Urinary tract infection

Dr. Mai Banakhar

UTI
inflammatory response of urothelium to
bacterial invasion.

Bacteriuria : bacteria in urine

Asymptomatic or symptomatic
Bacteriuria + pyuria= infection
Bacteriuria NO pyuria = colonization

Pyuria :
WBCs in urine.
Infection
T.B
Bladder stone.

Complicated VS uncomplicated
Un complicated UTI:
UTI structurally &
functionally normal
urinary tract.
Female.
Respond to short
course of antibiotic

Complicated UTI:
Anatomical or
funtional abnormality.
Male.
Longer time to
respond to ttt

 Isolated UTI:
6 months between infections.

Recurrent UTI:>2 infections in 6 months

3 UTI in 12 months.
Reinfection by different bacteria.
Persistence : same organism from focus within
the urinary tract.
Struvate stone.
Bacterial prostatitis.
Fistula
Urethral diverticulum.
atrophic infected kidney.

 Unresolved infection:
in adequate therapy , bacterial resistance
to ttt.

Risk factors to bacteriuria

Female
Age
Low estrogen (
menopause)
Pregnancy.
D.M
Previous UTI.
FC

Stone
GU malignancy.
Obstruction.
Voiding dysfunction.
Institutionalized
elderly

Microbiology
Faecal-drived bacteria
Uncomplicated UTI
E.Coli, G-ve baccillus,
(85%- 50%)
Staph saprophyticus
Enterococ faecalis
Proteus
Klebsiella.

Complicated UTI
E.coli 505
Enterococ faecalis.
Staph aureus
Staph epidermidis
Pseudomonas
aeruginosa

Route of infection

Ascending
Short urethra
Reflux
Impair urteric
peristalisis.
Pregnancy
Obstruction
G-ve , Edotoxins
Organism P pili

Route of infection

Haematogenous:
Uncommon.
Staph aureus.
Candida fungemia.
T.B

Lymphatics:
Rarely in
inflammatory bowel
disease,
reteroperitoneal
abscess

 Increase UTI risk

Protect against UTI

Increase bacterial
virulence

Host defences

Factors increasing bacterial

virulence

Adhesion factors
Toxins
Enzyme production.
Avoidance of host defense mechanisms

Factors increasing bacterial

virulence
Adhesion factors
G-ve bacteria, Pili
Attachment to host
urothelial cells.
Single type or different
types e.x E.coli
Defined functionally be
mediating
hemagglutination (HA) of
specific erythrocytes

Mannose sensitive
(type 1)
Produced by all strains
E.coli
Certain pathogenic types
of E.coli mannose
resistant pili
( pyelonephritis)

Factors increasing bacterial

virulence
Avoidance of host
defense mechanisms
E.coli
Extracellular capsule

Immunogenisity

Toxins:
E.coli cytokines,
pathogenic effect on
host tissues

phagocytosis

M.Tuberculosis reisit
phagocytosis by
preventing
phagolysosome fusion

Enzyme production:
Proteus ureases
Ammonia struvite
stone formation

Host defences
Protective
Mechanical (flushing of urine) antegrade flow of
urine
Tamm-Horsfall protein (mucopolysaccharide
coating bladder prevent bacterial attachment)
chemical : Low Urine PH & high osmolality
Urinary Immunoglobulin I gA inhibit adherence

Lower UTI
Cystitis: infection& inflammation of the
bladder
Frequency, samll volumes, dysuria,
urgency, offensive urine SP pain,
haematuria, fever & incontinence.

Investigation
Dipstick of MSU
WBC ( pyuria )
75 -95% sensitivity
infection
False ve
False +ve
Other causes of
pyuria

Nitrite testing:
Bacteriuria.
Specificity >90%
Sensitivity 35- 85%
+ test ------- infection
--------infection

Investigation

Microscopy :
Bacteria :
False ve low bacterial count
False +ve contamination (lactobacilli &
corynebacteria ) epithelial cells
RBCs & pyuria

Investigation
Indications for further
investigations in LUTI.
Symptoms of Upper
UTI.
Recurrent UTI.
Pregnancy
Unusal infecting
organism ( proteus
suggest infection
stone)

KUB
Ultrasound
IVU
cystoscopy

DD

Non-infective cystitis:
radiation cystitis
Drud cystitis ( cyclophosphamide )
Haemorrhagic cystitis
Urethritis

Treatment
Aim :
Eliminate bacterial
growth from urine.
Empirical ttt before
culture & sensitivity
for the most likely
organism.
Adgusted according
to the culture &
sensitivity.

Resistance :
Intrinsic (proteus)
Genetically
transferred between
bacteria by R
plasmids.

Recurrent UTI
>2 in 6 months or 3 within 12 months

Reinfection

Bacterial persistence

Recurrent UTI
Reinfection ( different Bacterial persistance
bacteria)
( same organism
from a focus within
After prolonged
tract) within short
interval with
interval
adifferent organism
Reinfection in females Functional or
anatomical problem.
No anatomical nor
The underlying
functional pathology
problem should be
In males BOO,
treated
urethral stricture

Management Reinfection UTI

Females
KUB, Ultrasound, cystoscopy
Simple Reinfection
TTT
Avoid spermicides
Estrogen replacement therapy
Low dose antibiotic prophylaxis

Female recurrent reinfection

Prophylactic antibiotic:
Reduce infection 90% at bed time 6-12
months
Symptomatic reinfection
Trimethoprim
Nitrofurantoin
Cephalexin
Fluoroquinolones

Female recurrent reinfection

Natural youghart
Post-intercourse antibiotic prophylactic
Self-started therapy

Management of bacteria
persistance

Investigations:
Kub, renal ultrasound.
C.T, IVU
Cystoscopy

Treatment :
For the functional or anatomical anomaly

Antibiotics
Empirical therapy.
Definitive therapy.
Bacterial resistance to drug therapy.

Acute pyelonephritis

Clinical Dx:
Flank pain
Fever.
Elevated WBCs

DD:
acute cholecystitis.
Pancreatitis.

Acute pyelonephritis

Risk factors:
VUR
UTO
Spinal cord injury
D.M
Malformation
pregnancy
FC

Acute pyelonephritis
Pathogenisis :
Initially patchy
Inflammatory bands from renal papilla to
cortex.
80% E.coli, others klebsiella, proteus&
pseudomonas.

Acute pyelonephritis
Urine analysis & culture.
CBC , U&E
KUB & ultrasoundif no response with I.V
antibiotic for 3 days go for CTU

Perinephric abscess

Pathogenesis.
Suspected??
C.T, ultrasound
PC drainage .
Open surgical

Pyonephrosis

Infected hydronephrosis.
Pus accumulation
Causes
Ultrasound. C.T
Management: PCN, I.V antibiotic, I.V
fluids.

Emphysematous pyelonephritis
Severe form of acute pyelonephritis
Gas forming organism
Fever, abdominal pain with radiographic
evidence of gas within the kidney.
D.M
Urinary obstruction.
High glucose level-------fermentation,CO2
production

Emphysematous pyelonephritis

Presentation: sever acute pyelonephritis

High fever & systemic upset
E.coli, commonly,
Klebsiella & proteus less frequent

Management

KUB
Ultrasound, C.T
Patients are unwell
Mortality is high

Management

Conservative ?
I.V antibiotic , IVF
PC drainage
Control D.M

Sepsis is poorly controlled

Nephrectomy

Xanthogranulomatous
pyelonephritis

Severe renal infection

Renal calculi & obstruction.
Result in non-functioning kidney
E.coli & proteus common.
Macrophage full of fat deposit around the
abscess
Kidney, perinephric fat

Xanthogranulomatous
pyelonephritis
Acute flank pain
Fever & tender flank mass

C.T , Ultrasound
Stone , mass ?? RCC

Xanthogranulomatous
pyelonephritis
IV antibiotic ,
Nephrectomy