URINARY TRACT INFECTION BY Mahmoud A.

Bazeed
Professor of Urology Urology & Nephrology Center Mansoura Faculty of Medicine Mansoura University

Important observations
The commonest bact. infection at all ages. Pyuria doesnt correlate well with the diagnosis of U.T.I. The duration of treatment varies between 714 days. Tissue infection (kidney &prost) need a longer period than cavity. Sometimes history and physical examination alone can't differentiate upper from lower U.T.I. A search for a predisposing factor must be considered. E. coli represents 90% of organisms.

Protective factors
1. 2. 3. 4. 5. High vascularity of the kidney. Effective ureteral peristalsis. Competent ureterovesical junction. Efficient bladder evacuation. Antimicrobial properties of urine. - Urinary antibodies. - High osmolality. - P.H. - Surface mucine. 6. General immunity.

Predisposing factors
1. Bact. Virulence 2. Lowering of body resistance eg diabetis. 3. Urologic factors. - Preiurethral colonization. - Ch. Prostatitis. - Incomplete evacuation of the bladder. - V.U.R. - Obstructive uropathy.

Classification
I. First infection. II. Unresolved U.T.I. due to bact. Resistance or mixed infections. III. Bacterial persistance due to presence of a source of infection by the same organism. eg. * Stone * Ch. Prost. IV. Reinfections: Infection by a new organism, possibly due to host defensive mechanism imbalance.

Organisms
Gram positive cocci: - Staph - aureus. - epidemidis - saprophyticus. - Strept - faecalis. - Bovis Gram negative cocci: - N-Gonorhea. Gram negative rods: - E. coli. - proteus. - Klebsiella - Pseudomonas. Other organisms: - Fungi candida. - Trichomonas V. - Viruses.

Routes of U.T.I.
1. Ascending: is the commonest. 2. Haematogenous: - blood borne 3. Lymphogenous: - rare: through the colonic or periuterine lymphatics to the prost & bladder. 4. Direct extension. - Fistulae. - tubes.

localization
- Paranephric space. - Perinephric space. - Parenchymal I. - Pelvi-calyceal system. - Cystitis. - Prostatitis & s-vesiculitis. - Epidydimitis/ or orchitis. N.B.: It can spread from one site to the other & may be acute or chronic.

Fig. 1: Causative organisms in acute urinary tract infection In patients without obstruction who have not been treated with antimicrobial agents or subjected to Urologic procedures.

I. Perinephric infection
A. Primary blood borne. B. Secondary to: - Renal infection. - Retrocecal appendix. - Liver abcess. - Gall bladder. The clinical picture is the same in both.

Clinical picture
Fever. Loin pain; increases with movement. Swelling, ill-defined. Oedema of overlying skin. Scoliosis & flexion of thigh.

Treatment
1. Early cases: No collection: conservative. 2. Frank abscess. Drainge 3. Secondary primary. type: deal with the

Renal infections
Diffuse nephritis. Multiple cortical abscesses. Single abscess. Renal carbuncle.

Clinical picture
Constitutional symptoms. Tender renal angle. Urine cultures +ve Ultrasound : cystic lesion. Radiologic: space occupying lesion.

Diagnosis
1. Meticulus history taking. 2. Clinical Ex. 3. Urine Ex. 4. Ultrasound. 5. Scout film. 6. Excretory urography!!!

Treatment
Early before abscess :conservative Renal abscess - PCN. - Open. : Drainage.

Acute pyelonephritis
It is inflammation affecting: - Renal pelvis. - Calyces. - adjacent parenchyma. Etiology: - Haematogenous * Staph. & Strept. - Ascending infection: * E- coli, proteus..

Diagnosis
Clinical data including the history. Positive urine cultures. Renal functions are normal in unilateral cases. Ultrasound: ill differentiation cortex & medulla. between

Rdiologic: attenuated calyces& fleeting dye.

Differential Diagnosis
Basal penumonia: - X-ray chest. Herpes zoster: - Pain is superficial. - Skin hypersensitive. - The rash is diagnostic. Acute pancreatitis. - serum amylase.

Acute pyelonephritis: treatment

1. Control of the acute attack.

Aim:

2. Search for the cause.

3. Prevention of recurrence.

1. General measures - Sedation and bed rest. - Fluids & antispasmodics. 2. Urine sample for culture. 3. Start full dose antimicrobial therapy. 4. Remove the obstruction - Residual urine catheter. - Ureteric stone remove.

Chronic pyelonephritis
It is a small contracted or scarred kidney due to bacterial infection.

Clinical findings
Unless an acute infection develops no specific physical findings are typical of chronic pyelonephritis. Advanced cases: hypertention.

Investigations
Lab: Urine: - bacteria - pyurea. - proteinuria. glom. Affection advanced. S creatinine : depending on stage.

Radiologic
Small irregular kidney. Delayed excretion of dye. Poor concentration. Dilated calyces. Dilated ureter! V.U.R. Compensatory hypertrophy opposite kidney. Voiding cystourethrography. of the

Management of ch. pyelonephritis

1. Medical: - Identification & management of U.T.I.
- Prevention of recurrence. - long-term use of anti-microbial therapy is required. - Duration of treatment depends on the case.

Management of ch. pyelonephritis

2. Surgical:
- Contributing anatomic defects should be corrected eg. - Stones - High grade V.U.R. removed corrected

3. Hypertention with unilateral kidney may be renin-mediated:

- Investigate for nephrectomy.

atrophic

Importance of chronic pyelonephritis Complications: Recurrent acute attacks. Renal stones. Hypertention. Chronic renal failure in bilateral cases.

cystitis
The bladder is resistant to infection unless: Depression of the local resistance. Constant reinfection. Incomplete emptying. Fixed pathology eg. Ulcer. N.B.: The organisms and the routes are the same as other parts of U.T.

Symptoms of acute cystitis

Cystitis syndrome. - Pain. - Frequency. - Pyuria. - haematuria.

Management of acute cystitis

Analgesics & antispasmodics. Warmth suprapubic & perineal. Anti-microbial drugs. - 10 days. Full dose. First attack : No culture.

The management of
Recurrent U.T.I., is not anti-microbials. It is due to a pathology in the U.T. - Investigate first. - Then treat the pathology.

Management of recurrent cystitis

Removal of the cause. Appropriate anti-microbial for longer periods. Possible suppressive therapy.

Acute Bact. prostatitis

Common disease in adult males. Usually associated with posterior urethritic & S. vesiculitis. Non-venireal origin. Due to: sexual irregularities, instrumentation stones, septic foci. Prolonged congestion lowers the resistance & produces a fertile field for organisms.

 Organisms responsible. - E. coli. - Pseudononas. - S. faecalis. The routes are: - ascent from the urethra. - infected urine. - lymphatic from the rectum. - haematogenous.

Clinical findings
Constitutional symptoms. Low back & perineal pain. Dysuria, urgency & frequency. Variable degrees obstruction. of bladder outlet

D.R.E: tender, swollen prost. Cultures of urine & prostatic secretion gives heavy growth. Instrumentations should be avoided.

Management of acute prostatitis

N.B.: The inflammatory reaction enhances the passage of anti-microbial

agents into prostatic tissue & secretions. So, what is called prostatic barrier is broken.

 Gentamycin or tobramycin: 3-5 mg/k./d for one week. Trimethoprim sulfa methoxazol: 160mg +800mg /12 h.
Either from the start or

After gentamycin. Should be continued for one month in full dose.

Chronic Bacterial Prostatitis

May follow acute attacks. Insidiously.

Clinically
Irritative symptoms: Dysurea frequency & urgency. Pain within the pelvis & genitalea. Post-ejaculation pain. Haemospermia.

 The diagnosis of ch. Bact. Prost. Depends on a relapsing U.T.I. caused by the same organism. Bact. Cultures localize the organisms in the prost. Fluid.

The anti-microbial agents should be

Lipid soluble. Anti-m base. Minimal protein binding. Bactericidal against G-ve org.

Figure : Factors determining diffusion and concentration across biologic membranes (From Stamey, T.A.: Pathogenesis and Treatment of urinary Tract Infection. Baltimore. The Williams & Wikins Co., 1980. The Williams & Wilkins Co., Baltimore.

Management of Bact. Ch. Prost.

1. Trimethoprim sulfa methoxasol: 160mg + 800 mg twice daily for 12 weeks 2. Trimethoprim: 200mg/12hours. 12 weeks 3. Tetracyclines: 100mg/12hours. 4 weeks 4. Erythromycin: 500mg/8hours. 4 weeks 5. Rifampicin. 6. Quinolone derivatives. N.B.: According to cultures.

Other measures
Hot baths. Anti-inflammatory drugs. Anti cholinergic: Probanthin. E adrenergic blockers.

Special Sitiations
In pregnancy. In children. In C.R.I. In diabetics. In the presence of catheters.

Pregnancy and U.T.I.

Certain anti-microbials should be avoided: Tetracyclines: * Maternal liver decompensation. * Fetal malformation. * Staining of the teeth. Chloramphenicol:* Gray syndrome. * Neonatal mortality. Erythromycine: * Cholestatic juandice. Long-acting sulpha:* should be Avoided in 3rd. Trimister D hyperbilirubinemia.

 Trimethoprime: * should be Avoided in the last trimester. F potential teratogenic activity. Nitrofurantoin: * Haemolytic anemia in 10% of black people with glucose 6-phosphate dehydrogenase deficiency may occur. Aminoglycosides:* Autotoxicity in the fetus and mother.

Safe anti-microbials in pregnancy are:

Penecillines. Cephalosporenes. Short acting sulfa: First 6 months. Nitrofurantoin: first 6 months.

Antimicrobial Treatment of U.T.I.

Collection of a urine sample. Confirmation of diagnosis (105). Site of infection: Kidney & prostate. Acute versus chronic & recurrence. Adverse reaction to drugs. Drug susceptibility: * Disk tests. Cultures for chronic & recurrent.

Management of U.T.I.
The end point is a sterile urine. Urine culture during therapy must not contain any no. of bact. A conventional treatment period of 10 days (7-14). Cure is dependent on the urine level of antimicrobials.

 Most antimicrobial drugs are secreted by the kidney and their concentration in urine is much higher than in blood or tissues.

The common drugs used:

Ampicillins. Sulfonamides. Cephalosporenes. Aminoglycosides. Tetracyclenes. Quinolones. Trimethoprim. Nitrofurantion.

Ampicillins
Bactericidal drugs. Readily absorbed orally. Must be given I h. before or after meals. Amoxycellin has better absorption and higher tissue levels. Active against G+ve, G-ve organisms. Antipsedumonas penicillins eg. Carbinicillin. Suitable for U.T.I. in children, pregnancy, renal failure.

Sulfonamides
Soluble sulfa is one of the drugs of choice for initial treatment of a first U.T.I. Urine should be alk. & more than 1.5L/day. Unsuitable for long-term use.

Trimethoprim
Inhibits G-ve enteric bacteria E.coli,

proteuns, klebsiella. 100 mg/12h. Crosses the prostatic barrier. Fixed dose combination with

sulfamethoxasole is available.

Cephalosporines
Pharmacologically related to penicillin. First, second and third generations. Activity against G+ve decreases from 1-3rd. Activity against G-ve increases from 1-3rd. Some are active against anaerobic bacteria. Some are active against pseudomonas. The old members are nephrotoxic. One of the best drugs used in U.T.I.

Aminoglycosides
Gentamycin. Amikacin Tobramycin Natilimicn - They are ototoxic & nephrotoxic. - Act better in alk. pH. - Not absorbed orally. - Against G-ve bacteria. - Combination with carbinicllin is effective against pseudomonas. - Dose adjustment in renal impairment.

Nitrofurantion
Inhibitory and can be bactericidal. 400 mg/day for treatment of acute infections. 200 mg/day for chronic UTI. Long acting preparations 100 mg twice daily. Can be used for months. Activity enhanced in acid pH. Rarely causes GIT intolerance.

Quinolones
First generation: nalidixic & oxolonic acids

Second generation : Pipedemic acid. Third generation: Fluorinaed

Norfloxin & ofloxacin.

Fourth generation: once daily

Action of Quinolones
G ve organisms: E-coli, proteus, klebsiella. New members are active against pseudomonas. Bactericidal, inhibit DNA synthesis. Resistance is easily acquired. Readily absorbed from GIT, & diffuse into tissues including prostate. Metabolized in the liver & excreted in urine D high concentration.