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URINARY TRACT INFECTION by

Hasyim kasim MD

Urinary Tract Infections (UTI)


Frequent clinical problem
Any site in the urinary tract may be involved : the urethra, prostate, bladder, ureter, kidney and perinephric space. Bacterial infection is most common, but fungi, chlamydia, viruses and parasites may be responsible in some patients Women >>> Men

Terminology of Urinary Tract Infections (1)


Bacteriuria : Presence of bacteria in the urine. Asymptomatic bacteriuria : 105 CFU/ml urine with or without pyuria, in a patient without symptoms of UTI. Cystitis : inflammation of the bladder Bacterial cystitis Abacterial cystitis (urethral syndrome) Acute pyelonephritis: acute bacterial infection of the kidney characterized by chills and fever (often high) and flank pain (usually unilateral), as well as tenderness. Chronic pyelonephritis : Radiological diagnosis where there is evidence of focal scarring of the kidneys with associated calyceal abnormality indicating renal damage due to a combination of reccurent infection with obstruction of the pelviocalyceal system (chronic obstructive nephropathy) or vesicoureteral reflux (reflux nephropathy).
Ribeiro RM, et al. Int Urogynecol 2002;13:198-199.

Terminology of Urinary Tract Infections (2)


Reinfection : An infection with a different strain of microorganism or a different serological type after (end of therapy) eradication of previous infection. Most likely represent infections of the bladder, occur weeks to months after treatment of the previous infection, response well to therapy, usually associated with a normal urinary tract

Relapse : A consecutive urinary infection caused by the same strain or serotype of bacteria, usually represent infection of the kidney or prostat, often recur within 1 6 weeks after antimicrobials have been discontinued, some cases represent persistent infection, anatomic abnormalities or renal insuficiency are more common with relapsing or persistent infection, a long course of antimicrobials or surgery may be required if the urine is to be permanently sterilized

Ribeiro RM, et al. Int Urogynecol J 2002;13:198-199.

Terminology of Urinary Tract Infections (3)


Persistence : the continued presence of the microorganisms isolated at the beginning of the treatment, owing to resistance to antimicrobial therapy, inadequate drug dosage, or a urological abnormality. These unresolved infections may be also in consequence of the patients non-compliance in taking medication, mixed infections with two different bacterial strains with mutually exclusive susceptibilities, or renal insufficiency (leading to an inadequate drug concentration in the urine).

Recurrent UTI: patients with at least two infections within 6 months or three or more during a single year, in which the initial episode is resolved and is followed by another infection.

Ribeiro RM, et al. Int Urogynecol J 2002;13:198-199.

Diagnosis Urinary Tract Infection


1. Symptoms :
Lower UTI : Frequency, dysuria, suprapubic pain Upper UTI : Fever, flank pain, and chills as well as symptoms similar to bladder infection

2. Urinalysis
The presence of 10 WBC / mm3 fresh un-spun midstream urine The presence of 10 WBC / high-power field sediment midstream urine

3. Culture 4. Radiological evaluation


Ultrosound Plain abdominal radiography Intravenous urography CT scanning

Criteria for diagnosis of significant bacteriuria


Symptomatic women :

102 coliform organisms/ml urine plus pyuria, or


105 of any pathogenic organism/ml urine, or Any growth of a pathogenic organism from urine obtained by suprapubic aspiration Symptomatic men : 103 pathogenic organism/ml urine

Asymptomatic patients :
105 pathogenic organism/ml urine in two consecutive samples

Classification of Urinary Tract Infection (1)

I. Lower urinary tract infection ( Cystitis ) Frequency, dysuria, suprapubic pain

II. Upper urinary tract infection ( Pyelonephritis )


Fever, flank pain, and chills as well as symptoms similar to bladder infection

Classification of Urinary Tract Infection (2)


I. Uncomplicated urinary tract infection
Occurs in individuals with structurally and functionally normal genitourinary tracts Most common bacterial infection that occurs in women, but is uncommon in men May involve the bladder or the kidneys and may be symptomatic or asymptomatic

II. Complicated urinary tract infection


As acute or chronic parenchymal infection associated with a functional or structural urinary tract abnormality e.g. : Neurogenic bladder, urinary tract obstruction, immunocompromized patients, diabetes mellitus, polycystic kidney disease, renal transplant recipient.

Bacterial etiology of urinary tract infection


E. coli : 70-95% (uncomplicated UTI), 21-54% (complicated) S. Saprophyticus : 5-20% (uncomplicated), 1-4% (complicated) Enterococci : 1-2% (uncomplicated), 1-23% (complicated) Proteus mirabilis : 1-2% (uncomplicated ), 1-10% (complicated) Klebsiella spp : 1-2% (uncomplicated), 2-17% (complicated) Pseudomonas aeruginosa : <1% (uncomplicated), 2-19% (complicated)

Clinical Classification of Urinary Tract Infection

1. Acute uncomplicated cystitis in women 2. Acute uncomplicated pyelonephritis in women

3. Complicated UTI in both sexes


4. Recurrent infections in women 5. Asymptomatic bacteriuria

McBryde C, Redington. Primary Care Case Rev 2001 ; 4 : 2

Acute uncomplicated cystitis in women


Single dose or 3-day course of treatment (trimethoprim sulfamethoxasole, quinolone, amoxycillin)

Follow-up urine culture 7-14 days later

Cured (sterile urine)

Failure or relapse (identical pathogens)

Reinfection (new pathogen)

No investigation

Ultrasonography urinary tract KUB radiograph Treatment for 2 weeks

Catel WR. Clin Drug Invest 1995 ; 9 (suppl 1) : 8-13.

Clinical Classification of Urinary Tract Infection

1. Acute uncomplicated cystitis in women 2. Acute uncomplicated pyelonephritis in women

3. Complicated UTI in both sexes


4. Recurrent infections in women 5. Asymptomatic bacteriuria

McBryde C, Redington. Primary Care Case Rev 2001 ; 4 : 2

Acute uncomplicated pyelonephritis in women

Moderate severity

Severe illness

Outpatients and oral therapy possible (trimethoprim sulfamethoxasole, quinolone, amoxycillin)

Hospitalization with initial parenteral therapy (trimethoprimsulfametaxazol, ceftriaxone, quinolone, gentamicin with/without ampicilin Urologic evaluation

No resolution in 5 days

Resolution in 5 days

No resolution in 5 days Radiologic evaluation

Treatment 14 days

Oral treatment 14 days or longer as required

Clinical Classification of Urinary Tract Infection

1. Acute uncomplicated cystitis in women 2. Acute uncomplicated pyelonephritis in women

3. Complicated UTI in both sexes


4. Recurrent infections in women 5. Asymptomatic bacteriuria

McBryde C, Redington. Primary Care Case Rev 2001 ; 4 : 2

Complicated UTI in both sexes


Hospitalize, urine culture, blood culture Empiric therapy with parenteral regimen Significant clinical improvement

Yes
5 Days
Switch to or continue oral regimen For total 2 weeks

No

Review antimicrobial susceptibility pattern Radiologic & urologic evaluation Correct reversible risk factors

Review treatment plan as appropriate, treat for total 2 weeks or longers if necessary

Follow-up urine culture after treatment

Clinical Classification of Urinary Tract Infection

1. Acute uncomplicated cystitis in women 2. Acute uncomplicated pyelonephritis in women

3. Complicated UTI in both sexes


4. Recurrent infections in women 5. Asymptomatic bacteriuria

McBryde C, Redington. Primary Care Case Rev 2001 ; 4 : 2

Recurrent infections in women


Reccurent UTI in women

Relapse

Diagnosis

Reinfection

Conventional antibiotic therapy 2-6 weeks

3 year

2 year

Sexually active

Postmenopausal

Conventional antibiotic therapy 3-7 days

Antibiotic therapy : On demand or Postcoital or Longterm prophylaxis

Estrogen substitution (oral & topical) Antibiotic therapy : On demand or Longterm prophylaxis
Madersbacher S, et al. Curr Opin Urol 2000 ; 10 : 32.

Drug regimens for long-term, low-dose prophylaxis of recurrent urinary tract infection Drug
Nitrofurantoin Trimethoprim Co-trimoxazole
Norfloxacin Ciprofloxacin Cephalexin Hexamine hippurate

Dose*
50 mg 100 mg 0.24 g
200 mg 125 mg 125 mg ( useful if renal insufficiency) 1g

* Treatment is effective if taken each night, alternate nights, three times a week, or just after intercourse

Clinical Classification of Urinary Tract Infection

1. Acute uncomplicated cystitis in women 2. Acute uncomplicated pyelonephritis in women

3. Complicated UTI in both sexes


4. Recurrent infections in women

5. Asymptomatic bacteriuria

McBryde C, Redington. Primary Care Case Rev 2001 ; 4 : 2

Indication for the treatment of patients with asymptomatic bacteriuria


Definitive
Pregnancy Before an invasive genitourinary procedure

Possible
Diabetes mellitus Short-term indwelling catheterization

Not indicated
Elderly School girls and premanopausal women

Intermittent catheterization
Renal transplant Long-term indwelling catheter

Children with reflux


Patients with abnormal urinary tract

Raz R. Nephrol Dial Transplant 2001 ; 16 (suppl 6) : 135.

Indication for imaging studies in patients with Urinary Tract Infections


Infections in a newborn

Reccurent infection occuring in childhood


Two or more infections in adult females One infection in adult males Elevated creatinine level

History of urinary calculi


Neurologic bladder dysfunction Persistent hematuria Previous genitourinary surgery

Prolonged fever after initiation of antibiotic therapy


Relapsing infection Urea-splitting organisms Unusual causative organism