Urinary Tract Infections

Qiu bo
Anatomy
 Lower urinary tract ( superficial )
Urethritis
cystitis
 Upper urinary tract ( tissue
invasion)
Prostatitis
Kidney : Acute Pyelonephritis,
abscess
Urinary Tract Infection Defined
Definition

Women: Presence of at least 100,000 colony-

forming units (cfu)/mL in a pure
culture of voided clean-catch urine

Men: Presence of just 1,000 cfu/mL

indicates urinary tract infection

*Some labs do not routinely identify & determine

the
sensitivity of organisms for specimens with
<10,000
cfu/mL. May have to special request.
 Prevalence of urinary
tract infections (UTI)
 almost half of all women will have at least one UTI
in their lives.
 the risk of UTI in women increases after menopause
 after a UTI, 20 - 40 % will have a recurrence
 the recurring infections are usually reinfections.
 asymptomatic bacteriuria in women occurs in
 2.7% of 15 - 24 year olds

 9.3% of over 65 year olds and

 20 - 50% of over 80 year olds

 Prevalence of UTIs 2
 UTI is rare in young and middle-aged men
 UTI in men is often associated with catheterization
or urological obtruction.
 bacteriuria in elderly men occurs in
 about 10% of those living at home,

 about 20% of those living in nursing homes

 30% of those who are in-patients in hospitals

 urinary catheter increases the risk almost ten-fold

in hospitalised patients and those in other care
homes.
 pyelonephritis is common in patients who have
been catheterised for over a month.
Epidemiology
 Divide into two types:
Catheter associated ( nosocomial)
Non-catheter associated (community
acquired)
 Complicated urinary tract infection
Uncomplicated urinary tract infection
 Community acquired UTI is very common in young
sexual active women
 Unusual in men under 50, common among women
between 20 and 50
 Asymptomatic bacteriuria is more common among
elderly men and women ,with rate as high as 40%-50%
 “Complicated” or
“uncomplicated”?

‘Uncomplicated’ urinary tract infections are

 occasional lower urinary tract

infections in women with no predisposing

factors to infections

‘Complicated’ infections are other UTIs

including
 pregnant women, men, children

 urologic abnormalities, or calculi

 catheter-induced infections

The investigations and treatment of these

patients entail special features
Where are the bugs coming from ????
Etiology/Microbiology
 Gram –negative rods
 Escherichia coli cause 70% of acute
uncomplicated UTI
 Staphylococcus and saprophyticus
account for 10-15% of acute
symptomatic UTI in young females
 Proteus, Klebsiella, enterococcus
account for a smaller proportion of
uncomplicated UTI
Etiology/Microbiology

 Seratia and pseudomonas play a

major role in nosocomial, catheter-
associated infections
 Chlamydia and simplex virus related
to sexual activity
Community-Acquired UTI

E.coli

S.epi &
gm - enterics

Enterococcus
Proteus

K.pneumoniae S.saprophyticus
 Nosocomial UTI
catheter associated
Short Term Long Term
E.coli
Enterobacter E.coli

Enterococcus Proteus

Candida

Proteus
S.aureus Providencia
Morganella
Pseudomonas
Pseudomonas
Pathogenesis
Protective mechanisms of urinary tract
 Under normal circumstances, bacteria
placed in the bladder are rapidly
cleared.
 Through the flushing and dilutional
effects of voiding
 The antibacterial properties of the
urine and the bladder mucosa
 High urea concentration and high
osmolarity
 Pathogenesis of UTIs

 Urinary tract infection occurs when

bacteria which colonise the anal area
ascend through urethra to the bladder
 Risk factors include
 reduced resistance offered by the mucous
membranes (after menopause)
 sexual intercourse
 disturbances in ureteral functioning
 in children the re-entering of urine back into
the ureters (vesicoureteral reflux), which
predisposes them particularly to upper UTI’s
 Pathogenesis of UTIs 2
Other risk factors:

 benign prostatic hypertrophy

 any illness, such as diabetes, which affects the emptying of
the bladder
 spinal injury (associated with disturbances in bladder emptying
or urinary catheter)
 catheterization in hospital or residential care
 other urological abnormalities
 receiving immunosuppressive therapy
 Females with short urethra (4 cm), proximity of the urethra to
the anus
 Use of spermicidal agents
Conditions affecting
pathogenesis
Gender and sexual activity
 female prone to colonization with gram-
negative bacili because of its proximity to the
anus, its short length and its termination
beneath the labia
 sexual intercourse cause the introduction of
bacteria into the bladder
 In men <50 years old, without a history of
heterosexual or homosexual rectal intercourse,
UTI is uncommon, except for obstrution due to
prostate hypertrophy
Acute Uncomplicated Cystitis

 Sexually active young

women.

 Causes: anatomy and

certain behavioral
factors, including delays
in micturition, sexual
activity, and the use of
diaphragms and
spermicides tract.

 Aggressive diagnostic
work-ups are
unwarranted in young
women presenting with
an uncomplicated
episode of cystitis.
Conditions affecting
pathogrnesis
Obstruction
impediment to the free flow of
urine
such as tumor, structure
abnormality, stone and prostatic
hypertrophy can cause
hydronephrosis and UTI
may lead to rapid destruction of
renal tissue
Conditions affecting
pathogrnesis
Pregnancy
 about 2%-8% in pregnant women,
part of women with asymptomatic will
subsequently develop bacteriuria and
pyelonephritis
 reasons: results from decreased
ureteral tone and decreased ureteral
peristalsis, or temporary incompetence
of the vesicoureteral valves
Conditions affecting
pathogrnesis
Neurogenic bladder dysfuction
 Interference with bladder

enervation as in spinal cord injury,

multiple sclerosis, diabetes.
 May be initiated by use of

catheters and is favored by

prolonged stasis of urine in the
bladder
Conditions affecting
pathogrnesis
Vesicoureteral reflux
 Defined as reflux of urine from the

bladder into the ureters and

sometimes into the renal pelvis,
occurs during vioding or with
elevation of pressure in the
bladder.
 Is common among children with

anatomic abnormalitis of the

Anatomic Structure of The
kidney
•Retroperitoneally on
the posterior of the
abdomen
•11cm long 6cm wide
4cm thick
Conditions affecting
pathogrnesis
Bacterial virulence factors
 Markedly influence the likelihood of infection

 Most E. coli cause symptomatic UTI include a

small number of specific O,k,and H serogroups

 Fimbriae mediate the attachment of bacteria

to specific receptors on epithelial cells

 E. coli strains usually ptoduce hemolysin and

aerobactin and resistant to the bactericidal

action of human serum
 Fimbriated
Bacterial Cell

F = Flagellum
Note: All other
appendages
are fimbriae
(a.k.a., pili)
Conditions affecting
pathogrnesis
Genetic factors
 Increasing evidence suggests that host

genetic factors influence susceptibility

to UTI
 A materal history of UTI is more often

than among controls

 The number and type of receptors on

uroepicelial cells to which bacteria may

attach are least in part genetically
determined the urinary infection
Urinary tract infection

Clincal symptoms
Acute Uncomplicated
Cystitis
 Clinical Features:
dysuria,
frequency,
urgency,
suprapubic pain,
hematuria.
 Fever >38C, flank
pain,
costovertebral
angle tenderness,
and nausea or
vomiting suggest
Acute Uncomplicated Cystitis

 The microbiology is
limited to a few
pathogens.

 70%- 85% are caused

by Escherichia coli

 5-20%are caused by
coagulase-negative
Staphylococcus
saprophyticus

 5-12% are caused by

other
Enterobacteriaceae
such as Klebsiella and
Clinical presentation
Acute pyelonephritis
 Symptoms:generally develop rapidly over a

few hours or a day,including fever,shaking

chills,nausea,vomiting,diarrhea,tachycardia,m
uscle tenderness
 Physical examination:reveals tenderness on

deep pressure in one or both costovertebral

angles (between spinal column and the twelfth
rib); or on deep abdominal palpation
 Urine examination: leukocytosis and bacteria

in urine, leukocyte casts, hematuria

Clinical presentation
Urethritis
 30% of women with acute

dysuria,frequency,and pyuria have urine

culture that show no significant bacterial
growth
 Sexually transmitted pathogen, such as

C.trachomatis,gonorrhoeae,or herpes simplex

virus
 History of recent sex-partner change,especially

if the partner has recently developed

chlamydial urethritis
Clinical presentation
Catheter-associated UTI
 10%-15% of hospitalized patients with catheters
develop bacteriuria
 Pathogen:E.coli,
proteus,pseudomonas,klebsiella,serratia,staphylococci,e
nterococci,and candida
 Display markedly antimicrobial resistance than
community-acquired UTI
 Risk factors:female,prolonged catheterization,severe
underlying illness
 Cause minimal symptoms and no fever and often
resolved after withdraw of the catheter
 Treatment should be provided when symptomatic
infections arised, but treatment of asymptomatic
bacteriuria in such patients has no apparent benefit
diagnosis
Diagnostic testing
 Determination of the number and type of
bacteria in the urine is important
 In symptomatic patients: bacteria counts
>105/ml
 In asymptomatic patients: > 105/ml should be
demonstrable in both two consecutive urine
specimens
 or any degree in suprapubic puncture and or
>102/ml obtained by catheterization, usually
indicates infection
 Collecting a sample

 in adults and older children a mid stream urine

(MSU) sample usually reliably represents the
urine in the bladder.
 samples collected from urinary bags or bedpans
should not be used to diagnose UTI as they
invariably will be contaminated
 the most reliable sample is obtained via a
suprapubic puncture
 urine in bladder >4 hours (any shorter time
will increase the risk of false negative findings)
 Diagnosis of UTIs 1

 No need to do any urinalysis,

urinalysis if a
female patient, who does not belong to
any of the risk groups, clearly has
occasional cystitis based on her
symptoms
 Urine microscopy is not usually
necessary to diagnose cystitis
Diagnosis routine
Symptomatic
patient

Uncomplicated cystitis
in a woman, Yes
no risk factors
not a relapse

No
Typical symptoms,
No < 2 infections / year,
Bacterial culture,
patient familiar with
"on the spot" testing
her illness
to confirm diagnosis

Yes

Start
Antibiotic
treatment
based on therapy
results
 Diagnosis of UTIs 2

 Bacterial culture of urine should be carried out in all

cases, except in uncomplicated cystitis, even though
the results will not be available when medication is
commenced (B)

 In early pregnancy bacterial culture should be carried out

in all pregnant women if only to diagnose
asymptomatic bacteriuria (A)

 In adult febrile infections with generalised symptoms,

and in children’s infections, C-reactive protein (CRP)
CRP
concentration above 40 mg/l is suggestive of a kidney
infection (C)
diagnosis
Diagnostic testing
 Microscopy of urine from symptomatic patients
can be great diagnostic value
 Pyuria is a highly sensitive indicator of UTI in
symptomatic patients
 Pyuria in the absence of bacteriuria may
indicate infection with unusual agents such as
trachomatis,mycobacterium,or with fungi
 Or in noninfectious urologic conditions such as
calculi ,anatomic abnormality, vesicoureteral
reflux, interstitial nephritis, or polycystic
disease
diagnosis
Urologic evaluation
 Cystoscopy and intravenous pyelograpy

should be taken in women with

relapsing infection, a history of
childhood infections, stone or painless
hematuria, or recurrent pyelonephritis
 Most males should be considered to

have complicated infection and thus

should be evaluated urologically
diagnosis
Localization of infection
 Unfortunately, currently available

methods of distinguishing renal

parenchymal infection from cystitis
are neither reliable nor convenient
enough
 Fever or an elevated level of c-

reactive protein often accompanies

acute pyelonephritis
Treatment principle
1.Except in acute uncomplicated
cystitis in women, a quantitative
urine culture or a comparable
alternative diagnostic test should
be performed before empirical
treatment is begun
2.When culture results become
available, antimicrobial sensitivity
testing should be used to further
Treatment principle
3.Factors predisposing to infection ,such
as obstruction and calculi, should be
identified and corrected if possible
4.Relief of clinical symptoms does not
always indicate infections cured
5.Each course of treatment should be
classified after its completion as a
failure or a cure
6.In general, uncomplicated infections
confined to the lower urinary tract
respond to short courses of therapy,
while upper tract infection require
longer treatment.
Treatment principle
7.After therapy, early recurrences due to the
same strain, may result from an unresolved
upper tract infection, recurrences>2weeks
after the cessation of therapy always
represent reinfection with a new strain or with
the previously infecting strain that has
persisted in the vaginal and rectal area
8.Despite increasing resistance, community
acquired infections, especially initial infections
are usually due to more antibiotic-sensitive
strains
Treatment principle
 Many have advocated single-dose treatment
for acute cystitis,but often be recurrent
quickly, and single dose therapy does not
eradicate vaginal colonization with E.coli
 A 3-days course of therapy with (TMP-SMX,
norfloxacin, ciprofloxacin, or ofloxacin) are
prefered for acute cystitis. If TMP-SMX
resistance exceeds 20%, fluoroquinolone and
nitrofurantoin can be used
 Pyelonephritis , urologic abnormalities, stones
or previous infection due to antibiotic-resistant
organisms, a 7-14 days course of therapy is
needed
Treatment principle

 Acute uncomplicated pyelonephritis, a 7-14

days course of a fluoroquinolone, an
aminoglycoside, or a third generation
cephalosporin is usually adequate.
 Complicated UTI,usually due to hospital
acquired bacteria, such as E.coli, klebsiella,
proteus, serratia, pseudomonas, enterococci,
and staphylococci, many of the strains are
antibiotic resistant, empirical antibiotic
therapy should provide broad spectrum
coverage against these pathogens
 Antimicrobial therapy in UTIs 1

Acute uncomplicated cystitis:

 patient with typical symptoms, not belonging to any of the
risk groups, is treated without laboratory investigations
 if the symptoms are atypical, a strip test urinalysis may be
carried out to support diagnosis
 if the strip test is negative, the urine should be cultured
and other reasons for the symptoms should be considered

First choices:
 trimethoprim for 3-5 days

 nitrofurantoin for 5-7 days

 Antimicrobial therapy in UTIs 2
Reserve drugs:
 Quinolones (norfloxacin, ofloxacin or ciprofloxacin) for 3

days
 if first choice drugs are not suitable or

 if the infection has not responded to first choice drugs or

 recurrent infection within 4 weeks

 if there is a relapse, urine must be cultured and the

treatment should be continued for 7 days

 In special cases:

 cefalexin or cefadroxil for 5 days (if the above are

contraindicated)
 sulphatrimethoprim for 3 days (particularly if the

level of infection is unclear)

 amoxicillin for 5 days (particularly in enterococcal

infections)
 Single-dose therapy

 single-dose therapy is slightly less effective

than conventional therapy
 effective in infections caused by E. coli,
coli
but less effective in S. saprophyticus
infections
 Preparations:
 phosphomycin 3 g

 norfloxacin 800 mg

 ciprofloxacin 500 - 750 mg

 ofloxacin 200 mg as a single dose

 Treatment of pyelonephritis

Uncomplicated pyelonephritis:

 A pyelonephritis patient who is not

unduly ill can be looked after at home
(C)
 Treatment with either a
fluoroquinolone or
sulphatrimethoprim orally for 10-14
days
 Treatment of pyelonephritis 2
An unwell pyelonephritis patient with or without high
temperature should be admitted to hospital

 in hospital the treatment is commenced with cefuroxime i.v.

0.75-1.5g every 8 hours or with an fluoroquinolone orally
 third-generation cephalosporins are usually not recommended
for the treatment of uncomplicated pyelonephritis, but
ceftriaxone may be chosen as the initial therapy, if either
once a day or intramuscular administration are considered
beneficial
 aminoglycosides have shown no additional benefits over other
forms of treatment
 Treatment during pregnancy

Bacteriuria during pregnancy is

associated with increased risk of
premature labour and pyelonephritis

 asymptomatic bacteriuria and cystitis are treated in

the same way
 single-dose treatment is not recommended
 drugs of choice

beta-lactamase (mecillinam, amoxicillin or
first-generation cephalosporins) for 5 – 7 days.
 due to foetal risk fluoroquinolones should be
avoided during the whole of pregnancy
 and sulphatrimethoprim during the latter part of
pregnancy
 Lower UTIs in children

 treatment principles are the same

as for adults
 little evidence to support short
term treatment in children (C)
 drugs of choice
 nitrofurantoin 5 mg/kg/day or
 trimethoprim 8 mg/kg/day
 treatment to continue for 5 days (C)
 UTIs in men

 a UTI in men can be associated with either

acute or chronic bacterial prostatitis
 prostatitis or epididymitis may
play a part particularly in febrile UTI
 it is advisable to palpate both the prostate
and scrotum
 chronic bacterial prostatitis, or at least the
retention of bacteria in the prostatic ducts,
should be suspected in relapses with the
same causative bacteria
 UTIs in men 2

Afebrile lower urinary tract infection in men:

men

 if the infection is not associated with urinary stricture or

prostatitis,it is treated with the same drugs as cystitis in
women, but the treatment should continue for 7 -
10 days
 nitrofurantoin should not be used in men as
adequate prostatic concentrations are not achieved (D)

Febrile urinary tract infection in men is treated with

 a long course of antibiotics with good prostatic and

epididymal penetration
 first choice: a fluoroquinolone for 2 weeks
 UTIs in men 3
UTI in men associated with acute
bacterial prostatitis
 treatment for 4 - 6 weeks (depending how
quickly patient responds to treatment)
 to be followed up with low dose prophylaxis
with e.g. trimethoprim or nitrofurantoin

Chronic bacterial prostatitis

 recurrent UTI’s and calcifications in prostate
 oral quinolones for 2 – 3 months (D)
 to be followed up with prophylactic medication
 Treatment of UTI in diabetics

Cystitis in diabetics
 drugs of choice for initial treatment are same as for
uncomplicated UTI
 always be based on the
antibiotic treatment must
results of urine culture
 treatment to continue for 7 days

Acute pyelonephritis in diabetics

 treatment is the same as for uncomplicated
pyelonephritis
 consider urological imaging earlier than normal, if there
is no response to appropriately chosen medication
 the causative agents of recurrent UTI’s in diabetics are
often unusual, resistant microbes (species of
Antimicrobial therapy in association
with a urinary catheter 1

 the treatment of UTI in a

catheterized patient should
always be based on the identity
and sensitivity of the causative
microbe
 the catheter should always be
removed, at least for the duration of
treatment, as otherwise the bacteria
will not be eradicated
 if this is not feasible, the
recommendation is to continue
 Antimicrobial therapy in
association with a urinary
catheter 3

Fungal bladder infection in a

catheterised patient:
 systemic fluconazole is slightly more
effective than topical amphotericin B
 removal of the catheter will improve the
eradication of the microbe during therapy

Suprapubic catheter:
 its use is associated with a lower incidence
of bacteriuria in postoperative care
 any infections are treated as any other
infections associated with urinary
treatment
 Asymptomatic bacteriuria
 In noncatheterized patients is common,
especially among elderly patients, but
has not been linked to adverse
outcomes in most circumstances, thus
antimirobial therapy is unnecessary.
 But patients with high-risk patients with
neutropenia, renal transplants,
obstruction, or other complicating
conditions may require treatment
Complications
 Papillary necrosis
 Risk factors: vascular diseases of the
kidney, urinary tract obstruction,
diabetes, chronic alcoholism
 Manifestations: hematuria, pain in the
flank or abdomen, chills and fever,
acute renal failure,
 Diagnosis: necrotic tissue pass in the
urine, or a “ring shadow” on
pyelography
prognosis
 Uncomplicated cystitis or
pyelonephritis, results in complete
resolution
 Cytitis may result in upper tract
infection or in bacteremia, but seldom
develop renal impairment
 Repeated upper tract infection will lead
to renal dysfunction, a search for renal
calculi or urologic abnormality should
be taken
prevention
 Women experience frequent
symptomatic UTI (>3 thrice/year), long-
term administration of low-dose
antibiotics should be given to prevent
recurrences
 Daily or thrice/week administration of a
single dose of TMP-SMX, or
nitrofurantoin has been particulary
effective
 Women should be advised to avoid
spermicide use, and to void soon after
sexual intercourse
 After voiding, wipe from front to back