Dr. dr.

Sahala Panggabean, SpPD-KGH

Madical Faculty
Christian University of Indonesia

URINARY TRACT INFECTION
Second most common
infection following
respiratory infections

UTI occur when bacteria
(E. coli) from the
digestive tract get into
the opening of the
urinary tract and
multiply

Bacteria first infect the
urethra, then move to
the bladder and finally
to the kidneys

UTI tend to occur more
in women than men
Urinary tract is normally
sterile due to the fact that
bacteria moving upwards
are regularly washed out
by urination

Normal flora found in the
urethra consist of
lactobacillus and
staphylococcus to name a
few


URINARY TRACT INFECTION
Figure 23.2
Figure 23.3
What are UTIs?
A significant bacteriuria in the presence of symptoms

Bacteria most often of faecal origin

Common causes of acute UTIs:
50-70% = E. coli strains
5-15% = Klebsiella pneumoniae
5-15% = Enterobacteriaceae or enterococci
6
Epidemiology
Second only to respiratory infections (>6 million visits
to doctors per year USA)

Large majority of adult cases are females - 30:1

Women generally don't have many problems with
UTI's until they become sexually active.

Postmenopausal:
bladder or uterine prolapse
loss of estrogen that causes a change in the vaginal flora
loss of lactobacilli in the vaginal flora which results in periurethral
colonisation

Males experience a rapid increase in the incidence
UTI's sometime in their 50s - benign prostatic
hypertrophy.
7
Predisposing factors
Sexual activity in females
(7590%)
Abnormality of the UT
that obstructs or slows the
flow of urine (i.e. kidney
stone)
Elderly males: prostatic
hypertrophy
Pregnancy
Catheterisation
Surgery, e.g.
prostatectomy
Diabetes mellitus

Immunosuppressed
patients

Congenital abnormalities in
infants that sometimes
require surgery, e.g. vesico-
uretic reflux

Women who use the
diaphragm and spermicides

Patients with a neurogenic
bladder or bladder
diverticulum

Routes of spreads

Ascending transurethral route
From the lower UT is the
commonest
At first there is colonisation
of the distal
urethra & introitus in female
by coliform
bacteria
Hematogenous
Through blood stream e.g.
septicaemia
Lymphatics
Direct extension from vesico
colic fistula
Hematogenous Infection
Chronic infections (skin, respiratory tract)
blood circulation kidney (cortex)
small abscess renal tubular
renal pelvis renal papillary
Ascending Infection

The ability of host defense
Urinary tract mucosal cells damaged
The power of bacterial adhesions(toxicity)
organisms urethra,periurethral tissues
bladder ureters renal pelvis
renal medulla
Classification
Lower urinary tract infection (Urethritis, Cystitis, Prostatitis)
Upper urinary tract (Pyelonephritis)
Complicated UTI
Is considered to be present when there are underlying factors that
predispose to ascending bacterial infection.
Uncomplicated UTI
Occurs without underlying abnormality or impairment of urine flow.
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URINARY TRACT INFECTION
TYPES
LOWER TRACT INFECTION UPPER TRACT INFECTION
URETHRITIS

PROSTATITIS

CYSTITIS
PYELONEPHRITIS



PERI NEPHRIC ABSCESS
Symptoms of UTIs
Cystitis and urethritis
Abrupt onset of
frequency of
micturition
Dysuria
Lower back pain,
abdominal pain, and
tenderness over
bladder
Suprapubic pain
during and after
voiding
Urgency
Urine may appear
cloudy and
unpleasant smell
haematuria

Pyelonephritis
Fever > 38
Loin pain
Prostatitis
Pain in lower back ,
perirectal area and
testicles
High fever, chills and
symptoms similar to
bacterial
Inflammatory
swelling of prostate,
which can lead to
urethral obstruction
Urinary retention,
which can cause
abcess formation or
seminal vesiculitis
Findings on Exam in UTI
Physical Exam:
CVA tenderness (pyelonephritis)
Urethral discharge (urethritis)
Tender prostate on DRE (prostatitis)
Labs: Urinalysis
+ leukocyte esterase
+ nitrites
More likely gram-negative rods
+ WBCs
+ RBCs
Uncomplicated (simple) Cystitis
Definition
Healthy adult woman (over age 12)
Non-pregnant
No fever, nausea, vomiting, flank pain

Risk factors:
Sexual intercourse
May recommend post-coital voiding or prophylactic
antibiotic use.

Treatment
Trimethroprim/Sulfamethoxazole for 3 days
Fluoroquinolone (ciprofoxacin or levofloxacin) in
patient with sulfa allergy, areas with high rates of
bactrim-resistance
Complicated Cystitis
Definition
Females with comorbid medical conditions
All male patients
Indwelling foley catheters
Urosepsis/hospitalization
Diagnosis
Urinalysis, Urine culture
Further labs, if appropriate.
Treatment
Fluoroquinolone (or other broad spectrum
antibiotic)
7-14 days of treatment (depending on severity)
May treat even longer (2-4 weeks) in males with UTI
Special cases of Complicated cystitis
Indwelling foley catheter
Try to get rid of foley if possible!
Only treat patient when symptomatic (fever, dysuria)
Leukocytes on urinalysis
Patients with indwelling catheters are frequently colonized with
great deal of bacteria.
Should change foley before obtaining culture, if possible
Candiduria
Frequently occurs in patients with indwelling foley.
If grows in urine, try to get rid of foley!
Treat only if symptomatic.
If need to treat, give fluconazole (amphotericin if
resistance)

Recurrent Cystitis
Want to make sure urine culture and
sensitivity obtained.
May consider urologic work-up to
evaluate for anatomical abnormality.
Treat for 7-14 days.
Pyelonephritis
Infection of the kidney
Associated with constitutional symptoms fever, nausea,
vomiting, headache
Diagnosis:
Urinalysis, urine culture, CBC, Chemistry
Treatment:
2-weeks of Trimethroprim/sulfamethoxazole or fluoroquinolone
Hospitalization and IV antibiotics if patient unable to take po.
Complications:
Perinephric/Renal abscess:
Suspect in patient who is not improving on antibiotic therapy.
Diagnosis: CT with contrast, renal ultrasound
May need surgical drainage.
Nephrolithiasis with UTI
Suspect in patient with severe flank pain
Need urology consult for treatment of kidney stone



Prostatitis
Symptoms:
Pain in the perineum, lower abdomen, testicles, penis, and with
ejaculation, bladder irritation, bladder outlet obstruction, and
sometimes blood in the semen
Diagnosis:
Typical clinical history (fevers, chills, dysuria, malaise,
myalgias, pelvic/perineal pain, cloudy urine)
The finding of an edematous and tender prostate on physical
examination
Will have an increased PSA
Urinalysis, urine culture
Risk Factors:
Trauma
Sexual abstinence
Dehydration
Treatment:
Trimethoprim/sulfamethoxazole, fluroquinolone or other
broad spectrum antibiotic
4-6 weeks of treatment

Urethritis
Chlamydia trachomatis
Frequently asymptomatic in females, but can present with dysuria, discharge
or pelvic inflammatory disease.
Send UA, Urine culture (if pyuria seen, but no bacteria, suspect Chlamydia)
Pelvic exam send discharge from cervical or urethral os for chlamydia PCR
Chlamydia screening is now recommended for all females 25 years
Treatment:
Azithromycin 1 g po x 1
Doxycycline 100 mg po BID x 7 days

Neisseria gonorrhoeae
May present with dysuria, discharge, PID
Send UA, urine culture
Pelvic exam send discharge samples for gram stain, culture, PCR
Treatment:
Ceftriaxone 125 mg IM x 1
Cipro 500 mg po x 1
Levofloxacin 250 mg po x 1
Ofloxacin 400 mg po x 1
Spectinomycin 2 g IM x 1
You should always also treat for chlamydia when treating for
gonnorhea!


Antibiotics used in the management of urinary tract
infections
Treatment based on organism
Organism Treatment
Escherichia coli Trimethoprim, cephalexin, Gentamicin
Proteus spp. Trimethoprim, cephalexin, Gentamicin
Klebsiella spp. Trimethoprim, cephalexin, Gentamicin
Pseudomonas aeruginosa Ciprofloxacin, Gentamicin
Enterococcus spp Amoxicillin, Vancomycin
Staphylococcus aureus Trimethoprim, cephalexin, Gentamicin
Coagulase-negative staphylococci Trimethoprim, cephalexin, Gentamicin
Treatment of UTIs-Antibiotic doses
Lower Urinary Tract
Infection
Acute Pyelonephritis Bacterial Prostatitis Prophylactic
therapy
Trimephoprim 200mg twice a day for
three days
200mg twice a day for 7-14
days
200mg twice a day
for 4-6weeks
100mg at night
Nitrofurantoin 50mg four times a day
for three days
50mg twice a day for 7-14
days
- 50-100mg at
night
Co-amoxiclav 375mg 8-hourly for
three days
375mg 8-hourly for 7-14 days - -
Ciprofloxacin
(adjust dose in
renal impairment)
100mg 12-hourly for
three days

250mg-500mg every 12-
hourly for 7-14 days
250mg 12-hourly for
4-6 days

-
Norfloxacin (adjust
dose in renal
Impairment)
400mg 12-hourly for
three days
400mg 12-hourly for three
days
400mg 12-hourly for
4-6 days

-
Ceufuroxime
(adjust dose in renal
impairment)
125mg 12-hourly for
three days

250mg 12-hourly or 750mg
6-8hourly IV in seriously ill
patient, for 7-14 days
- -
Cefalexin 500mg 12-hourly for
three days
500mg 12-hourly for three
days
- 125mg at night
Measures to prevent UTIs
Keep Hydrated (fluid intake at least 2L per day)
Encourage regular complete emptying of the bladder
Good personal hygiene
For women, avoid feminine hygine sprays
Encourage front toback cleansing
Showers preferable to baths
Cranberry juice maybe effective
Frquently change those who use incontinence pads