Urinary Tract Infection / Pyelonephritis

Classification:
Definitions: Uncomplicated Complicated
UTI: >105 of pure growth of colony forming unit/mL of MSU. N renal tract Male patients
Bacteriuria: Bacteria in urine. May be asymptomatic (covert) or N renal function AbN renal tract
N host defence Obstruction
symptomatic.
Calculi
Asymp. Bacteriuria: requires further invx and Rx ONLY if it Vesico-ureteric reflux
occurs with infants, pregnant women or abN urinary tract Neurological abN
Abacterial cystitis / urethral syndrome: symptoms of UTI in 1/3 of In-dwelling catheter
women who do not have bacteriuria. Chronic prostatitis
Recurrent UTI: a further infection with a new organism Cystic kidney
Analgesic nephropathy
Relapse UTI: further infection with the same organism
Renal scarring
Impaired renal function
Differential diagnosis:
Impaired host defences
Acute appendicitis
Virulent organisms
Diverticulitis
Cholecystitis
Salpingitis Risk factors:
Perinephric abscess Female DM
Sex Immunosuppression
Presentations: Diaphragm contraceptive Malformations
1. Prostatitis Vaginal spermicide Residual urine bladder outflow
2. Cystitis / urethritis Pregnancy obstruction, gynae abN, pelvic floor weakness,
3. Pyelonephritis Menopause neurological problems, vesico-ureteric reflux
4. Septicaemia Instrumentation
5. Asymptomatic bacteriuria Foreign body in bladder depresses
vesical defence
Typical patient profile:
Women prevalence increases with age Organisms:
Men uncommon. Usually in 1st yr of life, or >60 YO a/w BPH. Must Community Hospital
always rule out renal tract abnormalities. E coli (>70%) often from fecal E coli ( 41%, but still
reservoir predominates)
Proteus Klebsiella
Pseudomonas Streptococci

DGIM Last updated March 2005

 Streptococci All patients
Staph. epidermidis Urine dipstix Leucocytes, nitrites, proteinuria, haematuria, glucose
Urine C/S
Symptoms: UFEME White cells, red cells, cast; Fragments of renal papillae in acute
pyelonephritis, analgesic nephropathy and sickle cell disease
Cystitis Frequency
Systemically unwell
Dysuria
FBC Paeds, acute pyelonephritis, prostatitis
Urgency
CRP
Strangury
U/E/Cr Paeds, acute pyelonephritis, recurrent UTI
Suprapubic pain Fever, rigor, septic shock
Blood C/S
Haematuria
Gender based
Urine cloudy and foul smelling
Pelvic exam Women with recurrent UTI
Acute pyelonephritis Fever Men
Prostate exam
Rigors
Further Invxs
Vomiting Indications: Paeds, men, recurrent UTI, pyelonephritis, haematuria, unusual organism,
Loin pain and tenderness persistent fever
Tenderness / guarding Renal U/S Physiological and anatomical abN eg obstruction, cysts, calculi
Dysuria IVU
Acute renal failure MCU (Micturating Dx and quantify vesico-ureteric reflux and disturbed bladder
Septicaemia cysto- emptying (eg Neurogenic bladders)

*Paeds urethrography)
Cystoscopy For invx of chronic haematuria and suspected bladder lesions.
Convulsion, abdo distension,
diarrhoea
Prostatitis Flu-like symptoms Management:
Low back ache Empirical ABx Timethoprim or amoxicillin (vs E coli) 3 days
Change as required when urine C/S results returns
Swollen & tender prostate
Symptomatic relief expected within 2 days
Few urinary symptoms
Persistent UTI Usually in complicated UTI
Longer course or change ABx
Signs:
Fever Renal mass Dx and treat underlying cause
Abdo/ loin tenderness Bladder distension Advice Drink >2 L/day of water
Positive renal punch Enlarged prostate Urinate frequently
Ensure complete bladder emptying
Empty bladder before and after sex
Investigations:
 Application of cetrimide cream to periurethral area ix) Chemical cystitis eg cytotoxic drugs
pre-coital
Empty bladder before bed
Empty bladder twice if reflux present Urinary catheters and their lifespans:
Wipe from front to back after micturition (women) Foleys = 2 wks
Prevention ABx prophylaxis in recurrent UTI continuous or Silicon coated = 4-6 wks
post-coital. Silicon = 3 mths
Rx of candiduria: fluconazole for 1-2 wks
Rx of uncomp upper UTI: 2 wks of usual ABx or 1 wk of Cipro

Renal TB
Secondary to TB elsewhere, spread via blood.
Initial lesion in renal cortex may ulcerate to pelvis, spreading toupdated March 2005
DGIM Last
bladder, epididymis, seminal vesicles and prostate.
Symptoms:
DGIM Last updated March 2005
o General TB symptoms malaise, fever, lassitude, LOW
o Bladder involvement - recurrent haematuria and dysuria
Invx:
i) Urine culture may be sterile in spite of pyuria!
o Always check for TB in sterile pyuria UTI
ii) Cystoscopy examine extent of infection or LUT
Cx: renal failure secondary to
i) Urinary tract obstruction; or
ii) Destruction of kidney tissue

DDx of sterile pyuria:

i) Inadequately Rx UTI
ii) Prostatitis
iii) Calculi
iv) Appendicitis
v) Bladder tumour
vi) Interstitial nephritis
vii) PKD
viii) Papillary necrosis 2o to analgesia