URINARY TRACT INFECTIONS

(UTIs)

LABORATORY OF MICROBIOLOGY
MEDICAL FACULTY
BRAWIJAYA UNIVERSITY
What is
UTIs?

UTIs are defined by

the presence of
microorganisms within
the urinary tract
 Why UTIs?

Importance of UTIs is demonstrated by the

fact that 20% of women between ages 20-65
suffer one attack per year
Approximately 50% of women develop a UTI
during their lives and there is a prevalence
rate of 5% per year of asymptomatic infection
non pregnant women between ages 21 and 65
STRUCTURE OF THE URINARY SYSTEM

Urinary system consists of :

Two kidneys
Two ureters
A single urinary bladder
A single urethra
FUNCTION OF THE URINARY SYSTEM

Certain wastes are

removed from the blood
as it circulates through
the kidneys
The wastes are
collectively called urine
The urine passes through
the ureters into the
urinary bladder, where it
is stored prior to
elimination from the body
Elimination occurs
through the urethra
 Note :
The urinary tract has certain
characteristics that help
prevent infection !

Valves ureters : to prevent the back flow of urine to the kidneys

Acidity of normal urine has some antimicrobial properties
Flushing action of urine to the exterior
 NORMAL MICROBIOTA OF
THE URINARY SYSTEM
Normal urine is sterile in the urinary bladder
and the organs of the upper urinary tract
Urine becomes contaminated with members of the
skin microbiota during its passage through the
urethra
The vaginal introitus and distal urethra are normally
colonized by diphtheroids, streptococcal species,
lactobacilli, and staphylococcal species but not by
the enteric gram-negative bacilli that commonly
cause UTIs.
 DISEASES OF URINARY SYSTEM

Acute infections of the urinary tract can be

subdivided into two general anatomic
categories: lower tract infection (urethritis and
cystitis) and upper tract infection (acute
pyelonephritis, prostatitis, and intrarenal and
perinephric abscesses)
From a microbiologic perspective, urinary tract
infection (UTI) exists when pathogenic
microorganisms are detected in the urine,
urethra,bladder, kidney, or prostate.
(Harrisons, 2005)
 ETIOLOGY
Many different microorganisms can infect the urinary
tract, but by far the most common agents are the gram-
negative bacilli.
Escherichia coli causes 80% of acute infections.
Other gram-negative rods :
Proteus
Klebsiella
Enterobacter
Serratia
Pseudomonas
Proteus spp.
Gram-positive cocci play a lesser role in UTIs:
Staphylococcus aureus
Staphylococcus saprophyticus
Enterococci
 PATHOGENESIS AND SOURCE OF
INFECTION
Enteric gram-negative organisms residing in the
bowel colonize the introitus, the periurethral
skin, and the distal urethra before and during
episodes of bacteriuria.
In the vast majority of UTIs, bacteria gain access
to the bladder via the urethra. Ascent of bacteria
from the bladder may follow and is probably the
pathway for most renal parenchymal infections
 Condition affecting pathogenesis (1)

1. Gender and Sexual Activity

2. Pregnancy
3. Obstruction
4. Neurogenic Bladder Dysfunction
5. Bacterial Virulence Factors
6. Genetic Factors
 Condition affecting pathogenesis (2)
1.Gender and Sexual Activity
The female urethra appears to
be particularly prone to
colonization with colonic gram-
negative bacilli because of its
proximity to the anus, its
short length (4 cm), and its
termination beneath the An important factor
labia. predisposing to bacteriuria in
men is urethral obstruction due
Sexual intercourse causes to prostatic hypertrophy
the introduction of bacteria into
the bladder and is temporally
associated with the onset of
cystitis; it thus appears to be
important in the pathogenesis
of UTIs in younger women.
 Condition affecting pathogenesis (3)

2. Pregnancy 3. Obstruction
This predisposition to Any impediment to
upper tract infection the free flow of urine
during pregnancy (tumor, stricture,
results from stone, or prostatic
decreased ureteral hypertrophy) results
tone, decreased in hydronephrosis
ureteral peristalsis, and a greatly
and temporary increased frequency
incompetence of the of UTI.
vesicoureteral valves.
Condition affecting pathogenesis (4)

4.Neurogenic Bladder Dysfunction

Interference with bladder enervation, as in

spinal cord injury, tabes dorsalis, multiple
sclerosis, diabetes, and other diseases,
may be associated with UTI.
The infection may be initiated by the use
of catheters for bladder drainage and is
favored by the prolonged stasis of urine in
the bladder.
 Condition affecting pathogenesis (5)

5.Bacterial Virulence 6.Genetic Factors

Factors Increasing evidence
Fimbriae suggests that host
Hemolysin genetic factors
Aerobactin (a siderophore influence
for scavenging iron) susceptibility to UTI.
Bacteria resistant to the
bactericidal action of human
serum
 CLINICAL PRESENTATION
1. Cystitis
dysuria, frequency, urgency, and suprapubic pain.

2. Acute Pyelonephritis
fever, shaking chills, nausea
symptoms of cystitis may or may not be present
hematuria may be demonstrated during the acute
phase of the disease

3.Urethritis
acute dysuria, frequency, pyuria
 DIAGNOSTIC TESTING
From a microbiologic perspective, UTI exists
when pathogenic microorganisms are detected
in the urine, urethra,bladder, kidney, or prostate

Growth of 105 organisms per milliliter

(105 CFU/ml urine) from a properly
collected midstream clean-catch
urine sample Significant
The presence of bacteriuria of any bacteriuria
degree in suprapubic aspirates
102 bacteria per milliliter of urine
obtained by catheterization
 Treatment

Nitrofurantoin
Cotrimoxazole
Fluoroquinolon
 Methods for Urine Collection

1.Clean catch mid stream urine

a. For men :
Tip of the penis is cleaned by saline and soap, followed by
warm sterile water; or using Benzalkonium 1/1000 solution,
followed by sterile water.
Patient is asked to urinate, the first part of urine is not
taken, then the mid stream urine is collected in sterile
container.

b. For women:
Vulva & labia fold is washed as in men.
Urinate in standing position, and the midstream urine is
collected.
2. Catheterization
In and out catheter
Indwelling catheter

3.Supra pubic needle aspiration

Particularly for children
Sterile disposable syringe is used, punctured over
symphisis pubis, reaching the bladder.
 URINE STORAGE AND DISPATCH

Urine may not be examined more than 1 hour

after collection.

If postponed, urine should be stored at

refrigerator with 4oC temperature.
URINE EXAMINATION

A. Screening test
1. Microscopy
Specimen is shaken (without centrifugation)
slide smear Gram staining
observe under microscope
> 1 (one) microbe/visual field is equivalent to >105
microbe /ml in colony counting.
2. TTC Reduction (Triphenyl Tetrazolium Chloride)
This test is dependant on respiratory activity of
the growing microbe.
Active microbe reduces TTC 4 hours pink
precipitate.

3. Gries Nitrit test

Based on properties of pathogenic bacteria that
can reduce nitrate to nitrite in urine.
Reaction is observed by simple diazo method.
B. Quantitative Urine Culture Method

1.Calibrated Loop Direct Method/Standardized Loop

Inoculation
Calibrated loop is used (with volume 0,01 ml or 0,001 ml)
Urine is shaken loop is filled
Culture on BAP & EMB / MCA
Incubate 24 hours, 35-37oC
Colony counting on BAP/EMB/MCA
Multiply by calibration factor : 100 x for 0,01 ml loop
1000x for 0,001 ml loop
Identify bacteria and perform antibiotic sensitivity test.
2.Spread Plate Method
A diluted urine is used:

1 ml urine + 9 ml aquadest sterile ( 10 1)

shake 25x

10 2, 10 3

0,1 ml of each dilution

BAP & EMB / MCA

Spread on agar using L spreader glass

Incubate for 24 hours, 35-37oC

Colony counting x dilution factor

Identify bacteria & run antibiotic sensitivity test

3.Simplified Spread Method
No dilution is performed
A pipette is used, where 20 drops = 1 ml (2 drop =
0,1 ml)

Take urine with sterile pipette

Throw away the first 2 drops

Pour 2 drops of urine on the agar vertically with

distance 1 inch from the media

Trypticase soy agar plate

Spread with L spreader glass
 Incubate 24 hour, 35-37oC

Colony counting x dilution (10)

Identify & run antibiotic sensitivity test

This method is used for children suspected with

pyelonephritis. For adults it is better to use
dilution method

Next slide
4. Tube Dilution, End Point Method
Ten tubes containing 9 ml trypticase soy broth is
used.
1 ml urine 1 ml 1ml 1ml 1ml 1ml until 10th tube

BAP & EMB/MCA as in method no. 3

Incubate 24 hours, 35-37oC
Colony counting x dilution (10)
Identify & run antibiotic sensitivity test
5.Pour Plate Method
Make a dilution of urine 10-1, 10-2, 10-3

1 ml

pour into nutrient agar 12-15 ml (50oC)

Shake to mix urine with media

Media solidifies incubate

Colony count (30-300 colony)

Multiply with dilution factor
INTERPRETATION OF RESULT

A. Clean catch mid stream

> 105 microbes /ml urine, positive UTI
103 104 microbes /ml urine, need a repeat examination
< 103 microbes / ml urine contaminant

B. Catheterization in and out, Indwelling catheter,

Supra pubic aspiration
103 -105 microbes / ml urine, confirmed UTI
True UTI may give inappropriate lab result
in the following conditions:
Patient on antibiotic treatment
Early hematogenous pyelonephritis
Total urinary obstruction
BJ urine < 1,003
pH < 5
High urine concentration
TERIMA KASIH
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FOR YOUR ATTENTION
MATUR NUWUN