Urinary Tract Infections

1. URINARY TRACT INFECTIONS
(UTIs)
Dr. OKIDI OSCAR P’OKELLO
(MPS)

2. URINARY TRACT
INFECTIONS

3. INTRODUCTION
• Leading cause of morbidity and health care
expenditures in persons of all ages.
• Common especially among women, an estimated 50 %
of women report having had a UTI at some point in
their lives.
• In men are less common and primarily occur after 50
years of age.
• 8.3 million office visits and more than 1 million
hospitalizations, for an overall annual cost > $1 billion.
• Usually occur by ascending route (urethra to bladder).
• Occur in two general settings: community-acquired and
hospital (nosocomially) acquired.

4. DEFINITIONS
• Urethritis: Infection of anterior urethral tract.
Dysuria (burning pain on passing urine).
Urgency (the urgent need to pass urine.
Frequency of micturition.
• Cystitis: Infection/inflammation involving the bladder, a
part of the lower urinary tract. (dysuria, frequency, pyuria
and haematuria).
• Bacteriuria: Presence of bacteria in urine. A count of 105
organisms/ml or more in urine.
• Pyuria: Presence of pus in urine (more than 10
cells/HPF).
• Pyelonephritis: from Greek– pyelum, meaning "renal
pelvis", nephros, meaning "kidney", and -itis, meaning
"inflammation"). Infection of kidney, one or both. (but not
usually involving the glomeruli)(loin pain, pyuria, rigors,
fever).

5. ETIOLOGY OF URINARY TRACT INFECTIONS
• Causative organisms:
- Escherichia coli (the commonest causing 60-90%)
- Klebsiella, Proteus and Pseudomonas,
1- Bacterial - S. aureus, S. epidermidis and S. saprophyticus
- Enterococci (Strept. faecalis)
- Mycobacterium tuberculosis
- Chlamydia trachomatis, Mycoplasma
2- Viral - Rubella, Mumps and HIV
3- Fungal - Candida, Histoplasma capsulatum
4- Protozoal - Trichom. vaginalis, Schistosoma haematobium

6. CLINICAL FEATURES
• Acute lower UTIs (Urethritis and Cystitis):
Rapid onset of:
- Dysuria
- Urgency
- Frequency of micturition
• Upper UTIs (Pyelonephritis):
- Fever
- Chills
- Dysuria
- Urgency
- Frequency of micturition

7. ACUTE UNCOMPLICATED CYSTITIS

8. ACUTE UNCOMPLICATED CYSTITIS
• It is a common manifestation of uncomplicated
UTI (Urinary Tract Infection) in nonpregnant
women. (i.e. Sexually active young women).
• Uncomplicated cystitis is less common in men
and needs to be differentiated from prostatitis
and urethritis (sexually transmitted).
• Causes:
• Anatomy and certain behavioral factors, including
delays in micturition, sexual activity, and the use
of diaphragms and spermicides tract.
• Bacterial infection, usually gram negative (from
intestinal flora) e.g. Escherichia coli

9. ACUTE UNCOMPLICATED CYSTITIS
• The microbiology is limited to a few
pathogens.
• 70%- 85% are caused by E. coli.
(intestinalflora)
• 5-20% are caused by coagulase-negative
Staphylococcus saprophyticus.
• 5-12% are caused by other
Enterobacteriaceae such as Klebsiella and
Proteus.

10. • Clinical Features:
Dysuria (pain and difficulty in passing urine)
Urgency of passing urine, frequent passing of
small amounts of urine
Suprapubic pain and tenderness
Pyuria/haematuria (pus/blood in the urine making
it cloudy)
Foul smelling urine
There may be retention of urine in severe
infection
- Fever > 380C, flank pain, costovertebral angle
tenderness, and nausea or vomiting.
ACUTE UNCOMPLICATED CYSTITIS

11. ACUTE UNCOMPLICATED CYSTITIS
• Guidelines for acute cystitis recommend
empiric antibiotic treatment.
• Clinical criteria for Diagnosis:
- Dysuria, presence of > trace urine
leukocytes, and presence of nitrites.
- Dysuria and frequency in the absence of
vaginal discharge.
- Urine Culture (UCx): Not necessary
- Culture and sensitivity (if
resistant/repeated infections)

12. • Susceptibility:
–E.coli
• 30% isolates resistance to ampicillin and
sulfonamides
• Increasing resistance to TMP-SMX
• Resistance to nitrofurantoin is < 5%
• Resistance to fluoroquinolones < 5%
–S.saprophyticus
• 3% resistant to TMP-SMX
• 0.4% resistant to ciprofloxacin
• 0% resistant to nitrofurantoin
ACUTE UNCOMPLICATED CYSTITIS

13. • Treatment:(In non-pregnant women)
–Short course is preferred except with beta-
lactam agents.
–Ensure high fluid intake
First line agents:
–Nitrofurantoin (100 mg BD x 5 - 7 days)
–TMP-SMX (960 mg BD x 3 days) first-line
treatment if: no allergy to the drug, no
antibiotics in the past 3 months, no recent
hospitalization.
–Analgesia: Paracetamol 1 g TID x 3 days
ACUTE UNCOMPLICATED CYSTITIS

14. ACUTE UNCOMPLICATED CYSTITIS
Second line agents:
• Ciprofloxacin 500 mg every 12 hours for 3-7
days (adults)
• Children: amoxicillin 125-250 mg 8 hourly for 7
days
• If poor response or recurrent infections
• Refer for investigation of culture and sensitivity and
further management
Prevention:
• Improved personal/genital hygiene
• Pass urine after coitus
• Drink plenty of fluids

15. ACUTE URETHRAL SYNDROME

16. ACUTE URETHRAL SYNDROME
• Acute symptomatic women with dysuria and
frequency with a midstream culture
containing < 105 CFU/mL.
• > 102 CFU/mL in women with acute
symptomatic pyuria = UTI.
• Treatment as an uncomplicated UTI.
• MO (Microgarnism): Mycoplasma
genitalium, Ureaplasma urealyticum.

17. ACUTE COMPLICATED CYSTITIS

18. ACUTE COMPLICATED CYSTITIS
• UTI when/with structural, functional or
metabolic abnormalities (polycystic, solitary,
transplant kidney; DM, CRF, indwelling
catheter, neurogenic bladder) or elderly, male,
child, pregnant or history of recurrent UTI).
• E. coli accounts for fewer than one third of
complicated cases.
• Clinically, the spectrum of complicated UTIs
may range from cystitis to urosepsis with
septic shock.

19. • Urine culture and susceptibility are necessary.
• These infections are usually associated with high-
count bacteriuria (> 105 CFU/mL).
• MO: Proteus, Klebsiella, Pseudomonas, Serratia,
Providencia, Enterococci, Staphylococci and fungi &
E. coli.
• Empiric therapy should include (a broad spectrum
agent with activity against the expected uropathogens:
fluoroquinolone, ceftriaxone, ceftazidime,
cefepime, aztreonam, imipenem-cilastatin. (Obtain
UCx prior to treatment).
• Treatment for 7-14 days
• Follow-up UCx should be performed within 14 days
after treatment.
ACUTE COMPLICATED CYSTITIS

20. RECURRENT CYSTITIS
• Up to 27% of young women with acute
cystitis develop recurrent UTIs.
• The causative organism should be identified
by urine culture.
• Relapse: infection with the same organism
(multiple relapses = complicated UTIs).
• Recurrence: infection with different
organisms.

21. UNCOMPLICATED PYELONEPHRITIS

22. UNCOMPLICATED PYELONEPHRITIS
Clinical features:
• Loin pain, tenderness in one or both kidney areas
(renal angle)
• Severe illness with fever, rigors (generalised body
tremors), chills, nausea, vomiting, abdominal pain.
• If associated Cystitis-like illness and accompanying
flank pain, dysuria, urgency, frequency
• Diarrhoea and convulsions (common in children)
• In infants and elderly: may simply present as fever
and poor feeding/disorientation without other signs

23. UNCOMPLICATED PYELONEPHRITIS
Cause:
• Gram-negative bacteremia (e.g. Escherichia coli,
usually due to ascending infection (faecal-perineal-
urethral progression of bacteria)
• Clinical diagnosis, confirm with:
– Urinary Analysis: pyuria and/or WBC casts
– UCx with > 105 CFU/mL (80%)

24. UNCOMPLICATED PYELONEPHRITIS
• Treatment: 14 days total
– Oral: TMP/SMX, fluoroquinolones (Ciprofloxacin
500 mg every 12 hours for 10-14days (only adults).
– IV: 3rd gen cephalosporin, aztreonam,
quinolones, aminoglycoside.
• Patients with symptoms after 3 days of appropriate
antimicrobial treatment should be evaluated by renal
US or CT for obstruction or abscess.
• Ensure adequate intake of fluid (oral or IV) to
irrigate bladder and dilute bacterial
concentrations
• Give paracetamol 1 g every 6-8 hours for
pain and fever

25. PROSTATITIS
• Acute inflammation/infection of the
prostate, a gland present in the male and
located below the bladder, around the
proximal urethra.
• Cause
Bacterial infection as for UTI

26. PROSTATITIS
• Clinical features
• Fever, chills
• Rectal, perineal and low back pain
• Urinary urgency, frequency and dysuria
• May cause acute urinary retention
• At rectal examination: tender enlarged
prostate (avoid vigorous examination)

27. PROSTATITIS
• Investigations
• Haemogram
• Urine analysis and C&S
Management
TREATMENT
• IV fluids, antipyretics, bed rest
• Stool softeners
• Ciprofloxacin 500 mg 12 hourly for 4-6
weeks

28. UTI IN MEN
• At risk: Older men with prostatic disease, UT
instrumentation, anal sex, or partner colonized
with uropathogens.
• Additional studies is not necessary in young
healthy men who have a single episode.
• Treatment:
– Uncomplicated cystitis:
• TMP/SMX or fluoroquinolones x 7 days
– Complicated cystitis:
• Fluoroquinolones x 7-14 days
– Bacterial prostatitis:
• Fluoroquinolone x 6-12 weeks

29. CATHETER-ASSOCIATED UTI
• Risk of bacteriuria is ~ 5%/day (long term catheter
bacteriuria is inevitable).
• 40% of nosocomial infections.
• Most common source of Gram-negative bacteremia.
• Dx: UCx 102 CFU/mL
– MO: E.coli, Proteus, Enterococcus, Pseudomona,
Enterobacter, Serratia, Candida.
• Mild to moderate: oral quinolones10-14days
• Severe infection: IV/oral Quinolones14-21days
• Asymptomatic bacteriuria in patients with an
indwelling Foley should not be treated unless they are
immunosuppressed, have risk of bacterial endocarditis
or are about to undergo UT instrumentation.

30. ASYMPTOMATIC BACTERIURIA
• UCx: > 105 CFU/mL with no symptoms.
• Three groups of patients with asymptomatic
bacteruria have been shown to benefit from
treatment:
–Pregnant
–Renal transplant
–Patients who are about to undergo urinary
tract procedures

31. PREGNANT PATIENTS
• Asymptomatic bacteriuria: The prevalence is about 4
to 7% and there is a 30 to 40% risk of developing
acute pyelonephritis (reason why bacteriruria of
pregnancy should be treated).
• It correlates with prematurity, low birth weight and
maternal hypertension.
• Treatment with a 7 day course of an antibiotic safe to
be used.
– Cephalexin 250MG QID
– Amoxi/Clav 500mg BD or 250 TID
– Ampicillin 500 mg QID
– Nitrofurantoin 100mg BD

32. BLADDER OUTLET OBSTRUCTION
• Obstruction of urinary tract anywhere below the
bladder, causing distension and incomplete
emptying of the bladder.
• It can be acute (Acute Urinary Retention) or chronic.
Causes
• BPH/ prostate cancer
• Bladder tumors, stones
• Pelvic masses (rarely pregnancy)
• Rarely neurological causes
• Infections can precipitate acute retention
• Chronic obstruction can cause hydronephrosis and
chronic kidney damage

33. BLADDER OUTLET OBSTRUCTION
Clinical features
• Acute: painful and tender pelvic mass,
difficulty in passing urine
• Chronic: obstructive and irritative
symptoms (see BPH), painless pelvic
mass

34. BLADDER OUTLET OBSTRUCTION
• Investigations
Urine analysis, C&S
Abdominal ultrasound
Renal function tests
Other specialized investigations
(Cystourethrogram)

35. BLADDER OUTLET OBSTRUCTION
Management
• TREATMENT
Urethral catheter to relieve obstruction
Suprapubic catheter if urethral fails
Treat infection if present
Refer to specialist for assessment/care

36. THANK YOU