07/10/2017

Urinary Tract Infection : TOPICS

What Should We Know ? • WHAT IS URINARY TRACT INFECTION ?
• HOW RELEVANT IS THIS TO MY
PRACTICE ?
• WHAT CAN I DO IN MY PRACTICE ?
Medan Update „99 Return : • WHEN SHOULD I REFER TO A
“Bersama Alumni Membangun Prestasi” SPECIALIST ?
Riyani Susan Bt. Hasan
A Former Student ’99
• TAKE HOME MESSAGES
School of Medicine Islamic University of Sumatera Utara
Medan
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WHAT IS URINARY TRACT WHAT IS URINARY TRACT

INFECTION ?
• Urinary tract infection (UTI) is a collective
term that describes any infection
involving any part of the urinary
tract (the kidneys, ureters, bladder
and urethra).
• The urinary tract can be divided into the
upper (kidneys and ureters) and lower
(bladder and urethra).
INFECTION ?
• The EAU Guidelines (European Associations of
Urology, 2015) give a short summary of a tentative
improved system of classification of UTI based on:
A. Anatomical level of infection;
 Urethra : Urethritis (UR)
 Urinary bladder : Cystitis (CY)
 Kidney : Pyelonrphritis (PN)
 Bloodstream : Sepsis (US)
B. Grade of severity of infection (level 1- 6);
C. Underlying risk factors (according to ORENUC –
Table 1);
D. Microbiological findings (Pathogen).

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WHAT IS URINARY TRACT

INFECTION ?

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WHAT IS URINARY TRACT HOW RELEVANT IS THIS TO MY

INFECTION ?
• Example :
– CY-1R: E. coli (a) : simple cystitis but recurrent
with susceptibility to standard antibiotics.
– PN-3U: K pneumonia (b) : severe pyelonephritis
(with high fever and vomiting), with underlying
urological disease (e.g. stones or obstruction)
due to Klebsiella sp., with a moderate antibiotic
resistance profile.
– US-5C: Enterococcus sp. (a): severe urosepsis
with an antibiotic-sensitive Enterococcus sp. in a
patient with an indwelling catheter.
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PRACTICE ?
• Uncomplicated lower UTI remains one of
the most commonly treated infections in
primary care.
• It is reported that one in three women have their
first episode of UTI by the age of 24 years.
• UTIs are most commonly seen in sexually active
young women.
• Other susceptible adults include the elderly and
patients requiring urethral catheterisation
(Foxman, 2002 citation by Tan, CW. & Chleibicki,
MP., 2016)

HOW RELEVANT IS THIS TO MY HOW RELEVANT IS THIS TO MY

PRACTICE ?
• In children, UTIs are a frequent health
problem, with the incidence only a little lower
than that of upper respiratory and digestive
infections.
• UTIs are among the most commonly
encountered infections in the pediatric age
group. both in the community and hospital
settings (Ronald et al., 2001; Stamm and Norrby,
2001; Nicolle, 2002; Hooton et al., 2004).
PRACTICE ?
• Paediatric UTI is the most common cause of
fever of unknown origin in boys aged < 3
years.
• The clinical presentation of UTI in infants and
young children can vary from fever to
gastrointestinal and lower or upper urinary
tract symptoms.

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WHAT CAN I DO IN MY
PRACTICE ?
• EARLY DIAGNOSIS
• PROMPT MANAGEMENT

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WHAT CAN I DO IN MY
PRACTICE ?

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WHAT CAN I DO IN MY WHEN SHOULD I REFER TO A

PRACTICE ?
RECURRENT UTI
• Antimicrobial prophylaxis can be given continuously
(daily, weekly) for longer periods of time (3-6 months).
• The choice of antibiotics is the same as for sporadic
acute uncomplicated UTI (Table 3).
• Continuous antimicrobial prophylaxis regimens for
women with recurrent UTIs include e.g. nitrofurantoin
50 mg or 100 mg once daily, fosfomycin trometamol 3 g
every 10 days, and during pregnancy e.g. cephalexin
125 mg or 250 mg or cefaclor 250 mg once daily.
SPECIALIST ?
Referral to a specialist is recommended for these cases :
1. All lower urinary tract symptoms in men :
a) Lower urinary tract symptoms that have not responded to
conservative management or drug treatment;
b) Lower urinary tract symptoms complicated by recurrent or
persistent UTIs
c) Suspected urological cancer.
2. UTIs in the paediatric age group :
a) Infants aged under 3 months with a possible UTI;
b) Infants and children aged 3 months or older with acute
pyelonephritis/upper UTI.

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WHEN SHOULD I REFER TO A

TAKE HOME MESSAGES
SPECIALIST ?
Referral to a specialist is recommended for these cases : 1. ABU does not require antibiotic therapy.
3. UTIs with : 2. UTIs are one of the most common bacterial infections
a) Severe symptoms; encountered by primary physicians and most
b) Failed medical therapy; uncomplicated UTIs can be treated in the outpatient
c) Evidence of retention (acute or chronic); setting with appropriate antibiotics.
d) Abnormalities detected on USG or cytology : calculi or bladder 3. Differentiating UTIs into simple (uncomplicated) and
tumour. complicated using the European Association of
4. Recurrent UTIs (defined as ≥ 3 UTIs in 12 months) Urology’s ORENUC classification aids in appropriate
a) Risk factors for complicated UTI are present; clinical management for better patient outcomes.
b) A surgically correctable cause is suspected;
c) A diagnosis of UTI is uncertain for recurrent lower urinary tract
symptoms.
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TAKE HOME MESSAGES REFERENCES

4. Simple lower-tract UTIs can be treated with
appropriate oral antibiotics with no need for urine
culture.
5. All males with a UTI and all infants aged under 3
months with a possible UTI should be reviewed by a
urologist.
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• Tan, CW., Chlebicki, MP. Urinary tract infections in adults.
Singapore Med J2016; 57(9).
• Grabe M, Bjerklund-Johansen TE, Botto H, et al; European
Association of Urology. Guidelines on urological infections 2015.
Available at: http:// uroweb.org/wp-content/ uploads/19-Urological-
infections_LR2.pdf. Accessed September 20, 2017
• National Institute for Health and Care Excellence. Urinary tract
infection in under 16s: diagnosis and management. In: NICE
guidelines [CG54]. Available at https://www.nice.org.uk/
guidance/cg54. Accessed September 20, 2017
• Dason S., Dason JT.,Kapoor A. Guidelines for the diagnosis and the
management of recurrent urinary tract infection in women. Can Urol
Assoc J 2011;5(5). Accessed September 20, 2017
• Scottish Intercollegiate Guidelines Network. Management of
suspected bacterial urinary tract infection in adults. In : Scottish
Intercollegiate Guidelines Network (SIGN 88). Accessed September
20, 2017
• Hanna-Wakim RH, Ghanem ST, El Helou MW, et al. Epidemiology
and characteristics of urinary tract infections in children and
adolescents. Front Cell Infect Microbiol 2015
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