levels of antibiotic ? important in pyleonephritis

? Penicillins and cephalosporins ? drugs of choice for UTI

with renal failure.

Treatment duration

? Single dose therapy

? 3 day course

? 7 day course

? 10 ? 14 day course
Single dose therapy

o Trimethoprim- sulfamethaxole

? Amoxicillin- clavulnate 500mg

? Ciprofloxacin 500mg

? Norfloxacin 400mg

? For uncomplicated UTI

? Not for patients with

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

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

resistance

? Disadvantages: increased recurrence or relapse

3 day therapy

? Efficacy same as 7 day therapy with less adverse

effects

? Drugs used include

1. quinolines
2. TMP-SMZ
3. betalactam antibiotics

? Extended release ciprofloxacin 500mg for

uncomplicated UTI 1000mg for complicated UTI


7 day therapy

? Used less for uncomplicated UTI
? Useful in

1. recurrent cases

2. pregnancy
3. UTI with other risk factors

14 day therapy

? For complicated UTI
? High risk of mortality and morbidity



Pathogen specific treatment

Pathogen

Treatment options

Escherichia coli

Ceftriaxone 50mg/kg

i.v

/I.M Qday

Pseudomonas

Gentamycin 6-7.5mg /kg

aeroginosa

i.v Q8hr / Qday

Klebsiel a sps

Enterobacter sps Proteus

Ceftadizine 100-

sps

150mg/kg/day i.v Q8hr

Enterococcus sps

Ampicil in 100-

200mg/kg/day Q6hr

Acute pyelonephritis

? Parenteral antibiotics

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

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

? 10-14 days treatment

? Ceftazimide, imipenam, ciprofloxacin ? for hospital

acquired pyelonephritis
Asymptomatic bacteriuria

? Children ? treatment same as symptomatic bacteriuria

? Adults ?

treatment required in cases of

a. pregnancy
b. patient with obstructive structural abnormalities

Bacteriuria in pregnancy

? To prevent risk of pyelonephritis

? 7 day course with following antibiotics

Cephalaxin
Nitrofurantoin
Amoxicil in

? Therapy continued at regular intervals of

pregnancy.
Relapsing UTI

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

? Structural abnormalities corrected by surgery
? 6week course ?

a. children
b. adults with continuous symptoms
c. high risk of renal damage

Prophylaxis for urinary tract infection

Given when:

? Women of child bearing age have recurrent cystitis.

? Catheterization or instrumentation inflicting trauma to

the lining of the urinary tract is performed; bacteremia

frequently occurs and injured lining is especial y

susceptible.

? Indwel ing catheters are placed.

? Uncorrectable abnormalities of the urinary tract are

present.

? Inoperable prostate enlargement or other chronic

obstruction causes urinary stasis.

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The most frequently used drugs for prophylaxis of lower

UTI are:
? Cotrimoxazole 480 mg*
? Nitrofurantoin 100 mg*
? Norfloxacin 400 mg*
? Cephalexin 250 mg*
* Al drugs are given once daily at bed time.

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Surgical treatment

v Surgical removal of renal calculi,

bladder calculi

v Treatment of anatomic obstruction

b) Ureteroplasty

c) Reimplatation of ureters if VUR

present
Conclusion

Urinary tract infections are the 2nd most common

bacterial infections.

Women are the most infected subjects in the

population.

Development of resistance to antibiotics by the

bacteria result in problems during the treatment

and lead to relapse or recurrence.

Recent advances such as development of

immunologicals like intranasal vaccines may result

in life time cure of the infection

This post was last modified on 08 April 2022