URINARY TRACT INFECTION

S Y A K I B

B A K R I

Introduction
UTIs represent a wide variety of
syndromes including urethritis,
cystitis, prostatitis, and
pyelonephritis.
One of the most commonly occurring
infections.

Introduction
Young women are particularly
susceptible, 40% of all women will
suffer at least one UTI at some
point.
Infection in men occurs less
frequently until the age of 50, when
incidence in men and women is similar.

Epidemiology of UTI
Nearly 20% of women who have a
UTI will have another, and 30% of
those will have yet another. Of
this last group, 80% will have
recurrences

Prevalence of UTI
Age group

Ratio
(male:female)

Neonatal

3:2

Preschool

2-3

1:10

School age

1-2

1:30

Reproductive age

2-5

1:50

Elderly

20-30

1:10

Terminology of Urinary Tract Infections (1)

Microbiologic Terminology
Urinary tract infection (UTI) is the presence of microorganisms in the

urinary tract, including the bladder, prostate, collecting system, or kidneys.

Bacterial infection is most common, but fungi, chlamydia, viruses and parasites
may be responsible in some patients

Bacteriuria : Presence of bacteria in the urine.

Asymptomatic bacteriuria : significant bacteriuria in a patients without

symptoms attributable to the urinary tract.

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

Terminology of Urinary Tract Infections (2)

Clinical Terminology
Acute pyelonephritis: a syndrome that consists of localized flank or back
pain combined with systemic symptoms such as fever, chills, and
prostration, caused by infection of the renal parenchyma and
collecting system, and is often complicated by bacteremia

Chronic pyelonephritis :
Cannot be defined in terms of a clinical syndrome.
It refers to a spesific pathologic appearance of the kidney.
Occurs as a result of recurrent UTIs. This pathology is not
specific and is commonly found in association with other renal
diseases, such as chronic obstruction, uric acid nephropathy,
analgesec abuse, and hypokalemic nephropathy.
Chronic pyelonephritis is the result of progressive inflammation of
the renal interstitium and tubules.
Grossly, the kidneys show uneven scarring and contraction.
To avoid the the implication that chronic pyelonephritis indicates
infection, many authors suggest that the term chronic interstitial
nephritis be used to describe this pathologic condition of the
kidneys.

Cystitis :
Typical symptom are dysuria, frequency, and urgency.
Onset is abrupt
Lower abdomen heaviness and/or lower back pain may be prenet
Urine may be turbid, sometimes foul smelling.
Occasionally, it shows a bloody tinge or its frankly bloody

Acute prostatitis
Acute bacterial infection of the prostate gland. The syndrome manifests
with abrupt onset of fever and perineal pain associated with symptoms of
irritative and obstructive voiding dysfunction

Chronic prostatitis

Bacterial infection of the prostate gland, which the inflammation is

persistent and low-grade. The syndrome manifests with voiding

dysfunction and abdominal or low back dyscomfort .

Urosepsis

Symptomatic bacteremia of urinary tract origin

Terminology of Urinary Tract Infections (3)

Treatment Terminology
Reinfection :
Reccurence of bacteriuria with an organism different from that originally isolated.
Tend to occur more than 2 weeks after completion of therapy

Response well to therapy, Most likely represent infections of the bladder,

occur weeks to months after treatment of the previous infection, usually
associated with a normal urinary tract

Relapse :
Reccurence of bacteriuria with the same organism as originnally isolated.
Often recur within 2 weeks after antimicrobials have been discontinued.

Usually represent infection of the kidney or prostat.

Anatomic abnormalities or renal insuficiency are more common.
A long course of antimicrobials or surgery may be required if the urine is
to be permanently sterilized

Reinfection indicates acquisition of new pathogen,

whereas relapse indicates persistance of the
organism within the urinary tract. Reinfection
may occur with an organism identical to the
original strain, cannot be distinguished from
relapse.

Chronic UTI : Frequent recurrennces of

sympromatic UTI. True chronic infection
should mean persistence of the same
organism in the urine after months or years
(situation of a patient with multiple relapses
of infection, not the patient with frequent
reinfections).

Classification
Upper UTI = Pyelonephritis
Lower UTI = Cystitis
Complicated UTI
Uncomplicated UTI

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 abnor mality

Underlying factors associated

with complicated urinary tract infection
Systemic Conditions
Diabetes mellitus
Papillary necrosis (e.g. analgesic nephropathy)
Immunodeficient states (including immunosuppressive
drug therapy e.g. transplant recipient)
Abnormal drainage of urine
Renal calculi
Obstruction at any site in the urinary tract (extra/intra)
Vesicoureteric reflux
Foreign body in the urinary tract (stent, catheter)
Pregnancy
UTI in men

Diagnosis Urinary Tract Infection

1. Symptoms :
Lower UTI
Upper UTI

2. Urinalysis
The presence of 5-10 WBC / high-power field sediment
midstream urine

3. Culture
4. Radiological evaluation

Ultrasound
Plain abdominal radiography
Intravenous urography
CT scanning

Indication of Radiological evaluation

Severe UTI (sign of septic shock) regardless of age
and sex
Males of any age except young, sexually active men
with risk factors of UTI
Complicated UTI
Atypical cases of pyelonephritis in young women
Slow or no resolution of symptoms in young women
Recurrent pyelonephritis regardless of age and sex
Relaps of cystitis (not recomended for young women
with recurrent cystitis caused by reinfection)

Clinical features of acute lower and

upper urinary tract infection in adult

Lower UTI

Upper UTI

Dysuria

Systemically unwell

Frequency

Fever rigors

Suprapubic pain

Loin pain and tenderness

Malodorous urine

Nausea and vomiting

Haematuria
Normal temperature

Hypotension and shock

Features of lower urinary
tract infection

 Pyuria is not, by itself, diagnostic of

urinary tract infection or an indication
for antimicrobial therapy.

however
The absence of pyuria has a high
negative predictive value to exclude UTI

Culture interpretation

Bacterial etiology of urinary tract infection

Treatment
Desired outcome
Prevent or treat systemic
consequences of infection
Eradicate the invading organism
Prevent reoccurrence of infection

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
6. Catheter associated UTI

Acute uncomplicated cystitis in women

Single dose or 3-day course of treatment

Follow-up urine culture 7-14 days later

Cured
(sterile urine)

No investigation

Failure or relapse
(identical pathogens)

Ultrasonography urinary tract

KUB radiograph
Treatment for 2 weeks

Reinfection
(new pathogen)

Empiric antibiotics can be prescribed using a

first-line agent for a 3-day course without
further evaluation

Women younger than 55

No other comorbidities
Not postmenopausal
Not pregnant
No recent UTI
No vaginitis or cervicitis symptoms
Presence of increased urinary frequency
Presence of dysuria.

Antimicrobial therapy for

uncomplicated cystitis

Abbreviations: DS, double strength; TMP-SMX, trimethoprim-sulfamethoxazole.

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
6. Catheter associated UTI

Acute uncomplicated pyelonephritis in women

Moderate severity
Outpatients and oral
therapy possible

No resolution
in 5 days

Treatment 14 days

Severe illness

Hospitalization with initial

parenteral therapy

Resolution
in 5 days

Oral treatment 14 days or

longer as required

Urologic evaluation

No resolution
in 5 days

Radiologic evaluation

Antimicrobial therapy for

uncomplicated pyelonephritis

Abbreviation: IV, intravenous

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
6. Catheter associated UTI

Complicated UTI in both sexes

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

Yes
Switch to or continue
oral regimen
For total 2 weeks

5 Days

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
6. Catheter associated UTI

Recurrent infections in women

Reccurent UTI in women
Relapse

Conventional antibiotic
therapy 2-6 weeks

Sexually active

Antibiotic therapy :
On demand or
Postcoital or
Longterm prophylaxis

Diagnosis

Reinfection

3 year

2 year

Postmenopausal

Conventional antibiotic
therapy 3-7 days

Estrogen substitution
(oral & topical)
Antibiotic therapy :
On demand or
Longterm prophylaxis

Drug regimens for long-term, low-dose prophylaxis of

recurrent urinary tract infection

Drug

Dose*

Nitrofurantoin

50 mg

Trimethoprim

100 mg

Co-trimoxazole

0.24 g

Norfloxacin

200 mg

Ciprofloxacin

125 mg

Cephalexin

125 mg

Hexamine hippurate

( useful if renal insufficiency)

1 g

* 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
6. Catheter associated UTI

Indication for the treatment of patients with

asymptomatic bacteriuria
Definitive

Possible

Not indicated

Pregnancy

Diabetes mellitus

Elderly

Before an invasive
genitourinary procedure

Short-term
indwelling
catheterization

School girls and

premanopausal women

Intermittent
catheterization
Long-term indwelling
catheter

Children with reflux

Renal transplant

Patients with abnormal

urinary tract

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

6. Catheter associated UTI

Prevention of bacteriuria: keep the closed catheter system

closed and remove the catheter as soon as possible.

Irrigation of the catheter and bladder with antibacterial

solutions has not curtailed bacteriuria.

Asymptomatic bacteriuria need not be treated as long as

catheter short term or long-term, remains in place.
EXCEPTIONS :
1. For patients who may be at high risk of serious
complications (e.g. granulocytopenic patients, solid organ
transplant patients, and pregnant women)
2. Patients undergoing urologic surgery

 In case of symptomatic catheter

associated UTI it may be reasonable to
replace or remove the catheter before
Starting antimicrobial therapy if the
indwelling catheter has been in place for
more than 7 days

How do you prevent a UTI in

Women

Drink lots of water every day.

Dont resist the urge to urinate, do so when
you feel the need.
Urinate before and after you have sex.
Wipe from the front to the back after going
to the bathroom.
Avoid deodorant tampons or pads, or feminine
hygiene sprays, which can irritate the urethra.
Do not douche.
Take showers instead of tub baths.

Patient education on the following

behaviors has not been shown to reduce
recurrent UTIs

Wiping techniques,
Hygiene
Postcoital voiding
Douching,
Use of hot tubs,
Wearing of pantyhose
Timing of voiding

Take Home Messages

Acute uncomplicated UTI is common in women of any age.
These women have a normal genitourinary tract and can
usually be effectively treated with short courses of
antimicrobial therapy.
Complicated UTI occurs in individuals with structural or
functional abnormalities of the genitourinary tract. A
principal goal of therapy in these patients is the
characterization and correction of abnormalities that
promote infection
Escherichia coli is the single most common cause of
urinary tract infection. E. coli isolated from women with
acute uncomplicated urinary infection express diverse
virulence factors.

Pyuria is not, by itself, diagnostic of urinary tract

infection or an indication for antimicrobial therapy.
However, the absence of pyuria has a high negative
predictive value to exclude urinary tract infection.

Asymptomatic bacteriuria should be screened for

and treated only in pregnant women or individuals
who are to undergo an invasive genitourinary
procedure likely to be associated with mucosal
bleeding.

Asymptomatic bacteriuria need not be treated as

long as catheter short term or long-term, remains
in place. EXCEPTIONS granulocytopenic patients,
solid organ transplant patients, pregnant women and
patients undergoing urologic surgery