Urinary tract infections (UTI)

Y3S2 Infection 2 2009/10 Batch 2013 Champa Ratnatunga Department of Microbiology Faculty of Medicine

Objectives
1) Explain the pathogenesis of uncomplicated and complicated urinary tract infections 2) Explain the principle underlying microbiological diagnosis of UTI 3) Describe the methods of collection and transport of urine for culture 4) Outline principles of treatment and prevention of UTI

UTI

UTI 1st infection

Recurrent infection

LUTI

(cystitis)

UpUTI (pyelonephritis)

Complicated

Uncomplicated

Cystitis (Child, male, with risk factors,

Cystitis in -female, child bearing age, no risk factors (anatomical, metabolic, neurological, renal abnormalities) no other diseases, not pregnant

 Factors that inhibit bacterial growth in urine

ph<5.5 (organic acids) High urea concentration Osmolarity Frequent , complete voiding of the bladder

Other defense mechanisms

Secretory Ig A Urothelium Vaginal lactobacilli

Predisposing factors host

SHORT URETHRA Low volume Sexual intercourse Outflow obstruction (BOO) Instrumentation - . Reflux

Pathogenesis
Uncomplicated LUTI (Cystitis)
Invasion of the bladder mucosa by pathogen, usually perineal flora that ascend via the urethra
E coli (most common > 70% in both males and females ), S saprophyticus (in females), Proteus spp, Pseudomonas sp, Klebsiella sp. Enterococcus feacalis, Virulence factors adhesins, pili, fimbria, swarming capability

Can have asymptomatic bactiriuria

 Complicated LUTI
Predisposing factor
CATHETERIZATION duration, gender, DM, poor catheter care, debilitated, diarrhoea etc Females - Elderly, pregnant, structural abnormality Stone disease Pelvic examination ? Frequent/ long duration antibiotic use

Aeitiological agents
Catheter E coli, Proteus spp., Pseudomonas sp., Enterococcus sp. , S aureus, Candida spp. Calculi Proteus spp. , Pseudomonas spp. UTI in CHILDREN requires proper diagnosis, treatment, follow up and long term management according to protocols due to risk of renal scarring

 Upper UTI ( Kidney/ renal pelvis Pyelonephritis and perinephric abscess)

Ascending organisms of LUTI Haematogenous S aureus, Predisposing factors
Impaired defenses in the Lower urinary tract VU - reflux Renal calculi Transplantation DM Chronic nephropathy and other abnormalities (PCKD)

Organisms similar to LUTI

Perinephric abscess E coli, Proteus spp, S aureus, MTB,

Table 1. Incidence of Urinary Tract Infection According to Age and Sex

Age Group Neonatal Preschool age School age Reproductive age Geriatric Incidence (%) 1.0 1.5-3.0 1.2 3-5 10-30 Approximate Sex Ratio (Male:Female) 1.5:1.0 1:10 1:30 1:50 1:1.5

Hx and Ex
.. .. .. ... Infant/Child .. .. ................................. .

 Uncomplicated UTI no need to Ix. Start treatment Complicated LUTI - UFR, urine culture (MSU)
specimen collection, container, timing, transport, interpretation of reports etc

Ix

Pyelonephritis Urine culture, UFR, USS-KUB, S Creatinine

Is severe with evidence of blood stream spread blood culture

Urolithiasis suspected X ray KUB

If ?TB - 3 early morning urine samples for TB CULTURE

Collection, transport of specimens

Specimen- Clean catch mid stream urine Wide mouthed screw capped sterile container Transport - Within 2 hours Or Refrigerate (max 8 hrs)
Or 1.8% Boric acid in container

Difficulties in collecting MSU

sample of urine from catheterized patient

Bacteriuria bacteria in urine Significant bacteriuria - >105 cfu/ ml urine Asymptomatic bacteriuria Sterile pyuria
GU TB Stone disease Malignancy

Mx
Rx Antibiotics Emperical/ ABST .. . ..

Management of UTI
Predisposing factors
Can the predisposing factor be removed/ modified/ managed? Choice of antibiotic
antibiotics concentrated in urine cystitis tissue penetration not required

Pyelonephritis good tissue penetration required and should not be nephrotoxic

Duration of Rx
3 days - Uncomplicated LUTI 7 days 10 days

Management of UTI
Prevention
honeymoon cystitis void urine immidiately after intercourse, post coital antibiotic Obstruction /urinary retention double micturition or surgical treatment (uterine prolapse ) dry vagina vaginal suppositary (oestrogen) childhood UTI with reflux antibiotic prophylaxis

Ref: THP Microbiology quarterly bulletin July Sep 2012

Urinary Catheterization Commonest Predisposing Factor For Nosocomial UTI Only when really needed and remove as soon as possible Whenever possible use condom catheters,diapers etc... Done by a trained person using aseptic technique Document the date of catheterization, person catheterized, type and size of catheter, volume of water in the balloon

CATHETER INSERTION External meatus or vulva clean with sterile N.saline / Povidone Iodine Wash hands with soap and water and wear a pair of sterile gloves Lubricate urethra with a sterile, single use anaesthetic gel Insert the catheter gently and inflate the balloon Anchor to the thigh securely with a plaster

CATHETER CARE Maintain the closed system Urine bag below the level of the bladder Bag should not touch the ground When emptying wear clean gloves (NOT sterile) Daily meatal care with saline Keep the perineal area clean TRANSPORTATION WITH CATHETER Avoid pulling on the catheter when transferring the patient Maintain closed drainage system Keep the urine bag below the level of the bladder

Male UTI - Prostatitis

Acute or chronic Intraprostatic reflux of urine or haematognous Acute Prostatitis fever, pelvic pain, dysuria
Causes similar to UTI

Chronic prostatitis infective / non infective

Infective most common cause of relapsing UTI in men (E coli and other GNB) Ix - Prostatitis Acute Urine culture Chronic - urine sample pre/ post prostatic massage
Bladder outflow obstruction due to enlarged prostate is the most common risk factor in older males for UTI

Urethritis Gonococcal urethritis Urethritis urethral discharge for gram stain Hx- Epididymitis Retrograde ascent of infected urine via vas deferens. Causes
Young Chlamydia trachomatis, Neisseria gonorrhoeae Older E coli, GNB, USS scrotum

Orchitis Viral causes mumps, coxsackie B, mononucleosis, varicella (haematogenous)