Urinary-Tract Infections

Dr Robin Smith
• Definition
– Significant bacteriuria in the presence of
symptoms

• Importance
– Common community infection
• 25% of women will suffer at least 1 UTI in lifetime
• 5.5 million GP prescriptions per year
– Most common hospital-acquired infection
• 9% of inpatients have a hospital-acquired infection
• 25% of all hospital-acquired infections are UTIs
Epidemiology: changes with age
• Neonates
– 1 -2%
– Males > females

• 1 yr old
– F:M = 4.5 : 0.5%

• School
– F:M = 1.2 : 0.03%

• Adults
– F:M = 1-3 : 0.1%

• Elderly
– F:M = 20 : 10%
 Pathogenesis (1)

• Ascending infection
– Colonisation of urethra
• Women > men
– Bowel carriage of urovirulent strains
• Urovirulent E. coli, Staphylococcus saprophyticus
– Instrumentation
• Catheterisation, cystoscopy
– Stagnation of urine
 Pathogenesis (2)

• Haematogenous route
– Affect renal parenchyma
• Staphylococcus aureus bacteraemia / endocarditis

– (Lymphatic route)
 Host-parasite interaction:
host defence

• Urinary flow
• Urinary tract mucosa
• Urine itself
– pH and osmolality
– urinary substances
• Systemic immune system
• Surrounding area
– Genital tract / perineal environment
 Host-parasite interaction:
microbial virulence

• Bacterial virulence
– adherence
– evade immune system
– invasion
– nutrition and survival
 Symptoms
• Young children
– Non-specific: fever, failure to thrive, poor feeding,
vomiting
• Older Children and Adults
– Lower Urinary Tract (cystitis)
• Dysuria, frequency, urgency, suprapubic pain, turbid urine,
proteinuria, haematuria
– Upper urinary tract (pyelonephritis)
• + fever, loin pain, systemic symptoms
• Elderly
– Asymptomatic, incontinence, non-specific: confusion
 Diagnosis

• Method of urine collection

– Mid-stream clean catch
– Catheter urine
– Bag urine
– Suprapubic urine
– Ureteric urine
• Method will influence result and
management
Diagnosis: urinalysis sticks

• Dipsticks
– protein, leukocyte
esterase, nitrites
• negative predictive
value = 99%
 Diagnosis: microscopy

• Microscopy
– >50 WBC / mm3
• NB. sterile pyruria
– RBC, casts, crystals
– Gram stain – not routine
 Diagnosis: culture

• Culture
– mainstay of diagnosis
– impossible to sterilise urethra / periurethral
area
• degree of contamination is inevitable
• quantification aims to differentiate infection from
contamination
 Diagnosis: culture
• Criteria for laboratory diagnosis of UTI
– 100,000 (105) cfu of a single bacterial species / ml

• False negatives:
– Patient already on antibiotics
– Frequent bladder voiding
– Men
– Slower growing organisms
– Suprapubic and ureteric urine
• False positives:
– Contamination
 Diagnosis: culture

• Technique
– Calibrated loop containing 0.001ml urine
– 100 colonies on plate = 105 colonies / ml
 Diagnosis: culture
• Sources of error
– Errors in collection
• poor preparation of patient
• previous antibiotics
– Errors in transit
• delayed examination
– cells break down
• lack of refrigeration
– bacteria multiply
– Errors in laboratory
 Organisms

• 71% E.coli
• 13% Klebsiella
• 11% Proteus
• 4% Staphylococcus saprophyticus
• 1% others
– (enterococci, pseudomonas, other staphylococci)
 Management

• Antibiotic treatment
– Ideally await culture and sensitivity result
• 50% will settle
– Empirical choice for severe or complicated
infection
• cover the most likely pathogens
• local resistance rates
 GP urines sent to RFH – 2005

• Resistance of enterobacteriaceae in urine

sent by GPs
– Amoxycillin 50%
– Trimethoprim 28%
– Augmentin 20% (further 11% are intermediate)
– Cephalexin 13%
– Nitrofurantoin 11%
– Ciprofloxacin 7%
• Antibiotic options
– trimethoprim, co-amoxiclav, cephalexin, nitrofurantoin
– ciprofloxacin
– IV ceftriaxone, gentamicin

– Duration
• Uncomplicated: 3 days
• Complicated: 7-14 days

• Other management options

– remove catheters
– hydration
– voiding education
– cranberry juice, growing evidence for probiotics
 Special groups:
Infants / young children
• Reflux
– 30-50% with symptomatic bacteriuria
– Recurrent infection
• Renal scarring
– Renal failure
• Prompt treatment and prophylaxis
• Thorough investigation
• Importance of getting sample collection
right
 Special groups: Pregnancy

• Asymptomatic bacteriuria
– 30% will get pyelonephritis
• Association with prematurity and low birth-
weight infants

• Importance of screening and prompt

treatment
 Special groups: Others
• Young men
– single UTI requires investigation for structural
abnormality
• Diabetics
– kidneys are already under threat
– previous treatment → possible resistant organisms
• Hospitalised patients
– co-morbidity
– catheterisation: >10% get UTI
– possible resistant organisms
 Pyelonephritis
• 1% of UTIs progress to pyelonephritis
• Mainly women
• Elderly men: prostatism

• Symptoms
Usual UTI symptoms
+ Renal parenchyma involvement
• loin pain, nausea, vomiting
+/-Bacteraemia
• high fever, rigors, sepsis

• MSU, blood cultures

• Antibiotics for ≥10 days
• Image renal tract for abscess formation
Urethritis and urethral syndrome

• Symptoms may not be UTI

– No symptoms of bladder irritation
– STIs
• Gonococcus, Chlamydia, Non-specific urethritis
– Urethral/perineal lesions
• HSV, caruncle
– Chemical irritation
 Prostatitis
• Inflammation of the prostate
– Bacterial prostatitis
• STI
• Spread from urinary tract (NB: post-instrumentation)
• Haematogenous spread
– Rare: TB, Fungi
• Symptoms
– Fever, rigors, perineal/rectal/testicular pain,
hesitancy, incomplete voiding
• Diagnosis
– Sexual screen, MSU
– Three glass urine test
• MSU
• Prostatic massage secretions
• Post-massage MSU
 Case study 1

• A 40 year old lady presents with fever,

vomiting and loin pain
– What is the likely diagnosis?
– State two diagnostic investigations
• The isolate from her
blood cultures is
shown
– What aetiology is
likely?
– Suggest suitable
treatment plan
 Case study 2

• A one-year boy old presents with fever and vomiting:

– clinical examination does not reveal an immediate focus of
infection.
– several attempts to collect a clean catch sample fail and a
supra-pubic aspirate is performed.
• Urine microscopy and culture results are as follows:
– Microscopy: >50 WBC/mm3.
– No red blood cells
– Culture 104 - 105 cfu/ml of E. coli

• Is this a UTI?
• Are any additional investigations necessary?
 Case study 3
• A 75 year old man presents to a urology follow-up clinic
– Prostatic surgery for prostatic enlargement two weeks ago.
– He was sent home with a supra-pubic catheter attached to a bag.
– He is well and able to care for himself competently.
– On examination, he has mild lower abdominal discomfort but no
temperature.
– Urine in the bag appears cloudy, so CSU was sent for culture

• Urine microscopy and culture results are as follows:

– Microscopy: no white blood cells /mm3
– Culture: >105 cfu/ml of Klebsiella spp/ml

• Would you treat with antibiotics?

• Would management change if he develops signs of a fever or
increasing pain over the bladder?
• What concerns would you have if he had acquired this organism
while in hospital?
 Take home messages

• Very common infection

– Majority are straightforward
– Many clear without antibiotics
• Accurate diagnosis can be difficult
• Accurate diagnosis can be important
– Special groups at risk of complications
• Use antibiotics wisely
– Potential for massive misuse of antibiotics