Urinary Tract Infection

• Urinary Tract Infection

Definition:
• Is a common infection that usually occurs when bacteria enter the opening of the urethra and multiply in the urinary tract.
• “A UTI can manifest as several syndromes associated with an inflammatory response to microbial invasion that range from
asymptomatic bacteriuria to pyelonephritis.”
Classification &Etiology:
• Upper urinary tract Infections:
• Pyelonephritis
• Lower urinary tract infections
• Cystitis (“traditional” UTI)
• Urethritis (often sexually-transmitted)
• Prostatitis
• Pathogens which have colonized urethra, vagina, or perineal area enter urinary tract by ascending mucous
membranes of perineal area into lower urinary tract
• Bacteria can ascend from bladder to infect the kidneys
• Escherichia coli : the commonest urinary pathogen causing 60-90 % of urinary infection.
• Pseudomonas, Proteus, Klebsiella and S. aureus: are associated with hospital acquired infections because their resistance
to antibiotics favor their selection in hospital patients (catheterization, gynaecological surgery)
• Proteus infections are associated with renal stones.Proteus produce a potent urease which act on ammonia, rendering the
urine alkaline.
• S. saprohyticusinfections are found in sexually active young women.
• Candida urinary infection is usually found in diabetic patients and immunosuppression.
• Infection of the anterior urinary tract (urethritis) is mainly caused by N. gonorrhoae, staphylococci, streptococci and
chlamydiae
• M. tuberculosis is carried in blood to kidney from another site of infection (e.g. respiratory T.B.)
Classification -According to Degree

1-Uncomplicated
• Occur in individuals who lack structural or functional abnormalities in the UT that interfere with the normal flow of urine.
• Mostly in healthy females of childbearing age
2-Complicated
• Predisposing lesion of the UT such as congenital abnormality or distortion of the UT, a stone a catheter, prostatic
hypertrophy, obstruction, or neurological deficit
• All can interfere with the normal flow of urine and urinary tract defenses.
Recurrent UTIs
• Multiple symptomatic infections with asymptomatic periods
• Reinfection: caused by a different organism than originally isolated and account for the majority of recurrent UTIs.
• Relapse: repeated infections with the same initial organism and usually indicate a persistent infectious source.
• Causality
Normal mechanisms that maintain sterility of urine;
a. Adequate urine volume
b. Free-flow from kidneys through urinary meatus
c. Complete bladder emptying
d. Normal acidity of urine
e. Peristaltic activity of ureters and competent ureterovesical junction
f. Increased intravesicular pressure preventing reflux
g. In males, antibacterial effect of zinc in prostatic fluid
Bacterial infections of urinary tract are a very common reason to seek health services ,Common in young females and uncommon in
males under age 50.
• Differences Between the Male and Female Urinary System
• Risk Factors
1. Aging
• a. Increased incidence of diabetes mellitus
• b. Increased risk of urinary stasis
• c. Impaired immune response
2.Females: short urethra, having sexual intercourse, use of contraceptives that alter normal bacteria flora of vagina and perineal
tissues; with age increased incidence of cystocele, rectocele (incomplete emptying)
3.Males: prostatic hypertrophy, bacterial prostatitis, anal intercourse
4. Urinary tract obstruction: tumor or calculi, strictures
5. Impaired bladder innervation
• Predisposing factors
Abnormalities in the UT that interfere with natural defenses
• 1-Obstruction can inhibit urine flow, disrupting the natural flushing and voiding effect in removing bacteria from the bladder
and resulting in incomplete emptying
• 2-Condition that result in residual urine volumes
e.g.prostatic hypertrophy, urethral stricture, calculi, tumors, and drug such as anticholinergic agents, neurological malfunctions
associated with stroke, diabetes, and spinal cord injuries.
• 3-Other risk factors include: urinary catheter, mechanical instrumentation, pregnancy, and the use of spermicidies and
diaphragms.
• Diagnosis
Quantitative urine culture
• Based on properly collected urine
• Urine is normally sterile
• Determines the number of bacteria present in a urine sample
5
• 1/3 of symptomatic women have bacteria < 10
• one organism per oil immersion field correlates with 100,000 CFU/ml by culture.
Labs: Urinalysis:
• + leukocyte esterase
• + nitrites
• More likely gram-negative rods
• + WBCs
• + RBCs
• Positive Urine Culture = >105 CFU/Ml
Microscopic examination
• Pyuria: WBC > 10 WBC/mm3 it only signifies the presence of inflammation,Sterilepyuria is associated with urinary
tuberculosis, chlamydial, and fungal infections.
• Hematuria, non-specific, may indicate other disorders such as calculi or tumor
• Protenuria is found in the presence of infection
Biochemical tests
• 1-dipstick test for nitrite: bacteria in the urine reduce nitrate→ nitrite
• false –negatives are common and caused by gm+ve or pseudomonas that do not reduce nitrate.
• low urinary PH &frequent voiding and dilute urine
• 2- leukocyte esterase dipstick test rapid screening test for detecting the presence of pyuria
• Specific for detecting more than 10 WBC/mm3
Treatment:
Desired outcomes:
Prevent or treat systemic consequences of infection
Eradicate the invading organism
Prevent reoccurrence of infection
Management includes:
Initial evaluation
Selection of an antibacterial product
Selection of duration of therapy
Non-specific therapies:
1-fluid hydration:
Rapid dilution of bacteria and removal of infection through increased voiding
 2-cranberry juice
Increase the antibacterial activity of urine
3-urinary analgesics
phenazopyridine
has little clinical role in infection because symptoms respond rapidly to anitmicrobial therapy
1- Single dose therapy
• 65-100% cure rate with SMX-TMP, amoxicillin
advantages of single does:
• less expensive
• better compliance
• low side effects
• low potential for development of resistance
• Not all agents are effective as single dose
• 2 DS TMP/SMX is most effective
• Flouroquniolones: 800 mg norfloxacin, 125 mg ciprofloxacin, 200 ofloxacin
• B-lactam are less effective due to increasing resistance and because they are eliminated rapidly and do not achieve high urine
concentrations
2-Three day course
• single dose Tx was blamed for high rate of recurrence within six weeks
• this may be due to failure to eradicate gm-ve bacteria from the rectum
• TMP/SMX or fluoroquinilones is superior to single dose
• Amoxicillian, nitrofurantion, and sulfonamides are not appropriate due to increasing resistance of E.coli
Short course therapy is not appropriate for
• Patient with previous infection with a resistant bacteria
• Male patients
• Complicated UTI
• If symptoms do not respond or they reoccur, a urine culture should be obtained and conventional therapy started
Fluoroqunilones should not be used unless
• Patient cannot tolerate TMP/SMX
• High frequency of resistance due to recent antibiotic use
Management:
3-Seven-day course
• In pregnant women
• Diabetic women
• Women who have had symptoms for more than one week and are at higher risk for pyelonephritis
Symptomatic abacteriuria:
Acute urethral syndrome
• In females, present with dysuria and pyuria
5
• Urine culture reveals < 10 bacteria /ml
• Accounts for half the complaints of dysuria in women
• Most likely infected with a small number of bacteria
Causes:
• E.coli, S. saprophyticus, or chalmydia
• Other causes:
• Most patients will require short course therapy as above
Chlamydial treatment:
1g of azithromycin or doxycycline 100 mg bid for 7 days
• Concomitant treatment of sexual partner is required to cure this infection and prevent recurrence.
Asymptomatic bacteriuria
• Patients with no urinary symptoms
5
• Have two consecutive urine cultures with > 10
 • The majority are elderly and female
• Aggressive treatment does not affect infection, complications or mortality
• Also present in pregnant women
• Relapse and reinfection are common and chronicity occurs which is difficult to eradicate
Management:
Groups who benefit from treatment:
• pregnant women
• patient with renal transplant
• Patient who will undergo urinary procedure
• Depend on age and whether they are pregnant
• In children: conventional treatment because of greater risk for renal damage
• In non-pregnant female: controversial
• 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
• Treatment:
• Trimethoprim/sulfamethoxazole, fluroquinolone or other broad spectrum antibiotic
• 4-6 weeks of treatment
• Risk Factors:
• Trauma
• Sexual abstinence
• Dehydration
• 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!)
• Recurrent infection
• 80% 0f recurrent infection
• Infection by an organism different from the initial infection
• Mostly occurs in females where reinfection rate is 20%
Factors contributing to infection:
• 1-sexual intercourse
• 2-diaphram and spermicidal use
• 3- postmenopausal women
Divided into two groups:
1-Those with less than 2 or 3 episodes per year
• Each episode should be treated as a separate infection
• Short course therapy is appropriate
• Can be self administered
2-Those with more than 3 episodes per year
• Long-term prophylaxis may be needed
• Patient should be treated conventionally before prophylaxis is started
Regimen:
• TMP/SMX ½ SS tables OD
• TMP 100 mg OD
• Fluroqunilone
• Nitrofurantion 50-100 mg OD (Continued for 6 months)
• If symptomatic episodes develop they should be treated with a full course
• Recurrent episodes related to decreased estrogen and changes in bacterial flora
• TX: topical estrogen cream
Relapses
• Persistence of the infection with the same organism after therapy
• Usually indicate structural abnormality, renal involvement, or chronic bacterial prostatitis
In women:
• If relapse after short course treat with 2 week course
• In-patient who relapse after 2 wk course continue for another 2-4 wks
• If relapse after 6 wks of therapy, urologic evaluation and any obstruction corrected
• May need therapy for 6 months
In males
• Relapse usually indicate bacterial prostaitis
• TMP/SMX and fluroquniolones appear to be highly effective for relapses

Prevention of UTIs

• Encourage menopausal women to use estrogen vaginal creams to restore vaginal pH

• Maintain closed drainage system for hospitalized patients with an indwelling catheter and provide meticulous catheter care
• Ensure that patients understand the importance of taking all antibiotics and having repeat culture and sensitivities done
• Monitor older male patients, especially those with BPH, for the presence of infection.
• Teach female patients good perineal hygiene &to avoid using feminine hygiene sprays and other irritants
• Advice to shower instead of bathing in tub.
• Teach women to avoid using feminine hygiene sprays and other irritants
• Avoid tight jeans, sitting around in wet bathing suits
• Advice patients to void every 2 hours
• Teach patients the signs and symptoms of UTIs
• Maintain acidity of urine (use of cranberry juice, take Vitamin C, avoid excess milk and milk products, sodium bicarbonate

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