MICROBIOLOGY OF URINARY TRACT INFECTION

Alfred H L toruan Nugroho s.s m. Fatikh nanda

INTRODUCTION
Epidemiology of UTI by age group and sex
Age
<1 1-5 6-15 16-35 36-65

Female
0,7 4,5 4,5 20 35

Male
2,7 0,5 0,5 0,5 20

Risk factor
Foreskin,anatomic GU abnormalities Anatomic GU abnormalities Functional GU abnormalities Sexual intercourse,diaphragm use Surgery, prostate obstruction, catheterization Incontinence, catheterization, prostate obstruction

>65

40

35

DEFENSE MECHANISM OF THE URINARY TRACT

1.

Urine factor :
Urea concentration and high Low pH of urine kill bacteria osmolarity

2.

Hydrokinetic factor :
Periodic urinary flow Dilution of rest urine cause of urinary Bladder emptying

flow from kidney

3. Mucosal factor :
Mucosa of the bladder consist of more than one layer cells Mucosa of the urinary tract and bladder covered by mucus prevent microorganism attachment Prostatic secretion : has an antibacterial effect Secretion of local IgA prevent attachment of microorganism on uroepithelium later and neutralize toxin produce by microorganism Perioxidase on the mucosal layer has a bactericidal effect

PATHOGENESIS
Urine : steril Modes of bacterial entry :

Ascending Hematogenous Lymphatogenous Direct extension

PATHOGENESIS
A. Entry is normally by ascent from the urethra
Bacteria invade the urinary tract by ascending route through the urethra to infect the bladder and renal pelvis is the most common. Occasionally with hematogenous spread

B. Host factors
The larger number of UTI's present in women than in men is probably due to the much shorter urethra and the much closer association of the urethra to the anus Sexual intercourse contributes to the increased number of UTI's seen in women Any anatomic obstruction, or neurological disorder leading to the failure to completely eliminate the urine can lead to UTI Men in their 40's have problems with the prostate gland enlarging resulting in obstruction of the urethra followed by incomplete elimination of urine from the bladder and UTI's

C. Bacterial factors
>The most important virulence factor of bacteria is the enhanced ability to adhere to uroepithelial cells.

>Pseudomonas infections are both invasive and

toxinogenic

>S. Aureus expresses many potential virulence factors

such as proteins, enzymes and toxins

D. Spread to the kidney Infection of the kidney is due to ascent from the lower urinary tract and so any factor leading to retrograde flow of the urine to the kidney will predispose the host to pyelonephritis.
Such factors include:

1. 2. 3. 4.

Reflux of urine to the kidney Physiological malfunctions Urethral catheters Urinary tract stones

CLINICAL MANIFESTATION
LOWER URINARY TRACT INFECTIONS Acute cystitis : a superficial inflammation of the bladder and urethra
Acute prostatitis occurs when bacteria invade the prostate UPPER URINARY TRACT INFECTIONS Acute pyelonephritis is due to bacterial invasion of the renal tissue with inflammation and swelling, sometimes cause renal dysfunction

ETIOLOGY
-Escherichia coli, which is responsible for 80 %
of infections that are acquired outside of hospitals

-Other Gram-negative rods such as Klebsiella, Enterobacter, and Proteus spp. are relatively common, each accounting for 3 to 5 % of infections -Within the hospital environment, Pseudomonas aeruginosa, Serratia marscesens, and other Gram positive bacteria such as Enterococcus faecalis, and Staphylococcus epidermidis are more resistant, common hospital-acquired phatogens.

- Gram-positive organisms, particularly coagulase-negative staphylococci and enterococci, cause some infections

ETIOLOGY

-Staphylococcus saprophyticus causes

about 10 % of UTI in young women

-Candida albicans is also a frequent

pathogen in hospitalized patients, particularly if diabetes is present

ETIOLOGY

Anaerobes and fastidious organisms rarely cause urinary infections

A number of viruses, particularly mumps virus, cytomegalovirus, and coxsackieviruses, can be present in the kidneys and urine, but rare

A number of sexually transmitted pathogens (e.g., Neisseria gonorrhoeae) may invade the urethra. Chlamydia trachomatis and herpes simplex can present with symptoms that mimic acute cystitis in both men and women

URINARY TRACT INFECTION

Escherichia coli
- The most common cause of UTI - Accounts approximately 80 % of first UTI in young women - UTI can result in bacteremia with clinical signs of sepsis - Nephropathogenic E. coli typically produce hemolysin

E. coli
Member of the normal intestinal flora Motile, possess polysaccharide capsule Grow on nonselective media Red colonies on Mac Conkey agar An isolate from urine can be identified by its hemolysis on blood agar Temperature for growth : 15 450C Some strains more resistant to heat viable at 600 C 15 minutes ,550 C 60 minutes

Klebsiella pneumoniae
-The most clinically important species

This bacterium produces large sticky colonies when plated on nutrient media - Klebsiella's pathogenicity can be attributed to its production of a heat-stable enterotoxin - K. pneumoniae urinary tract infections are common in catheterized patients - In fact, K. pneumoniae is second only to E. coli as a urinary tract pathogen.

ENTEROBACTER
Previously : Aerobacter, similar characteristics to Klebsiella, differ in motility The organisms has small capsule E. aerogenes may be found free- living as well as in the intestinal tract E. aerogenes & E. cloacae causes UTI & sepsis

PROTEUS
Infection in humans only when bacteria leave the intestinal tract Found in UTI, produce bacteremia, focal lesions in debilitated patients or receiving i.v infusions P. vulgaris & M. morganii important nosocomial pathogens

PROTEUS
P. mirabilis UTI, occasionally other infection
Produces a typical swarming growth on blood agar Is primarily an opportunist, transmitted via catheters Produces a powerfull urease that hydrolyzes urea to ammonia and CO2 Results in stones and calculi, leading to urinary tract

SERRATIA
S. marscescens : is common opportunistic pathogen in hospitalized patient Causes pneumonia, UTI, meningitis, wound infections, bacteremia & endocarditis specially in narcotics addicts & hospitalized patients Often multiply resistant to aminoglycosides & penicillins Infections can be treated with 3rd generation cephalosporins

Pseudomonas aeruginosa
Opportunistic pathogen of humans. The bacterium almost never infects uncompromised
tissues, yet there is hardly any tissue that it cannot infect, if the tissue defenses are compromised in some manner Pseudomonas aeruginosa is a Gramnegative, aerobic rod, belonging to the bacterial family Pseudomonadaceae P. aeruginosa produces two types of soluble pigments, pyocyanin and (fluorescent) pyoverdin. Pyocyanin (from "pyocyaneus") refers to "blue pus" which is a characteristic of suppurative infections caused by Pseudomonas aeruginosa.

Staphylococcus
Staphylococci are Gram-positive spherical bacteria that occur in microscopic clusters resembling grapes Taxonomically, the genus Staphylococcus is in the bacterial family Micrococcaceae Staphylococci are facultative anaerobes The bacteria are catalase-positive and oxidase- negative, can grow at a temperature range of 15 to 450C and at NaCl concentrations as high as 15 %

Staphylococcus
S. aureus forms a fairly large yellow colony on rich medium; often hemolytic on blood agar Nearly all strains produce the enzyme coagulase S. epidermidis has a relatively small white colony, non hemolytic, nearly all strains lack the coagulase enzyme S. saprophyticus Is non hemolytic if culture on blood agar, coagulase-negative, novobiocinresistant. Lacks protein A

Enterococcus faecalis
The enterococci are facultative anaerobes, produce a small gray colony after 24 hour incubation at 35C on sheep blood agar A small gray colony that is slightly or hemolytic and sometimes -hemolysis, weakly catalase- positive is a typical presentation for Enterococcus Microscopically, Gram-positive cocci occurring in chains or pairs with individual cells being somewhat elongated can be presumed to be streptococci or enterococci

Microbiological diagnosis
Specimen has to be taken under strict precautions as lower part of urethra is colonized by fecal flora Thus catheterization is forbidden Midstream urine is the primary choice, while suprapubic puncture are alternatives In special cases after surgery on the kidney, urine is taken by renal catheter. Urine must be chilled and processed within 2 hours

DIAGNOSIS
The diagnosis of UTI : based on a quantitative urine culture : > 100,000 colonyforming units (105 CFU) per ml of urine, was termed "significant bacteriuria." This value was chosen because of its high specificity for the diagnosis of true infection, even in asymptomatic persons. However, several studies have established that one third or more of symptomatic women have CFU counts below this level (low-coliform-count infections). They have also shown that a bacterial count of 100 CFU per mL of urine has a high positive predictive value for cystitis in symptomatic women

Bacteriuria indicate UTI

Criteria of UTI
1. Bacteriuria with quantitative >100.000 cfu/ml 2. Bacteriuria with quantitative <100.000 cfu/ml and lekocyturia 3. Bacteriuria with quantitative <100.000 cfu/ml in repeated culture, and same kind of bacteria was found 4. Bacteriuria with quantitative <100.000 cfu/ml, only one species of bacteria, with definite clinical symptoms 5. If the result of culture is > 1000 cfu of fungus/ ml indicate fungal infection

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