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Introduction
UTIs: presence of micro organisms within the urinary tract
May be difficult to distinguish between contamination,
colonisation or infection
UTI can occur from infancy through old age, Incidence is
highest in sexually active adolescent females.
Rare in men and in children, common in females, 10 - 20% of
all females will experience a UTI during their lifetime
1%-6% of general practitioner visits are for UTIs,
If left untreated, simple cystitis may progress to renal scarring
ie/pyelonephritis which may develop renal insufficiency
Terminology
Asymptomatic
Bacteriuria
UTI
Cystitis
Asymptomatic
UTI
Symptomatic
UTI
Pylonephritis
Urosepsis
Pyuria
Definition of UTI
Cystitis
Infection of the urinary tract limited to the bladder, usually involving
only the mucosal surface
- painful/burning urination
- urgency or frequency
- absence of symptoms or physical signs suggesting
inflammation at other sites within the urinary tract
clinical criteria are notoriously inaccurate in identifying the actual
anatomic site of infection
Pyelonephritis
Infection of the kidney
clinical diagnosis which implies a more invasive
infection
inflammation of the kidney and renal pelvis is
assumed to be present when patients have pain or
tenderness involving the flank, together with other
clinical or laboratory evidence of UTI
-fever, nausea, chills, malaise, headache, etc
Asymptomatic Bacteriuria
The presence of bacteria in the urine of a person without symptoms of
infection.
Complicated infections
UTI Classification
Lower Tract
Upper Tract
Superficial or mucosal
Invasive
Urethritis
Pyelonephritis
- Urethra
Cystitis
- Bladder
prostatitis
- Acute or chronic
- intrarenal and
perinephric abscess
UTI Classification
Uncomplicated
Complicated
Due to predisposing
lesion
No sequelae
Congenital
abnormalities
Stone (kidney or any
part of tract)
Sexual intercourse
Urinary catheters
Vesicoureteral reflux
Diabetes mellitus
Inadequate fluid intake
Causative Organisms
Majority of UTI are due to a single pathogen
(commonly bacterial; virus rare)
>> by aerobic gram negative rod of the GIT.
~ 85% of all UTI : E. coli
~10% : Klebsiella, Proteus, Pseudomonas,
Enterobacter
~ < 5%: Staph aureus, enterococcus, chlamydia,
fungus, TB, other.
Causative Organisms
Community-acquired
Hospital-acquired
Escherichia coli*
Escherichia coli
Klebsiella pneumoniae
Pseudomonas aeroginosa
Proteus mirabilis
Proteus sp.
Staphylococcus
saprophyticus
Enterococcus faecalis
Enterobacter sp.
Serratia sp.
Enterococcus sp.
Uro-pathogens
E.coli, Klebsiella spp.
-intrinsic gut organisms
-highly motile
-produce fimbriae (pili) attachment
Proteus, Morganella, Providencia
-Urease producing organisms
-increases urinary pH - leads to crystal formation
Community-Acquired UTI
E.coli
S.epi &
gm - enterics
Enterococcus
K.pneumoniae
Proteus
S.saprophyticus
Nosocomial UTI
catheter associated
Short Term
Long Term
E.coli
Enterobacter
E.coli
Proteus
Enterococcus
Candida
Proteus
Providencia
S.aureus
Pseudomonas
Morganella
Pseudomonas
Capsules
K ag covers bacteria capsule
Protects phagocytosis and complement attack
Ureteric Paralysis
P. Fimbriae and endotoxin
Motility
Ascent of LUT
Urease Production
Hydrolyse urea and increases ammonia
which increases bacterial adherence
- CFAI/CFAII
- Type 1 fimbriae
- P fimbriae
- S fimbriae
- Intimin (non-fimbrial adhesin)
Invasins
- Hemolysin
- Siderophores & siderophore uptake
systems
- Shigella-like "invasins" for intracellular
- capsules
- K antigens
- LPS
- LPS
- K antigens
- capsules
- K antigens
- LPS
- antigenic variation
Motility/chemotaxis
Genetic attributes
- Flagella
Toxins
- LT toxin
- ST toxin
- Shiga-like toxin
- Cytotoxins
- Endotoxin (LPS)
Pathogenesis
- Ascending route of infection
Most common route in females (95%)
- Retrograde via the urethra
- Hematogenous route
- Rare (<3%)
- endocarditis, bacteremias, disseminated
infections
Complicating factors such as catheters, nephrostomy
tubes, surgery, urinary stones, etc
Clinical Presentation
Suprapubic pain, pain or burning during urination
frequency and urgency of urination
Dysuria
Nocturia
Hematuria
Cloudy urine
Foul or strong urine odor
Upper: fever, chills, malaise, N/V, weight loss, flank or
back pain
DIAGNOSTIC EVALUATION
Diagnosis of UTI
History
Physical exam (PE)
Lab
Urinalysis
Urine culture
Sensitivity
Imaging study
Diagnosis of UTI
Determination of the number and type of bacteria important
diagnostic procedure.
Symptomatic
105 CFU bacteria/ml
Asymptomatic
105 CFU bacteria/ml on 2 consecutive specimens
Catheterized patients
102 CFU bacteria/ml
Diagnosis of UTI
Rapid methods: detect bacterial growth by photometry,
bioluminescence rapid results, usually in 1 to 2 h.
Microscopic bacteriuria, is found in > 90% of specimens from patients
whose infections colony counts of at least 10 5/mL, (very specific).
Infections with lower colony counts (102 to 104/mL) bacteria ve.
Bacteria +ve infection, bacteria ve not exclude the diagnosis.
Pyuria is a highly sensitive indicator of UTI in symptomatic patients.
The leukocyte esterase "dipstick" method is less sensitive
Sterile pyuria unusual bacterial agents (C. trachomatis, U.
urealyticum, and M. tb or with fungi) or noninfectious urologic conditions
(calculi, anatomic abnormality, nephrocalcinosis, vesicoureteral reflux,
interstitial nephritis, or polycystic disease).
Specimen collection
Clean catch mid stream specimens
Specimen transport
Sent to and processed by lab as quickly as possible
- Require: method of collection
time of collection
patients antibiotics
Specimens not received by lab in 1-2 hours MUST be
refrigerated
Urines not received within 24 hours or not refrigerated will be
rejected by laboratory
Urinalysis
Offers a number of valuable clues for an accurate diagnosis:
- Color and cloudiness of urine
- Acidity
- White blood cells (leukocytes).
Treatment can be started without the need for further tests if
the following urinalysis results are present in patients with
symptoms and signs of UTIs:
- A high white cell count
- Cloudy urine
Urinalysis
Parameter
Normal values
UTI
Appearance
Yellow
Cloudy
pH
4.5-8.5
Alkaline
Protein
Negative
Positive
Nitrite test
Negative
Positive
RBC
Negative
Positive
WBC
0-5 / hpf
> 5 / hpf
Cast
Negative
Positive
Absent
Many present
Bacteria
Urine culture
Results are best interpreted with knowledge of the collection
method and results of the urinalysis.
A clean-catch urine sample with > 105 CFU of a single organism
is classic criteria for UTI.
102 to 104 accepted as significant if patient symptomatic
Contamination with perineal flora may mask an existing UTI.
UT abnormalities may be associated with multiple organisms.
Cultures with growth of more than 10,000 CFU from bladder
catheterization or suprapubic aspiration should be considered
significant for UTI with any colony count.
Imaging Techniques
Serious and recurrent cases of pyelonephritis
When structural abnormalities are suspected
If infections do not respond to treatment
If suspects obstruction or an abscess
VUR ultrasound and voiding cystourethrogram
TREATMENT
Goals of Therapy
Prevent or treat systemic consequences
Relieve symptoms
Eradicate invading organism
Eliminate uropathogenic bacterial strains from fecal
& vaginal reservoirs
Prevent reoccurrence of infection
Prevent long-term sequelae
Antimicrobial Selection
Empiric Therapy
- based on most probable pathogens
- local rates of resistance
- acute infection vs chronic
- reinfection or relapse
- indwelling catheter etc
Good urine concentration
Minimal effects on fecal and vaginal flora
Acceptable safety profile
Cost-effective
Skin/Soft Tissue
Peptococcus
Peptostreptococcus
Actinomyces
S. aureus
S. pyogenes
S. epidermidis
Pasteurella
S. aureus
S. epidermidis
Streptococci
N. gonorrhoeae
Gram-negative rods
Abdomen
Urinary Tract
Upper Respiratory
E. coli, Proteus
Klebsiella
Enterococcus
Bacteroides sp.
E. coli, Proteus
Klebsiella
Enterococcus
Staph saprophyticus
S. pneumoniae
H. influenzae
M. catarrhalis
S. pyogenes
Lower Respiratory
Community
Lower Respiratory
Hospital
Meningitis
S. pneumoniae
H. influenzae
K. pneumoniae
Legionella pneumophila
Mycoplasma, Chlamydia
K. pneumoniae
P. aeruginosa
Enterobacter sp.
Serratia sp.
S. aureus
S. pneumoniae
N. meningitidis
H. influenza
Group B Strep
E. coli
Listeria
Antimicrobial Therapy
Cystitis - usually responds to 3 days of treatment
- effective concentrations into the urine > serum
uncomplicated pyelonephritis - 2 weeks treatment
- effective concentrations into the urine = serum
complicated infections / prostatitis - 6 weeks
IV antibiotics may be required in seriously ill patients,
but oral drugs usually effective
Antimicrobial Therapy
Acute Uncomplicated cystitis
Trimethoprim/sulfamethoxazole (TMP/SMX)
1 DS (160/800 mg) BID x 3 days
Fluoroquinolones:
Ciprofloxacin 250 mg BID x 3 days
Levofloxacin 250mg QD x 3 days
Gatifloxacin 200 mg QD x 3 days
Nitrofurantoin: 100 mg QD x 3 days
Cephalosporins, doxycycline, amoxicillin/clavulanate
Antimicrobial Therapy
Acute pyelonephritis
Duration on therapy= 7-14 days
TMP/SMX
1 DS (160/800 mg) BID x 14 days
Fluoroquinolone
Ciprofloxacin 500 mg BID x 14 days
Levofloxacin 250mg QD x 14 days
Gatifloxacin 250 mg QDx 14 days
Cephalosporins, doxycycline, amoxicillin/clavulanate
For more seriously ill patients IV therapy
Specific
Recommendations
Contraindications of
short-course therapy
Any man with UTI
Anyone with overt PN
Patients with symptoms of > 7 days duration
Patients with underlying structural of functional defects of
the urinary system
Immunosuppressed individuals
Patients with indwelling catheters
Patients with a high probability of infection with antibioticresistant organisms
Asymptomatic
Symptomatic
No Further
Intervention
Pyuria,
No Bacteriuria
Treat for
Chlamydia
trachomatis
Bacteriuria
w./w.o Pyuria
Treat with
Extended
Course
Failure of Treatment
Patient has
Recurrent Reinfection
Antibiotic-Resistant
Infection
Candidate for
Long-Term
Low-Dose
Prophylaxis
Treat with
Short-Course
Regimen to Which
Organism
Susceptible
Success
Antibiotic-Susceptible
Infection
6 weeks of
High-Dose
Curative
Therapy
Failure
UTI in Pregnancy
should be screened for UTIs high risk for UTIs and their
complications.
Asymptomatic bacteriuria have a 30% risk for acute PN
short course of antibiotics (3 to 5 days).
Uncomplicated UTI need longer-term antibiotics (7 to 10
days).
Sulfonamides, nitrofurantoin, ampicillin, cephalexin safe
in early pregnancy
Avoid: sulfonamides (near term kern icterus ), TMP (toxic
effects in the fetus at high doses), fluoroquinolone (fetal
cartilage development),
UTI in Men
Failure treatment:
- Anatomic factors
- Infection due to E. faecalis or P. aeruginosa
Management of
Catheter-Induced UTI
Prevention
Adequate fluid intake (6-8 glasses/day)
Appropriate hygiene and cleanliness of the genital
Pre & post-coital urination
Avoid tight-fitting pants.
Wear cotton-crotch underwear and panty hose, changing
both at least once a day.
Take showers rather than baths.
Avoid douching or similar feminine hygiene products.
Urinate frequently.
Prognosis