5/4/2017 Approachtourinarytractinfections

IndianJNephrol.2009Oct19(4):129139. PMCID:PMC2875701
doi:10.4103/09714065.59333

Approachtourinarytractinfections
M.S.Najar,C.L.Saldanha, 1,2andK.A.Banday

DepartmentofNephrology,SheriKashmirInstituteofMedicalSciences,Soura,Srinagar,J&K,India
1
DepartmentofGynaecologyandObstetrics,SheriKashmirInstituteofMedicalSciences,Soura,Srinagar,J&K,India
2
DepartmentofSKIMSMedicalCollege,Bemina,Srinagar,J&K,India
Addressforcorrespondence:Dr.M.SaleemNajar,DepartmentofNephrology,SheriKashmirInstituteofMedicalSciences,Srinagar,J&K,
India.Email:saleem_najar@rediffmail.com

CopyrightIndianJournalofNephrology

ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommonsAttributionLicense,whichpermitsunrestricteduse,
distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.

Abstract
Urinarytractinfection(UTI)isthemostcommoninfectionexperiencedbyhumansafterrespiratoryand
gastrointestinalinfections,andalsothemostcommoncauseofbothcommunityacquiredandnosocomial
infectionsforpatientsadmittedtohospitals.Forbettermanagementandprognosis,itismandatorytoknow
thepossiblesiteofinfection,whethertheinfectionisuncomplicatedorcomplicated,reinfectionorrelapse,
ortreatmentfailureanditspathogenesisandriskfactors.Asymptomaticbacteriuriaiscommonincertainage
groupsandhasdifferentconnotations.Itneedstobetreatedandcompletelycuredinpregnantwomenand
preschoolchildren.Refluxnephropathyinchildrencouldresultinchronickidneydiseaseotherwise,urinary
tractinfectionsdonotplayamajorroleinthepathogenesisofendstagerenaldisease.Symptomaticurinary
tractinfectionsoccurmostcommonlyinwomenofchildbearingage.Cystitispredominates,butneedstobe
distinguishedfromacuteurethralsyndromethataffectsbothsexesandhasadifferentmanagementplanthan
UTIs.Theprostatitissymptomsaremuchmorecommonthanbacterialprostaticinfections.Thetreatment
needstobeprolongedinbacterialprostatitisandascureratesarenotveryhighandrelapsesarecommon,the
classificationofprostatitisneedstobeunderstood.TheconsensusconferenceconvenedbyNationalInstitute
ofHealthaddedtwomoregroupsofpatients,namely,chronicprostatitis/chronicpelvicpainsyndromeand
asymptomaticinflammatoryprostatitis,inadditiontoacuteandchronicbacterialprostatitis.Althoughwhite
bloodcellsinurinesignifyinflammation,theydonotalwayssignifyUTI.Quantitativeculturesofurine
providedefinitiveevidenceofUTI.Imagingstudiesshouldbedone36weeksaftercureofacuteinfection
toidentifyabnormalitiespredisposingtoinfectionorrenaldamageorwhichmayaffectmanagement.
Treatmentofcystitisinwomenshouldbeathreedaycourseandifsymptomsareprolonged,thenaseven
daycourseofantibioticsshouldbegiven.Selectedgroupofpatientsbenefitsfromlowdoseprophylactic
therapy.Upperurinarytractinfectionmayneedinpatienttreatment.Treatmentofacuteprostatitisis30day
therapyofappropriateantibioticsandforchronicbacterialprostatitisalowdosetherapyfor612months
mayberequired.Itshouldbenotedthatnoattemptshouldbemadetoeradicateinfectionunlessforeign
bodiessuchasstonesandcathetersareremovedandcorrectableurologicalabnormalitiesaretakencareof.
Treatmentundersuchcircumstancescanresultonlyintheemergenceofresistantorganismsandcomplicate
therapyfurther.

Keywords:Acuteurethralsyndrome,bacteriuria,imagingstudies,lowdoseprophylaxis,urinarytract
infection,urineculture

Introduction
Urinarytractinfection(UTI)isthethirdmostcommoninfectionexperiencedbyhumansafterrespiratoryand
gastrointestinalinfections.Infact,bacterialinfectionsoftheurinarytractarethemostcommoncauseofboth
communityacquiredandnosocomialinfectionsforpatientsadmittedtohospitalsinUnitedStates.Itis

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distressingandoccasionallylifethreatening.However,theprognosisandmanagementofurinarytract
infectionsdependsonthesiteofinfectionandanypredisposingfactors.

UTImaybedefinedasaconditioninwhichbacteriaareestablishedandmultiplyingwithintheurinarytract.
Diagnosisrequiresdemonstrationofbacteriuria.Exceptionstothisincludepatientswithpyogenicabscessof
kidneyorperinephrictissue,obstructedpyonephrosisorbacterialprostatitisinwhomtheurinemaybe
sterile.

Somedefinitionsarenecessarybecausetheinfectionoftheurinarytractmayresultfrommicrobialinvasion
ofanyofthetissuesextendingfromurethralorificetotherenalcortex.Althoughtheinfectionandresultant
symptomsmaybelocalized,thepresenceofbacteriainurineplacestheentireurinarysystematriskof
invasionbybacteria.

Significantbacteriuria
Itisdefinedasthepresenceof100000ormorecolonyformingunits(CFU)permlofurine.ThisKass[1]
criteriahasbeenquestionedandbacterialcountsof102ormoreorganismpermlparticularlywhen
accompaniedbypyuria(>10wbc/mm3)provideimpressiveevidenceofurinarytractinfectionin
symptomaticyoungwomen.[2]TheInfectiousDiseaseSocietyofAmerica(IDSA)gaveaslightlymore
relaxedconsensusdefinitionrequiring103organismspermltodiagnosecystitisand104permlfor
pyelonephritis.[3]

Anatomiclocation
Itisusefultodistinguishbetweenupper(kidney)andlower(bladder,prostateandurethra)urinarytract
infections.Infectionsconfinedtolowerurinarytractcommonlycausedysuria,frequencyandurgency.
Pyelonephritis(inflammationoftherenalparenchyma)isaclinicalsyndromecharacterizedbychillsand
fever,flankpainandconstitutionalsymptomscausedbybacterialinvasionofthekidney.

Thelocalizationofthesiteofinfectiononthebasisofsymptomsandsignscanbeinaccurate.Usingureteral
catheterization,ithasbeenshownthatapproximately50%ofwomenwithasymptomaticbacteriuriahad
infectionintheiruppertracts.[4]

Responsetotreatmentisnowusedtodistinguishbetweenthetwoupperversuslowerurinarytract
infections.Thisisbasedontheobservationthatmanywomenwithsymptomsofcystitisshownby
localizationstudiestobeconfinedtobladdercanbecuredbyasingledoseofantibiotic.[5]Recurrenceof
bacteriuriawiththesameorganismwithinsevendaysofsingledosetherapywasreportedtobemostoften
associatedwithuppertractinfection.

Complicatedanduncomplicatedurinarytractinfection
Thereisageneralagreementthatforthebestmanagementofpatientswithurinarytractinfections,itis
importanttodistinguishbetweencomplicatedanduncomplicatedinfections.Complicatedinfectionsinclude
thoseinvolvingtheparenchyma(pyelonephritisorprostatitis)andfrequentlyoccurinthesettingof
obstructiveuropathyorafterinstrumentation.Thepresenceofobstruction,stonesorhighpressurevesico
uretericreflux,perinephricabscess,lifethreateningsepticemiaoracombinationofthesepredisposeto
kidneydamage[Figure1].[6]Episodesmayberefractorytotherapy,oftenresultinginrelapsesand
occasionallyleadingtosignificantsequelaesuchassepsis,metastaticabscessandrarelyacuterenalfailure.
Anuncomplicatedinfectionisanepisodeofcystourethritisfollowingbacterialcolonizationoftheureteral
andbladdermucosae.Thistypeofinfectionisconsideredtobeuncomplicatedbecausesequelaearerareand
exclusiveduetothemorbidityassociatedwithreinfectioninasubsetofwomen.Asubsetofpatientswith
pyelonephritis(acuteuncomplicatedpyelonephritis),namely,youngwomenwhorespondwelltotherapy
mayalsohavealowincidenceofsequelae.

Recurrentinfectionreinfection,relapseandtreatmentfailure
Reinfectionisarecurringinfectionduetoadifferentmicroorganismthatisusuallydrugsusceptible.Most
recurringepisodesofcystouretheritisareduetoreinfectionsthataremuchmorecommonthanrelapseand
accountsforabout80%ofrecurrentinfections.[7]Unlikerelapse,reinfectiondoesnotrepresentfailureto
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eradicateinfectionfromurinarytractbutisduetoreinvasionofthesystem.Prophylacticmeasuresmustbe
initiated.Relapseisareturnofinfectionduetothesamemicroorganismwhichisoftendrugresistant.Itis
definedastherecurrenceofbacteriuriawiththesameorganismwithinthreeweeksofcompletingtreatment,
whichduringtreatmentrenderedtheurinesterile.Relapseimpliesthattherehasbeenafailuretoeradicate
theinfection.Thismostoftenoccursinassociationwithrenalscars,stones,cysticdiseaseorprostatitisandin
patientswithchronicinterstitialdiseaseorinthosewhoareimmunecompromised.[8]

Thetermtreatmentfailurehasbeenusedtodescribefailuretoeradicatebacteriuriaduringtreatmentand
failuretopreventrelapse.

Factorspredisposingtotreatmentfailure:

Recentantibiotictreatment
Hospitalacquiredinfection
Renalorbladdercalculi
Obstructiveuropathy
Renalcysts
Renaldiseasessuchasrefluxnephropathy,chronicinterstitialnephropathy,analgesicnephropathy,
diabeticnephropathy,sicklecellnephropathy,immunosuppression,andprostatitis.

Riskfactorsandpathogenesis
Theunderstandingofthepathogenesisandepidemiologyofurinarytractinfectionscanfacilitateearly
recognitionandpossibleprevention.

AssociationshavebeenestablishedbetweenUTIandage,pregnancy,sexualintercourse,useofdiaphragm
andaspermicide,delayedpostcoitalmicturition,menopauseandahistoryofrecentUTI.Factorsthatdonot
seemtoincreasetheriskofUTIincludediet,useoftampons,clothingandpersonalhygieneincluding
methodsofwipingafterdefecationandbathingpractices.[9]

Studiesonpathogenesishaveelucidatedspecificinteractionsbetweenthehostandmicrobesthatarecausally
relatedtobacteriuria.Bacteriaintheentericfloraperiodicallygainaccesstothegenitorurinarytract.Close
proximityofanusinwomentoperiurethraisalikelyfactor.Bacterialcolonizationofperiurethraoften
precedestheonsetofbladderbacteriuria.PfimbriatedstrainsofEscherichiacoliadheretouroepithelialcells
inwhichglycolipidsfunctionasreceptorsinwomenwhosecretebloodgroupantigens.Opposing
colonizationareseveralhostfactors,mostnotablyacidpH,normalvaginalfloraandtypespecificcervico
vaginalantibodies.[7]

Afterperiurethralcolonization,uropathogensgainaccesstothebladderviatheurethra,tokidneyviaureters
andtoprostateviatheejaculatoryducts.Theurethraandureterovesiclejunctionaremechanicalbarriersthat
preventascension.Inthebladder,theorganismsmultiply,colonizethebladdermucosaandinvademucosal
surface.Althoughurineadequatelysupportsthegrowthofmosturopathogens,thebladderhasseveral
mechanismsthatpreventbacteriuria.

1.Amucopolysaccaride(urineslime)layercoversthebladderepitheliumandpreventselonization.
2.TammHorsfallproteinwhichisacomponentofuromucoidadherestoPfimbriaandprevents
colonization.
3.Urineflowandbladdercontractionservetopreventstasisandcolonization.

BladderinfectionsetsthestageforsubsequentmigrationtothekidneyswhereorganismssuchasP
fimbriatedE.coliadheretorenaltubularcells.Outsidethesettingofobstructiveuropathy,thisstrainofE.
coliisthemostcommoncauseofpyelonephritis.Withobstruction,bacterialadherenceisunimportant.Other
hostfactorsthatpreventarenalinfectionarehighosmolality,highammoniumconcentration,phagocytesand
highurineflowrate.[10]

Clinicalsetting

Asymptomaticbacteriuria

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Thisisespeciallycommoninwomenasevidencedbyaminimumprevalenceof24%inyoungand10%in
elderlywomen.Thecumulativeprevalenceofasymptomaticbacteriuriainwomenincreasesabout1%per
decadethroughoutliferegardlessofethnicityandgeographiclocations.

Incontrasttowomen,theoccurrenceofasymptomaticbacteriuriainmenisrareuntilafter55yearsofage,at
whichtimetheprevalenceincreasesperdecadeandapproachestherateinelderlywomen.Prostatic
hypertrophyandincreasedlikelihoodofinstrumentationaccountforthebacteriuriainoldermen.[11]

Differencesbetweenmenandwomenintheratesofbacteriuriahavebeenattributedtotheshorterfemale
urethraanditsproximitytothevaginaandrectalmucosaandtheirabundantmicrobialflora.

Symptomaticurinarytractinfection
Theseoccurinallagegroups.Amongnewbornsandinfants,boysareaffectedmorethanthegirls.When
urinarytractisthesourceofneonatalsepsis,seriousunderlyingcongenitalanomaliesarefrequentlypresent.

Duringchildhood,persistentbacteriuriawithorwithoutrepeatedsymptomaticepisodesoccursinasmall
group(lessthan2%)ofschoolagedgirls.Suchgirlsandalsoschoolagedboyswithbacteriuriashouldhave
aurologicalevaluationtodetectcorrectablestructuralabnormalitieswhenUTIsaredocumented[Figure2].
[11]

Sexuallyactivewomenhaveamarkedlyincreasedriskofcystitis.Vastmajorityofacutesymptomatic
infectionsinvolveyoungwomen.Aprospectivestudydemonstratedanannualincidenceof0.50.7episodes
perpatientyearinthisgroup.[12]Intheabsenceofprostatitis,bacteriuriaandsymptomaticUTIsareunusual
inmen.Theriskofcystitisinyoungmenduetouropathogeniccoliincreasesbecauseoflackofcircumcision
orhavingapartnerwithvaginalcolonizationwithsuchPfimbriatedE.coli.Atanyage,bothsexesmay
developsymptomaticinfectionsinthepresenceofriskfactorsthatalterurinaryflow.Theseinclude:[13]

1.Congenitalanomalies
2.Renalcalculi
3.Ureteralocclusion(partialortotal)
4.Vesicoureteralreflux
5.ResidualUrineinbladder
Neurogenicbladder
Urethralstricture
Prostatichypertrophy
6.Instrumentationofurinarytract
Indwellingurinarycatheters
Catheterization
Urethraldilatation
Cystocopy

ClinicalFeatures

Acuteurethralsyndrome
Thecardinalsymptomsoffrequencyanddysuriaoccurinmorethan90%ofambulatorypatientswithacute
genitourinarytractinfections.However,onethirdtoonehalfofallthesepatientsdonothavesignificant
bacteriuria,althoughmosthavepyuria.Thesepatientshaveacuteurethralsyndromewhichcanmimicboth
bladderandrenalinfections.Vaginitis,urethritisandprostatitisarecommoncausesoftheacuteurethral
syndrome.[14]

Vaginitis
Thepresenceofanabnormalvaginaldischarge(leucorrhoea)andirritationmakesvaginitisthelikelycause
ofdysuriaunlessaconcomitantUTIcanbeconfirmedbyculture.Candidaalbicans,themostcommon
specificcauseofvaginitis,canbedemonstratedbycultureorbyfindingyeastcellsinagramstainedsmear
ofvaginalsecretionsorinasalinepreparationwiththeadditionofpotassiumhydroxide.

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Trichomoniasiscanbedocumentedwithasalinepreparationthatshowsthemotileprotozoaoftrichomonas
vaginitis.Generally,nonspecificvaginitisisassociatedwithgardenerellavaginitis.Aclueofthisdiagnosisis
thepresenceofmanysmallGramnegativebacillithatadheretovaginalepithelialcells.

Urethritis
Acuteurinaryfrequency,dysuriaandpyuriaintheabsenceofvaginalsymptomsfavorthediagnosisof
urethritisorUTI.Chlamydiatrachomatisisthecommoncauseoftheacuteurethralsyndromeinwomenand
ofnonspecificurethritisinmen.Neisseriagonorrhoeaeisanimportantcauseofurethritisanddysuria.Herpes
simplexvirus,usuallytype2,isanothersexuallytransmittedagentthatcancauseseveredysuriathrough
ulcerationincloseproximitytotheurethralorifice.ThediagnosisofHerpesprogenitaliscanbeconfirmedby
findinggiantmultinucleatedtransformedcellsinepidermalscrapingsstainedwithWright'sstain(Tzanck
Smear),byisolatingthevirusintissueculturesorbydirectfluorescentantibodytest.

Prostatitis
Prostatitisisacommonprobleminmenthatcausesdysuriaandurinaryfrequencyinmiddleagedand
youngermenmorefrequentlythanurinarytractinfectiondo.Prostatesyndromeshaveclassicallybeen
dividedintofourclinicalentities

Acutebacterialprostatitis
Chronicbacterialprostatitis
Nonbacterialprostatitis
Prostatodynia

Recently,consensusclassificationofprostatitissyndromeshascomeup.Thisclassificationincludesfour
categoriesandtwosubcategories.[15]

Acutebacterialprostatitis
Chronicbacterialprostatitis
Chronicprostatitis/chronicpelvicpainsyndrome(CP/CPPS)
Asymptomaticinflammatoryprostatitis.
CP/CPPShasbeendividedintotwosubcategories:
1.InflammatoryCP/CPPSand
2.NoninflammatoryCP/CPPS

Acutebacterialprostatitis:Thepatientoftenappearsacutelyillwiththesuddenonsetofchillsandfever,
urinaryfrequencyandurgency,dysuria,perinealandlowbackpainandconstitutionalsymptoms.Rectal
examinationshouldbeavoidedbecauseoftheriskofprecipitatingsepsis,butmaydiscloseatender,hotand
swollenprostate.Microscopicexaminationoftheurineusuallydisplaysnumerouswhitecells.Urineculture
isusuallypositiveforentericGramnegativebacteriaandGrampositivebacteriastaphylococciand
enterococciarelessfrequentlyisolated.

Chronicbacterialprostatitis:RelapsingUTIsisahallmarkofchronicbacterialprostatitis.Urinaryfrequency,
dysuria,nocturiaandlowbackandperinealpainaretheusualsymptoms,althoughpatientsmayhavea
minimumofsymptomsbetweenUTIs.Thepatientisoftenafebrile,doesnotappearacutelyill,andmay
haveanunremarkableprostateexamination.Initially,thereisanegativemidstreamurineexaminationand
culturebutafterprostatemassage,theurineispositiveforwhitebloodcellsandculturegrowsa
uropathogen.

Nonbacterialprostatitis:Thisisthemostcommonformofchronicprostatitis.Itmimicschronicbacterial
prostatitisclinicallyanddisplaysinflammatorycellsonpostprostatemassagespecimens.However,a
bacteriologicalcultureofurineandprostaticsecretionsaresterile.Theetiologyisunknown,butsome
evidenceexistsforaninfectiouscauseinvolvingorganismsthataredifficulttoculture.

Prostatodynia:Thishasalsobeenreferredtoaschronicnoninflammatoryprostatitis.Clinically,itpresents
withsymptomssimilartootherformsofchronicprostatitis.Itisdistinguishedbytheabsenceofinflammatory
cellsoruropathogensfromallspecimens.

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Chronicprostatitis/chronicpelvicpainsyndrome:Thetraditionalclassificationsuggestedthattheprostate
wasthecauseforsomepatients(nonbacterialprostatitis),whereasotherproblemswereresponsibleinothers
(prostatodynia).Thecharacteristicsymptomsforeithergroupwereverypoorlydefined.CP/CPPS
acknowledgesthecentralroleofpaincomplaintsinthesyndrome.Alsothereisinherentrecognitionthatthe
prostateglandmaynotberesponsibleforeverypatient'ssymptoms.Itstwosubcategoriesareasfollows:

a.InflammatoryCP/CPPS:Theconsensusclassificationconsiderssymptomaticpatientswithout
bacteriuriabutwhohaveinflammationintheirexpressedprostatesecretions,theirvoidedbladder3
(VB3)ortheirsemenfluidanalysis(SFA),tohaveinflammatoryCP/CPPS.
b.NoninflammatoryCP/CPPS:Patientswithoutinflammationintheirexpressedprostatesecretions,their
voidedbladder3(VB3)ortheirsemenfluidanalysis(SFA)areconsideredtohavenoninflammatory
CP/CPPS.

Asymptomaticinflammatoryprostatitis:Theconsensusclassificationalsoincludesacategoryforpatients
withobjectiveevidenceofprostaticinflammationnotedduringhistologicalevaluationofprostatictissue.
Thisdiagnosiscommonlyoccursinpatientswhohaveinflammationdocumentedduringevaluationofother
urologicconditions,forexample,prostaticevaluatedforaraisedprostatespecificantigen.Anotherexample
isseminalfluidinflammationnotedduringevaluationfromaninfertilecouple.Thelongtermconsequences
ofsuchasymptomaticinflammationareunknown.Further,onlylimiteddataareavailableontherelative
meritsofantimicrobialorothertherapiesforsuchasymptomaticpatients.

Urinarytractinfection:Despitethemimickingsyndromes,apresumptivediagnosisofinfectionsofurinary
tractcanbeestablishedeconomicallybyanalyzingurineinpatientswithcharacteristicsignsandsymptoms.
AcuteuncomplicatedUTIsmainlyoccurinwomenofchildbearingage.Thepresentingfeaturesareonly
suggestiveofthesiteofinfection.Patientswithbacterialcystourethritis,asdistinctfromurethritiscausedby
sexuallytransmitteddisease(STD)pathogens,willhavepriorepisodesandexperiencedsymptomsforless
thanoneweekandwillexperiencesuprapubicpain.

Diagnosis

Microscopicexaminationofurine
Inacentrifugedsediment,patientswithsignificantbacteriuriaalmostalwaysshowbacilliintheurine,
whereasonlyapproximately10%ofpatientswithlessthan105CFUpermlshowbacteria.About6085%
ofpatientswithsignificantbacteriuriahave10ormorewhitebloodcellsperhighpowerfieldinthesegment
ofmidstreamurine.Also25%ofpatientswithnegativeurineculturesalsohavepyuria,10ormorewhite
bloodcellsperhighpowerfieldandonlyapproximately40%ofpatientswithpyuriahave105ormore
bacteriapermlofurinebyqualitativecultures.

Pyuria

95%ofpatientswithpyuriahaveagenitourinarytractinfectionhowever,pyuriacannotdistinguisha
bacterialUTIfromacuteurethralsyndrome.Tuberculosis,[16]analgesicnephropathy,interstitialnephritis,
perinephricabscess,renalcorticalabscess,disseminatedfungalinfectionandappendicitismayalsoresultin
pyuria.

Gramstrain
AsimpleGramstainedsmearcanenhancethespecificityofthetestbecausemorphologyandstain
characteristicsaidinidentifyingthelikelypathogenandintargetingempirictherapy.

Urineculture
ThediagnosisofUTIfromsimplecystitistocomplicatedpyelonephritiswithsepsiscanbeestablishedwith
absolutecertaintyonlybyculturesofurine.Themajorindicationsforurineculturesare:

a.PatientswithsymptomsorsignsofUTIs
b.FollowupofrecentlytreatedUTI
c.Removalofindwellingurinarycatheter
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d.Screeningforasymptomaticbacteriuriaduringpregnancyand
e.Patientswithobstructiveuropathyandstasis,beforeinstrumentation.

Urinespecimensmustbeculturedpromptlywithin2horcanbepreservedbyrefrigerationorasuitable
chemicaladditive(boricacidsodiumformate).Acceptablemethodsofcollectionare:

Midstreamurineaftercarefulwashing
Urineobtainedbysinglecatheterization
Urineobtainedbysuprapubicneedleaspirationand
Sterileneedleaspirationofurinefromthetubeofaclosedcatheterdrainagesystem.

Resultsofculturesdependontheclinicalsettinginwhichbacteriuriaoccurs.Forexample,E.coliarefound
intheurineof8090%ofpatientswithacuteuncomplicatedcystitisandacuteuncomplicatedpyelonephritis.
Manypatientswithstaghorncalculiharbourureasplittingproteusorganismsintheirurine.Klebsiella,
PseudomonasandEnterobacterinfectionsarecommonlyacquiredinthehospital.Thepresenceof
StaphylococcusaureusoftenisacluetoconcomitantStaphylococcalbacteremia,unlessanunderlyingrisk
factorexists.

Microorganismsinyoungmenaresimilartotheorganismsthatcauseuncomplicatedinfectionsinwomen.
Enterococciandcoagulasenegativestaphylococciaremorecommoninelderlymenmostlikelyrepresenting
recentinstrumentationorcatheterization.C.albicansisrarelyencounteredexceptinpatientswithindwelling
catheters,nosocomialUTIsorrelapsinginfectionsaftermultiplecoursesofantibiotics.Althoughthelikely
organismandusualsusceptiblepatternsaresufficienttoguideinitialempirictherapyofuncomplicatedUTI,
adequatetreatmentofacutebacterialpyelonephritisandcomplicatedUTIsnecessitatesprecisetherapybased
onisolationofthecausativebacteriumanditsantimicrobialsusceptibility.[13]

Imagingstudies
Ingeneral,imagingshouldbedone36weeksaftercureofacuteinfectiontoidentifyabnormalities
predisposingtoinfectionorrenaldamageorwhichmayaffectmanagement.[17]Rarely,imagingiscarried
outintheacutephase,particularlywherethereissevereloinpain,toidentifypossiblesepsis(pyonephrosis
orabscess)ortodifferentiateacutepyelonephritisfromuretericcolic.Itisimportanttorecognizethat
abnormalitieswillbefoundinlessthan5%ofunselectedcases.

PlainXrayofabdomen Theseareusedtoshowthepresenceandextentofcalcificationintheurinarytract.
Theyarelesssensitiveinthedetectionofuretericcalculi.Plainfilmsareofvalueinmonitoringchangein
position,sizeandnumberofcalculi.

Ultrasound Ultrasound(USG)combinedwithplainXrayhasbecometheimagingmethodofchoicein
patientswithrecurrentinfections.Itisasensitivedetectorofpelvicalycealdilatation,indicativeofpossible
obstruction.Echoeswithinadilatedpelvicalycealsystem,eitherdiffuseorlayered,suggestthepresenceof
pyonephrosis.Drainageofanobstructedkidneycanbeguidedbyultrasonography.Itprovidesaccuraterenal
lengthmeasurementsandidentifiesthemajorityofrenalscars,abscessesandperinephricfluidcollections.
[18]

Ultrasoundmayshowshortsegmentsofdilatedureteradjacenttotherenalpelvis,atpelvicbrimlevelor
behindthefullbladder.Itcanalsoassessthebladderforwallthickness,calculi,diverticulaandemptyingas
wellasassessprostatesize.

Intravenousurography Intravenousurography(IVU)providesanatomicaldetailofthecalyces,pelvisand
ureternotobtainedfromultrasonography.Calycealdetailisessentialtodiagnosepapillarynecrosisand
medullaryspongekidneyandcarefulassessmentofthecalycesandoverlyingparenchymaisnecessaryto
diagnosereflexnephropathy.

GramnegativebacillihavetheabilitytoimpedeureteralperistalsisandtransientabnormalitiesoftheIVUare
commonwithacutepyelonephritis.Theseincludehydroureter,vesicouretericreflux,diminishedpyelogram,
lossofrenaloutlineandrenalenlargement.IVUshouldalsobeavoidedforthefirst612weeksafter
pregnancytoallowresolutionofthephysiologicaldilatationofthepelvicalycealsystemandureter.

Computedtomography
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CTisthemostcommonmethodofdetectingrenalanduretericcalculi,includingcalculithatarelucenton
plainradiographs.Itisasensitivedetectorofpelvicalycealdilatations,renalabscessesandperinephric
collectionsthanUS.ContrastenhancedCTisverysensitiveforacutepyelonephritis.[19]

However,CTinvolvesmoreradiationthanevenIVU,thepotentialrisksofcontrastmediaandismore
expensiveandlessreadilyavailablethanUS.Therefore,itshouldbereservedasasecondlineinvestigation
forpatientswithsevereinfectionnotrespondingtoappropriatetreatmentorfordiagnosticproblemsnot
resolvedbyIVUorUS.

Staticrenalscintigraphy Dimercaptosuccinicacid(DMSA)scintigraphyisasensitivedetectorofrenal
parenchymalinfectioninchildren.

Indicationsandchoiceofrenalimaging
Acuteinfection Patientswhohavesevereloinpainorwhoseinfectiondoesnotsettleontreatmentshould
haveUSandplainXraytoexcludepyonephrosis,intrarenalorperinephricsepsisorcalculi.CTmaybe
undertakenifnoabnormalityisseenonUSinsuchpatients.Ifuretericcolicissuspected,IVUorspiralCT
shouldbeused.[20]

Imagingaftertreatmentofinfection
Inwomen,thereisnoindicationforimagingfollowingasingleorinfrequentinfection.Recurrentattacks
moreoftenthan2per6monthsshouldbeinvestigatedbyUSGandplainKUB.Inmen,UTIismuchless
commonthaninwomen,andimagingisindicatedafterthefirstdocumentedbacteriuriatoexclude
predisposingfactorsespeciallyimpairedbladderemptying.USGandplainfilmarethebestfirstchoice.[21]

Imagingshouldbeconsideredifurinaryinfectionisslowtoresolve,ifthereisrelapseoriftherearerisk
factorsforpapillarynecrosis.IVUisthemethodofchoicetocheckforpapillarynecrosis,medullarysponge
kidneyorrefluxnephropathy.IVUisalsoindicatedinallpatientsovertheageof40whohavegross
hematuriabecauseoftheriskofassociatedcancer.

Micturatingcystourography MCUisnotusuallyindicatedinadultswithurinaryinfectionunlessthey
haveloinorabdominalpainduringvoiding,suggestiveofrefluxoraspartoftheinvestigationofimpaired
bladderemptying.

Urodynamicstudies
Thesemaybenecessaryinpatientswithunexplainedimpairmentofbladderemptying.

Treatmentofurinarytractinfection
ForeffectivemanagementofUTI,thefollowingprinciplesmustberecognized.

1.Asymptomaticpatientsshouldhavecolonycountsgreaterthanorequalto105permlonatleast2
occasionsbeforetreatmentisconsidered.
2.Unlesssymptomsarepresent,noattemptshouldbemadetoeradicatebacteriuriauntilcatheters,stones
orobstructionsareremoved.
3.Selectedpatientswithchronicbacteriuriamaybenefitfromsuppressivetherapy.
4.Apatientwhodevelopsbacteriuriaasaresultofcatheterizationshouldbetreatedtoreestablishsterile
urine.
5.Efficacyoftreatmentshouldbeevaluatedbyurineculture,oneweekaftercompletionoftherapy
exceptinnonpregnantadultwomenwithuncomplicatedcystitisanduncomplicatedpyelonephritis
whorespondtotherapy.

Asymptomaticbacteriuria
Pregnancy PregnancyincreasestheriskofUTIcomplications.Therateofprematurityinchildrenbornto
womenwhohavebacteriuriaduringpregnancyisincreased,and2040%ofthesepatientsdevelop
pyelonephritis.Successfultherapyofthesepatientswithbacteriuriadecreasestheriskofsymptomatic
infectionby8090%.Therefore,allwomenshouldbescreenedtwiceduringpregnancyforasymptomatic

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bacteriuria.Allbacteriuricpatientsshouldbetreatedforsevendays,withfollowupculturestoidentify
relapses.Inselectingtherapy,risktofoetusshouldbeconsidered.Amoxicillinorcephalexinusuallysuffice.
[22]

Children Asymptomaticbacteriuriainyoungchildrenandschoolagedgirlsmaysignifyunderlying
vesicoureteralreflux.Therefore,asymptomaticbacteriuriashouldbetreatedwithfollowupurologic
evaluationaftersixweeks.

Generalpopulation Asymptomaticbacteriuriainmenandnonpregnantwomen,acommonconditioninthe
elderly,[23]doesnotappeartocauserenaldamageintheabsenceofobstructiveuropathyorvesicoureteral
refluxandthereforeitshouldnotbetreated.

Instrumentationofgenitourinarytractshouldbeavoidedinpatientswithasymptomaticbacteriuriaor,if
necessarydoneunderthecoverofprophylacticantibiotictherapy.Selectedhighriskpatients(renal
transplantationorneutropenia)maybenefitfromtherapyforasymptomaticbacteriuria.

Diabetismellitus Patientswithasymptomaticbacteriuriawhohaveconditionspredisposingtopapillary
necrosissuchasdiabetismellitusmustbeconsideredatriskofpotentiallyharmfulextensionofinfectionto
thekidneywhichmayaccelerateinterstitialdamage.Treatmentissimilartothatusedforsysmptomatic
patients.

Uncomplicatedcystitis
Thisisalmostexclusivelyadiseaseofsexuallyactivewomenmostlybetweentheagesof15and45years.
Althoughreinfectioniscommon,complicationsarerare.

Shortcoursetherapy Infectionstrulyconfinedtobladderorurethrarespondaswelltosingledoseor
shortcourse(3day)therapyastoconventionaltherapyfor1014days.However,ithasbeenobservedthat
threedaytherapyismoreeffectivethansingledosetherapy.[24]Athreedayregimenofamoxillin
clavulinatewasfoundtobesignificantlylesseffectivethanathreedayregimenofciprofloxacinintreating
uncomplicatedUTIsinwomen.[25]However,resistancehasincreasedtovariousantimicrobialsandmore
thanonequarterofE.colistrainscausingacutecystitisareresistanttoamoxicillin,sulfadrugsand
cephalexinandresistancetocotrimoxazoleisnowapproachingtheselevels.Resistancetofluoroquinolones
isalsorising.Thus,knowledgeoflocalresistancepatternisneededtoguideempiricaltherapy.[26]

Sevendayregimen Alongercourseoftherapyforcystitisshouldbegiventopatientswithcomplicating
factorsthatleadtolowersuccessratesandahigherriskofrelapse.Thesefactorsincludeahistoryof
prolongedsymptoms(morethansevendays),recentUTI,diabetes,ageabove65yearsanduseofa
diaphragm.Importantly,bothelderlyanddiabeticwomenfrequentlyhaveconcurrentrenalinfection,thus
shortcoursetherapyshouldnotbeusedinthem.

Recurrentcystitis(reinfections)
Somewomenespeciallywhoseperiurethralandvaginalepithelialcellsavidlysupportattachmentofcoli
formbacteriasufferfromrecurrentepisodesofcystitisintheabsenceofrecognizedstructuralabnormalities
oftheurinarytract.Managementinsuchwomenincludethefollowing:

1.Postcoitalprophylaxis
2.Continuouslowdoseprophylaxisand
3.Selfadministeredtherapy.

PostcoitalprophylaxisisthemosthelpfulforpatientswhoassociaterecurrentUTIswithsexualintercourse.
Inthesewomen,asingledoseofanantimicrobialaftersexualintercoursesignificantlyreducesthefrequency
ofUTIs.

WomenwithrecurrentUTIs(morethanthreeUTIsperyear)benefitfromthriceweeklybedtimeantibiotic
therapy.Suchtherapysignificantlyreducesthefrequencyofepisodesofcystitisfromanaverageof3per
patientyearto0.1perpatientyear.[27]Thisregimenisknownascontinueslowdoseprophylaxis.

WomenwithfewerthanthreeUTIsperyearcanbeofferedselfadministeredtreatment.Atthefirst
sign/symptomofaUTI,suchwomenshouldtakeasingledoseregimenofTMPSMXorafluoroquinolone.
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Thisisbotheffectiveandwelltolerated.[28]
Severalprospectivestudieshavedemonstratedtheefficacyofeithernitrofurantoin50mgornitrofurantoin
macrocrystals100mgatbedtimeforprophylaxisagainstrecurrentreinfectionofurinarytract.Sucha
regimenhaslittleifanyeffectonthefaecalfloraandpresumablyactsbyprovidingintermittenturinary
antibacterialactivity.

Perhaps,themostpopularprophylacticregimencurrentlyusedinwomensusceptibletorecurrentUTIis
lowdoseTMPSMXaslittleashalfatablet(trimethoprim,40mg,sulfamethoxazole,200mg)threetimes
weeklyatbedtimeisassociatedwithaninfectionfrequencyoflessthan0.2perpatientyear.Theefficacyof
thisprophylacticregimenappearstoremainunimpairedevenafterseveralyears.SimilartoTMPSMX,the
fluoroquinolonesmaybeusedinalowdoseprophylacticregimen.Theefficacyoftheseregimensisfurther
delineatedbytheirpotencyinpreventingUTIinthefarchallengingpopulationofkidneytransplant
recipients.

Acutebacterialpyelonephritis
Inthissetting,bloodandurineculturesshouldbeobtained.

Outpatienttherapy Foruncomplicatedacutepyelonephritis,afluoroquinoloneorcotrimoxazoleisthe
drugofchoiceforinitialtherapy.Aftercultureresultsareavailable,afull1014daycourseofthe
antimicrobialtowhichtheorganismissusceptibleshouldbeinstituted.[29]

Inpatienttherapy Patientswhorequireadmissiontothehospitalshouldbetreatedinitiallywithathird
generationcephalosporinorafluoroquinoloneandgentamicin47mgsevery24hiftheurineshowsGram
negativebacillionmicroscopy.Ifgrampositivecocciareseenintheurine,intravenousampicillin1gevery
4hoursshouldbegiveninadditiontogentamicin,tocoverthepossibilityofenterococcalinfection.Ifno
complicationsensueandpatientbecomesafebrile,theremainingtwoweekcoursecanbecompletedwith
oraltherapy.

However,persistentfever,persistentbacteriuriain4872horcontinualsignsoftoxicitybeyondthreedaysof
therapysuggesttheneedforevaluationtoexcludeobstruction,metastaticfocusorformationofaperinephric
abscess.Adequatefluidsmustbegiventomaintainadequatearterialperfusion.Failuretorespondto
seeminglyappropriatetherapysuggeststhepossibilityofunderlyingpus.ExaminationbyUSorCTmay
discloseanobstructedureterorperinephricabscess,bothofwhichrequiresurgicaldrainage.[30]

Recurrentrenalinfections(Relapses)
Chronicbacterialpyelonephritisisoneofthemostrefractoryproblemsasrelapseratesareashighas90%
occur.

Riskfactors Toimprovethesuccessrate,itisimportanttorepairanycorrectablelesions,thatobstructionsto
urineflowberelievedandthatforeignbodies(indwellingurinarycathetersorrenalstaghorncalculi)be
removed.

Iftheriskfactorscannotbecorrected,longtermeradicationofbacteriuriaisalmostimpossible.Toattempt
eradicationinsuchinstancesleadsonlytotheemergenceofmoreresistantstrainsofbacteriaorfungi.In
suchcase,onemustberesignedtotreatmentofsymptomaticepisodesofinfectionandtosuppressionof
bacteriuriainselectedpatients.

Acutesymptomaticinfection ThetreatmentofacutesymptomsandsignsofUTIinapatientwithchronic
renalbacteriuriaisthesameasforpatientswithacutebacterialpyelonephritis.

Prolongedtreatment Somepatientswithrelapsingbacteriuriarespondtosixweeksofantimicrobial
therapy.Thisisespeciallytrueofpatientswithnounderlyingstructuralabnormalityandofmenwithnormal
prostaticexamination.

Suppressivetherapy Patientswhofailthelongertherapy,whohaverepeatedepisodesofsymptomatic
infectionorwhohaveprogressiverenaldiseasedespitecorrectivemeasures,arecandidatesforsuppressive
antibiotictherapy.Thesepatientsshouldhavetwotothreedaysofspecifichighdoseantimicrobialtherapyto
whichtheirinfectingbacteriaaresusceptibletoreducethecolonycountsintheirurine.Thepreferredagent
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forlongtermsuppressionismethenaminemandelate.Alternativetherapyiscotrimoxazole,twotabletstwice
dailyornitrofurantion50100mgtwicedaily.[31]

Prognosis AlthoughUTIsareacommoncauseofappreciablemorbidity,theydonotplayamajorrolein
thepathogenesisofendstagerenaldisease.Patientswhocometorenalreplacementtherapybecauseof
chronicbacterialpyelonephritisalmostalwayshaveanunderlyingstructuraldefect.Mostoften,thelesionis
chronicatrophicpyelonephritisassociatedwithvesicouretericrefluxthatstartedininfancy.Theroleof
surgicalcorrectionofvesicoureteralrefluxisnotclear,butwhatiscertain,istheimportanceofmeticulous
controlofinfectioninchildrentopreventprogressiverenalscarringandrenalfailurebyearlyadulthood.

Prostatitis
Acutebacterialprostatitis Thedrugofchoiceiscotrimoxazoleorfluoroquinolone.However,treatment
mustbeultimatelybasedonanaccuratemicrobiologicaldiagnosisandcontinuedfor30daystoprevent
chronicbacterialprostatitis.Urethralcatheterizationshouldbeavoided.Ifacuteurinaryretentiondevelops,
drainageshouldbebysuprapublicneedleaspirationorifprolongedbladderdrainageisrequiredbya
suprapubiccystostomytube.

Chronicbacterialprostatitis ThehallmarkofchronicbacterialprostatitisisrelapsingUTI.Itismost
refractorytotreatment.Althougherythromycinwithalkalinizationofurineiseffectiveagainstsusceptible
Grampositivepathogens,mostinstancesofchronicbacterialprostatitisarecausedbygramnegativeenteric
bacilli.Cotrimoxazoleorfluoroquinoloneisthedrugofchoice.

Approximately75%ofpatientsimproveand33%arecuredwith12weeksofcotrimoxazoletherapy.For
patientswhocannottoleratecotrimoxazoleorfluoroquinolone,nitrofurantoin50or100mgonceortwice
dailycanbeusedforlongterm(612months)suppressivetherapy.[32]

Nonbacterialchronicprostatitis Therapyisdifficultbecauseanexactetiologyhasnotbeenidentified.
OwingtoaconcernforC.trachomatis,Ureaplasmaurealyticumandotherfastidiousanddifficulttoculture
organism,manyexpertsrecommendedasixweektrialoftetracyclineorerythromycin.Symptomatic
therapywithNSAIDsandalphareceptorblockershasalsobeenused.

Catheterassociatedinfection Urinarycathetersarevaluabledevicesforenablingdrainageoftheurinary
bladderbuttheiruseisassociatedwithanappreciableriskofinfection.Forasingle(inandout)
catheterization,theriskissmall(12%),thoughthisprevalenceismuchhigherindiabeticandelderlywomen.
However,bacteriuriaoccursinvirtuallyallpatientswithindwellingcatheterswithinthreetofourdaysunless
placementisdoneundersterileconditionsandasterile,closeddrainagesystemismaintained.Theuseofa
neomycinpolymyxinirrigatedoesnotpreventcatheterassociatedinfection.

Catheterassociatedbacteriuriashouldonlybetreatedinthesymptomaticpatient.Whenthedecisiontotreat
ismade,removalofthecatheterisanimportantaspectoftherapy,becauseifaninfectedcatheterremainsin
place,relapsinginfectionisverycommon.Theinteractionbetweentheorganismsandcathetercausethe
organismtoformabiofilm,anareainwhichantibioticsareunabletocompletelyeradicatetheseorganisms.
TheempirictherapyoftheseinfectionsissimilartothatofcomplicatedUTIs.Patientswhorapidlyrespond
tothetherapymaybetreatedonlyforsevendays.

Theuseofcathetersimpregnatedwithantimicrobialagentsreducestheincidenceofasymptomatic
bacteriuriainpatientscatheterizedforlessthantwoweeks.Despiteprecautions,themajorityofpatients
catheterizedformorethantwoweekseventuallydevelopbacteriuria.[33]

Fungalurinarytractinfection
ThemostcommonformoffungalinfectionofurinarytractisthatcausedbyCandidaspecies.Such
infectionsusuallyoccurinpatientswithindwellingcatheterswhohavebeenreceivingbroadspectrum
antibiotics,particularlyifdiabetesmellitusisalsopresentorcorticosteroidsarebeingadministered.Although
mostoftheseinfectionsremainlimitedtothebladderandclearwiththeremovalofthecatheter,cessationof
antibioticsandcontrolofdiabetesmellitus,theurinarytractisthesourceofapproximately10%ofepisodes
ofcandidemia,usuallyinassociationwithurinarytractmanipulationorobstruction.[34]Spontaneously
occurringlowerUTIcausedbyCandidaspeciesisfarlesscommon,althoughpapillarynecrosis,caliceal

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invasionandfungalballobstructionhaveallbeendescribedasresultingfromascendingcandidalUTIthatis
notrelatedtocatheterization.

Hematogenousspreadtothekidneyandothersiteswithinthegenitourinarytractmaybeseeninany
systemicfungalinfection,butitoccursparticularlyincoccidioidomycosisandblastomycosis.[35]In
immunosuppressedpatients,acommonhallmarkofdisseminatedcryptococcalinfectionistheappearanceof
thisorganismintheurine.Cryptococcusneoformanscommonlyseedstheprostateandfarlesscommonly
maycauseasyndromeofpapillarynecrosis,pyelonephritisandpyuriaakintothatseenintuberculosis.

Therearenocriteriatodistinguishbetweencolonizationorinfectionwithcandiduria,sothefollowing
approachisadoptedforthetreatment.

InpatientswithcatheterassociatedcandidalUTI,removaloftheprecedingcatheter,insertionofathreeway
catheterandinfusionofanamphotericinrinseforaperiodofthreetofivedayseradicatesgreaterthan50%
infections.[36]Inpatientswithcandiduriawithoutanindewellingcatheter,fluconazole200to400mg/day
for10to14daysshouldbegiven.Inapopulationoforgantransplantpatients,suchanapproachhasbeen
successfulinmorethan75%ofpatientswithcandiduria.[37]

Anypatientwithcandiduriawhohastoundergoinstrumentationoftheurinarytractrequiressystemic
therapywithamphotericinorfluconazoletopreventtheconsequencesoftransientcandidemia.

Footnotes
SourceofSupport:Nil

ConflictofInterest:Nonedeclared.

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FiguresandTables

Figure1

Classificationofcomplicatedanduncomplicatedurinarytractinfection.(Adaptedfromreference6)

Figure2

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5/4/2017 Approachtourinarytractinfections

Frequencydistributionofsymptomaticurinarytractinfectionandprevalenceofasymptomaticbacteriuriabyageandsex
(MaleshadedareaFemaleline)

ArticlesfromIndianJournalofNephrologyareprovidedherecourtesyofMedknowPublications

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