Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Urology 12 Urinary Tract Infection PPT-Powerpoint Presentations and lecture notes
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