Urinary tract infection

Dr iwal reza ahdi

Internis

FKIK UIN Maulana Malik Ibrahim

Malang
 …did you KNOW?
incidence of UTI in men tends to rise
after the age of 50 years

and
one in three women will experience UTI
by the age of 24, which requires
antimicrobial therapy

causing

20%-60% of antimicrobial drug

treatments are initiated among older
patients
 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: • Complicated UTI:
• UTI structurally & • Anatomical or
functionally normal funtional abnormality.
urinary tract. • Male.
• Female. • Longer time to
• Respond to short respond to treatment
course of antibiotic
• 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 treatment.
 Risk factors to bacteriuria
• Socio economic • Stone
• Female • GU malignancy.
• Age • Obstruction.
• Low estrogen ( • Voiding dysfunction.
menopause)
• Pregnancy.
• D.M
• Previous UTI.
• urinary catheter
 Microbiology
Faecal-drived bacteria • Complicated UTI
Uncomplicated UTI • E.coli 505
E.Coli, G-ve baccillus, • Enterococ faecalis.
(85%- 50%) • Staph aureus
Staph saprophyticus • Staph epidermidis
Enterococ faecalis • Pseudomonas
Proteus aeruginosa
Klebsiella.
 Route of infection
• Ascending
• Short urethra
• Reflux
• Pregnancy
• Obstruction
 Route of infection
• Haematogenous: • Lymphatics:
• Uncommon. • Rarely in
• Staph aureus. inflammatory bowel
• Candida fungemia. disease,
reteroperitoneal
• TBC abscess
• Increase UTI risk • Protect against UTI

• Increase bacterial • Host defences

virulence
 Factors increasing bacterial
virulence
• Adhesion factors
• Toxins
• Enzyme production.
• Avoidance of host defense mechanisms
 Factors increasing bacterial
virulence
• Adhesion factors • Mannose –sensitive
• G-ve bacteria, Pili • (type 1)
• Attachment to host • Produced by all strains
urothelial cells. E.coli
• Single type or different
types e.x E.coli • Certain pathogenic types
of E.coli mannose
resistant pili
( pyelonephritis)
 Factors increasing bacterial
virulence
• Avoidance of host • Toxins:
defense mechanisms • E.coli cytokines,
• E.coli pathogenic effect on
• Extracellular capsule host tissues
• M.Tuberculosis avoid
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
• Symptoms:
• Frequency, small volumes, dysuria,
urgency, haematuria, fever & incontinence
• Sign:
• High temperature
• tenderness in suprapubic area
 Investigation
• Dipstick • Nitrite testing:
• WBC ( pyuria ) • Bacteriuria.
• 75 -95% sensitivity • Specificity >90%
infection • Sensitivity 35- 85%
• False –ve • + test ------- infection
• False +ve • - -------- non
• Other causes of infection
pyuria
 Investigation
• Microscopy :
• Bacteria :
• False –ve low bacterial count
• False +ve contamination (lactobacilli &
corynebacteria ) epithelial cells
• RBCs & pyuria
 Investigation
Indications for further • Ultrasound
investigations in LUTI. • IVU
• Symptoms of Upper • cystoscopy
UTI.
• Recurrent UTI.
• Pregnancy
• Unusal infecting
organism ( proteus
suggest infection
stone)
 DD
• Non-infective cystitis:
• radiation cystitis
• Drug cystitis ( cyclophosphamide )
• Haemorrhagic cystitis
• Urethritis
 Treatment
• Aim :
• Eliminate bacterial
growth from urine.
• Empirical treatment
before culture &
sensitivity for the
most likely organism.
• Adjusted according to
the culture &
sensitivity.
 Female recurrent reinfection
• Natural yogurt
• Post-intercourse antibiotic prophylactic
• Self-started therapy
 Management of bacteria
persistance
• Investigations:
• renal ultrasound.
• C.T, IVU
• Cystoscopy

• Treatment :
• For the functional or anatomical anomaly
 Antibiotics
• Empirical therapy.
• Definitive therapy.
• Bacterial resistance to drug therapy.
Antibiotik Dosis Interval Durasi

Trimetropim- 2 DS Tablet 1 kali dosis 1 hari

Sulfametoksazol 1 DS Tablet 2 kali sehari 3 hari

Ciprofloksazin 250 mg 2 kali sehari 3 hari

Norfloxacin 400 mg 2 kali sehari 3 hari
Gatifloxacin 200-400 mg 1 kali sehari 3 hari
Levofloxacin 250 mg 1 kali sehari 3 hari
Lomefloxacin 400 mg 1 kali sehari 3 hari
Enoxacin 200 mg 1 kali sehari 3 hari

6 x 500 mg 1 kali dosis 1 hari

Amoxicillin
500 mg 2 kali sehari 3 hari

Amoxiclav 500 mg 3 kali sehari 3 hari

Trimetroprim 100 mg 2 kali sehari 3 hari
Nitrofurantoin 100 mg 4 kali sehari 3 hari
Fosfomycin 3g 1 kali dosis 1 hari
 Acute pyelonephritis
• Clinical Dx:
• Flank pain
• Fever.
• Pain in renal provocation
• Elevated WBCs

• DD:
• acute cholecystitis.
• Pancreatitis.
 Acute pyelonephritis
• Risk factors:
• Spinal cord injury
• D.M
• Malformation
• pregnancy
• FC
 Acute pyelonephritis
• Pathogenisis :
• Inflammatory bands from renal papilla to
cortex.
• 80% E.coli, others klebsiella, proteus&
pseudomonas.
 Acute pyelonephritis
• Urine analysis & culture.
• CBC
• ultrasoundif no response with I.Vantibiotic
for 3 days
terimakasih