A complete knowledge of UTI urinary tract infection.

1. Urinary tract
infections
(UTI)
1

2. •At the end of this chapter, the student will be able to:
1. Determine the diagnostic criteria for urinary tract
infections.
2. Identify the signs and symptoms of urinary tract
infections (UTIs) and differentiate those of upper
versus lower urinary tract disease.
3. Identify the organism responsible for the majority of
uncomplicated UTIs
4. Determine the laboratory tests that help in diagnosing
patients with UTI.
5. Recommend appropriate drug, dose, and duration for
uncomplicated and complicated UTI, and prophylaxis
and empiric treatment.
6. Formulate appropriate monitoring and education
information for patients with UTIs. 2

3. •Introduction
•Infections of the urinary tract represent a wide variety
of syndromes, including urethritis, cystitis, prostatitis,
and pyelonephritis.
•Urinary tract infections (UTIs) are the most
commonly occurring bacterial infections and one of
the most common reasons for antibiotic exposure,
especially in females of childbearing age.
•Approximately 60% of females will develop a UTI
during their lifetime with about one fourth having a
recurrence within a year
3

4. •Infections in men occur much less frequently until
the age of 65 years at which point the incidence rates
in men and women are similar.
•A UTI is defined as the presence of microorganisms
in the urinary tract that cannot be accounted for by
contamination.
•UTIs are classified by lower and upper UTIs.
•Lower tract infections correspond to cystitis
(bladder)
•Pyelonephritis (an infection involving the kidneys)
represents upper tract infection
4

5. UTIs are designated as uncomplicated or
complicated
Uncomplicated infections occur in individuals who
lack structural or functional abnormalities of the
urinary tract that interfere with the normal flow of
urine or voiding mechanism.EX: premenopausal
females of childbearing age (15 to 45 years)
Infections in males generally are not classified as
uncomplicated because these infections are rare and
most often represent a structural or neurologic
abnormality.
Infections in children, and pregnant women are
automatically considered complicated
5

6. •Complicated UTIs are usually the result of a
predisposing lesion of the urinary tract, such as a
congenital abnormality or distortion of the urinary
tract, a stone, indwelling catheter, prostatic
hypertrophy, obstruction, or neurologic defects
•Complicated infections occur in both genders and
frequently involve the upper and lower urinary tract.
•Recurrent UTIs in healthy nonpregnant women—two
or more UTIs occurring within 6 months or three or
more UTIs within 1 year
6

7. ETIOLOGY
The most common cause of uncomplicated UTIs is
E.coli, which accounts for 80% to 90% of
community-acquired infections. Coagulase-negative
staphylococci (i.e., Staphylococcus saprophyticus)
account for another 5% to 20% of UTIs in younger
women
Organisms isolated from individuals with complicated
infections are more varied and generally are more
resistant than those found in uncomplicated infections.
E. coli is a frequently isolated pathogen, but it
accounts for less than 50% of infections. Other
frequently isolated organisms include K.
pneumoniae,P. aeruginosa, staphylococci……
7

8. •Reduction of estrogen production at the time of
menopause allows significant colonization of the
vaginal tract with E. coli and other enteric bacilli,
thus predisposing to subsequent infection.
•Urinary tract infections occur in up to 10% of
hospitalized patients and represent 20% to 30%
of all nosocomial infections.
•Candida is a common pathogen in hospital-
acquired infections and may be involved in 20%
to 30% of cases
8

9. •Most UTIs are caused by a single organism; however,
in patients with stones, indwelling urinary catheters,
or chronic renal abscesses, multiple organisms may
be isolated.
•The female urethra usually is colonized by bacteria
believed to originate from the fecal flora. The short
length of the female urethra and its proximity to the
perirectal area make colonization of the urethra likely.
•Other factors that promote urethral colonization
include the use of spermicides and diaphragms as
methods of contraception
9

10. Risk factors for UTI
• Instrumentation or catheterization of the UT
• Renal disease
• Previous antimicrobial use
-alteration of normal flora of the urogenital tract
• Diabetes mellitus:
-glucose in the urine…. promotes bacterial growth….. impairs
leukocyte function
-Anatomic, neurologic, and immunologic abnormalities of the
urinary tract
• Pregnancy:
-hormonal changes, anatomic changes, progressive urinary
stasis, and glucose in the urine
• Obstruction to free urine flow (stones, tumors, prostate
hypertrophy) 10

11. Menopause
-Reduction of estrogen production at the time of menopause
allows significant colonization of the vaginal tract with E.
coli and other enteric bacilli, thus predisposing to
subsequent infection
Sexual intercourse and contraception /spermicides
Oral contraceptive use: alterations in vaginal flora that
allow for bacterial overgrowth and subsequent infection
Patients with spinal injury, stroke, arthrosclerosis have
neurological dysfunction caused urinary retention, requiring
catheterization
11

12. 12
References: Guidelines on Urological Infections, European Association of Urology 2015

13. cystitis Case
V.Q., a 20-year-old woman with no previous history of
UTI, complains of burning on urination, frequent urination
of a small amount, and bladder pain. She has no fever or
CVA tenderness. A clean-catch midstream urine sample
shows gram-negative rods on Gram stain.
A urine sample for culture and susceptibility (C&S) testing
is ordered, and the results of a urinalysis are as follows:
13

14. 1. Appearance: straw-colored (normal:straw)
2. Specific gravity:1.015 (N: 1.005-1.03)
3. pH: 8.0 (N: 4.8-8)
4. Protein, glucose, ketones, bilirubin: negative (normal: all
negative)
5. WBC:10 to 15 cells/LPF (normal, 0–2)
6. Red blood cells:0 to 1 cells/LPF (normal:0–2)
7. Bacteria, many (normal: 0 -rare)
8. Epithelial cells, 3 to 5 cells/LPF (normal:0 -few)
V.Q. is presumed to have a lower UTI.
14

15. Symptoms commonly associated with lower UTI:
1. Burning on urination (dysuria)
2. Frequent urination
3. Suprapubic pain
4. Blood in the urine (hematuria)
5. Back pain
15

16. Acute Pyelonephritis
•Case:
•L.B., a 45-year-old woman with type 1 diabetes
mellitus, comes to the emergency department
complaining of severe nausea, frequent vomiting,
frequent urination, fever, shaking chills, and flank pain.
•Positive physical Findings include tem:42◦C, HR:110
beats/minute, BP: of 90/60 mm Hg, and CVA
tenderness.
16

17. •A Gram stain of urine: gram (-) rods
•Urinalysis: glucosuria, hematuria, 20 to 25 WBC/LPF,
numerous bacteria, and WBC casts. She also has a blood
sugar (400 mg/dL).
•L.B. is admitted to the hospital with a diagnosis of acute
bacterial pyelonephritis, and routine laboratory tests
including a blood chemistry profile and CBC with
differential, and specimens of urine and blood for C&S are
ordered.
•L.B. is started on intravenous (IV) normal saline, ampicillin
1 g IV every 6 hours, and a sliding-scale schedule of
regular insulin based on every 6- hour blood sugars.
17

18. Patients with upper tract infection
Further symptoms
1. Loin pain
2. Tachycardia
3. Hypotension
4. Costovertebral angle (CVA) tenderness
5. Fever, shaking chills(>38.3°C)
6. Nausea, and vomiting
7. Flank pain
Presence of dysuria, back pain, pyria, hematuria, bacteriuria,
and history of UTI enhance property of true infection
18

19. •Elderly patients frequently do not experience
specific urinary symptoms, but they will present
with altered mental status, change in eating
habits, or GI symptoms.
•Patients with indwelling catheters or neurologic
disorders commonly will not have lower tract
symptoms. Instead, they may present with flank
pain and fever.
19

20. CLINICAL PRESENTATION
20
Reference: Applied therapeutics, 2013, Chapters 68

21. Urine Collection
Examination of the urine is the cornerstone of laboratory
evaluation for UTIs. There are three acceptable methods of
urine collection. The first is the midstream clean-catch
method. After cleaning the urethral opening area in both men
and women, 20 to 30 mL of urine is voided and discarded.
The next part of the urine flow is collected and should be
processed immediately (refrigerated as soon as possible).
Specimens that are allowed to sit at room temperature for
several hours may result in falsely elevated bacterial counts.
The midstream clean-catch is the preferred method for the
routine collection of urine for culture. When a routine urine
specimen cannot be collected or contamination occurs,
alternative collection techniques must be used.
21

22.  The urinalysis (UA)
- A macroscopic analysis: using dipstick method
1. Describing: color; specific gravity; pH,
glucose, protein, ketone, blood, and bilirubin
2. Presence and quantity of leukocytes,
erythrocytes, epithelial cells, crystals, casts,
and bacteria WBC casts in the urine strongly
suggest acute pyelonephritis
3. Urine culture: gold-standard with (+ )urine
analysis (>10 2 colonies, > 103 in men)
4. Nitrite test: nitrite formation from nitrates by
bacteria
22

23. Bacterial Count
A quantitative count of greater than or equal to 105
CFU/mL (108 CFU/L) is considered indicative of a UTI;
however, up to 50% of women will present with clinical
symptoms of a UTI with lower counts (103 CFU/mL
[106 CFU/L]).
Pyuria is defined as a white blood cell (WBC) count of
greater than 10 WBC/mm3 (10 × 106/L) of urine…..
Nonspesific
Hematuria may indicate the presence of other disorders,
such as renal calculi, tumors, or glomerulonephritis.
Proteinuria is found commonly in the presence of
infection.
23

24. Treatment
Choosing of the antimicrobial agent
(a) Most likely pathogens
(b) Resistance rates within the geographic area
(c) Desired duration of therapy
(d) Clinical efficacy and toxicity profiles
(e) Cost and availability of specific agents
(f) Patient characteristics such as allergies, compliance
history, and underlying comorbidities
24

25. •Fluid hydration has been used to produce rapid
dilution of bacteria and removal of infected urine
by increased voiding.
•Acidification of the urine by cranberry juice or
ascorbic acid does not appear to play a significant
role.
•Lactobacillus probiotics also may aid in the
prevention of female UTIs by decreasing the
vaginal pH, thereby decreasing E. coli
colonization
25

26. Phenazopyridine hydrochloride:
is an over the counter urinary anesthetic/analgesic
that can be used for symptom relief in UTIs.
to alleviate the dysuria associated with UTIs.
has no antimicrobial properties and has a number of
adverse effects such as red-orange discoloration of
body fluids, rash, anaphylaxis.
its use can mask the symptoms of an untreated or
inappropriately treated UTI.
maximum 200 mg three times a day and it should be
limited to 1 to 2 days. 26

27. 27
a Caution in communities with
increased resistance (>10%–
20%).
b Drug selection based on culture
and susceptibility testing when
possible.
c Oral therapy when appropriate.
Nitrofurantoin,fosfomycin,
fluoroquinolone, or
cephalosporins should be used in
areas with increased TMP-SMX
resistance.
Reference: Applied therapeutics, 2013, Chapters 68

28. 28
Reference: Applied therapeutics, 2013, Chapters 68

29. 29
Reference: Applied therapeutics, 2013, Chapters 68

30. Evidence-Based Empirical Treatment of Urinary
Tract Infections
30
Reference: Applied therapeutics, 2013, Chapters 68

31. Overview of Outpatient Antimicrobial Therapy for Lower Tract
Infections in Adults
31
Reference: Applied therapeutics, 2013, Chapters 68

32. 32
Reference: Applied therapeutics, 2013, Chapters 68

33. •Resistance to E. coli is as high as 37% for amoxicillin
and ampicillin.
•resistance to the fluoroquinolones remains low, these
agents are being utilized more frequently and the
incidence of fluoroquinolone-resistant E. coli is
increasingly being reported.
•nitrofurantoin and fosfomycin are now considered
first-line treatments along with trimethoprim–
sulfamethoxazole in acute uncomplicated cystitis.
33

34. •Several fluoroquinolones are indicated for the
treatment of uncomplicated or complicated UTI;
these include norfloxacin, ciprofloxacin, and
levofloxacin. The fluoroquinolones are usually
administered orally in the treatment of UTI and
have excellent in vitro activity against most
gram-negative organisms, including P.
aeruginosa.
• The activity of many fluoroquinolones in vitro is
antagonized by urine (acidic pH, divalent
cations); however, this is unlikely to be clinically
significant because urine concentrations are
several hundredfold greater than serum levels.
34

35. •Fluoroquinolones are recommended as appropriate
alternatives for patients with allergies or other
contraindications to the use of other first-line agents,
or for patients infected with organisms resistant to
multiple antibiotics, such as P. aeruginosa.
Fluoroquinolones are appropriate initial therapy in
geographic areas with greater than 20% resistance of
E. coli to TMP-SMX
•the fluoroquinolones are effective in treating patients
with structural or functional abnormalities of the
urinary tract and other complicated infections
•Products containing multivalent cations (Mg2+,
Ca2+, Zn2+, Al2+, Fe2+) significantly decreased
fluoroquinolone absorption 35

36. •this interaction can be avoided by taking the antacids or
other products at least 2 hours before or 4 to 6 hours
after the fluoroquinolone dose
•Interactions of the fluoroquinolones with H2-receptor
antagonists and proton pump inhibitors are not
clinically significant
•Theophylline levels should be monitored closely in
patients receiving these quinolones
•ciprofloxacin interferes with the metabolism of caffeine
•carefully monitored for changes in their anticoagulation
if given with warfarin
36

37. •Fluoroquinolones are contraindicated in children
and adolescents younger than 18 years of age
because of concerns regarding potential
musculoskeletal toxicities in juvenile populations.
•Nausea is a common complication of nitrofurantoin
therapy, and the patient’s compliance with the
prescribed regimen may be affected by this side
effect.
•Taking nitrofurantoin with food may reduce nause
•Use of the macrocrystalline preparation may also
reduce adverse effects…. Cost and slow rate of
absorption
37

38. •Acute Uncomplicated Cystitis:
•Administer medication for 7 to 14 days. However,
acute cystitis is a superficial mucosal infection that
can be eradicated with much shorter courses of
therapy (3 days).
•Severely ill patients with pyelonephritis should be
hospitalized and IV antimicrobials administered. In
the mildly to moderately symptomatic patient in
whom oral therapy is considered, an effective agent
should be administered for 7 to 14 days, depending
on the agent used.
38

39. •If the patient has been hospitalized within the past 6
months, has a urinary catheter, or is a nursing home
resident, the possibility of P. aeruginosa and
enterococci, as well as multiple resistant organisms,
should be considered. In this setting, ceftazidime,
ticarcillin– clavulanate, piperacillin, aztreonam,
meropenem, or imipenem in combination with an
aminoglycoside is recommended.
•Effective therapy should stabilize the patient within
12 to 24 hours. A significant reduction in urine
bacterial concentrations should occur in 48 hours.
39

40. •After the patient has been afebrile for 24 hours,
parenteral therapy may be discontinued and oral
therapy instituted to complete a 2-week course.
•The management of UTIs in males is distinctly
different and often more difficult than in females.
•Infections in male patients are considered to be
complicated. The most common causes are
instrumentation of the urinary tract,
catheterization, and renal and urinary stones.
40

41. •Patients with diabetes should be hospitalized
because acute pyelonephritis may predispose her
to diabetic ketoacidosis.
•The association between diaphragm use and UTI
is much stronger than oral contraceptives .
Diaphragm users are approximately three times
more likely to experience a UTI than women
using other contraceptive methods
41

42. •Recurrent Infections:
•These patients most commonly are female.
•Reinfections can be divided into two groups: those
with less than three episodes per year and those who
develop more frequent infections.
•Therapy generally is prescribed for a period of 6
months, during which time urine cultures are
followed monthly.
•Most relapses occur within 1 to 2weeks after the
completion of therapy and are caused by persistence
of the organism in the urinary tract. Relapses often
are associated with an inadequately treated upper
UTI, structural abnormalities of the urinary tract, or
chronic bacterial prostatitis
42

43. •In treatment, consider:
•The probability that a resistant organism will be
responsible for the infection increases when the interval
between infectious episodes is short.
•The alteration of fecal flora caused by the sulfonamides
makes these drugs poor choices for repeated use in
cases of frequent reinfection
•Nitrofurantoin is highly effective against E. coli…
without significant alteration in the fecal or introital
flora
• The fluoroquinolones also are useful in this setting,
especially in geographic areas with high rates of TMP-
SMX resistance
43

44. •The duration of therapy for relapsing infections
usually is 14 days. In patients who relapse after a
second 2-week course of therapy, treatment for 6
weeks should be instituted.
•If relapse occurs after a 6-week course, some
experts recommend longer courses of 6 months to
1 year. These prolonged courses should be
reserved for children, adults who have continuous
symptoms, or adults who are at high risk for
experiencing progressive renal damage.
44

45. • How can I prevent them?
•Urination before and after sex.
•Do not use spermicides.
•If you have not undergone menopause, try taking
over-the-counter cranberry pills.
•If you have undergone menopause, talk to your
doctor about using prescription vaginal estrogen
cream.
•Talk to your doctor about antibiotics to prevent
urinary tract infections. Some people benefit
from taking a pill each time they have sex. Others
might need to take one every day.
45

46. UTIs in Pregnancy:
•UTI during pregnancy has been suggested to be
associated with increased rates of preterm labor,
premature delivery, and lower birth-weight
infants
severe dilation of the renal pelvis and ureters,
decreased ureteral peristalsis, and reduced
bladder tone occur during pregnancy.
These changes result in urinary stasis and
reduced defenses against reflux of bacteria to the
kidneys. In addition, increased urine content of
amino acids, vitamins, and nutrients encourages
bacterial growth.
46

47. •treatment with an appropriate antimicrobial agent
is currently recommended for all pregnant
patients with significant bacteriuria
•The administration of amoxicillin, amoxicillin–
clavulanate, or cephalexin is effective in 70% to
80% of patients. Nitrofurantoin has been utilized
in pregnancy; however, it must be used with
caution as occurrences of birth defects have been
reported.
•fluoroquinolones should not be given because of
their potential to inhibit cartilage and bone
development in the newborn.
47

48. •Catheterized Patients:
•Cleaning the periurethral area thoroughly and
applying an antiseptic (povidone-iodine) can
minimize infection occurring during insertion of the
catheter.
•The use of constant bladder irrigation with antiseptic
or antibacterial solutions reduces the incidence of
infection in those with open drainage systems
•Antibiotic prophylaxis should not be utilized in
short-term or long-term catheterized patients….
resistance
48

49. European guidelines for UTI
49

50. 50
Guidelines on Urological Infections, European Association of Urology 2015-2016

51. 51
Guidelines on Urological Infections, European Association of Urology 2015-2016

52. UTI in pediatrics
52
Guidelines on Urological Infections, European Association of Urology 2015-2016

53. 53
Guidelines on Urological Infections, European Association of Urology 2015-2016

54. 54
REFERENCES
 Recurrent Urinary Tract Infections, American Academy
of Family Physicians ,2016
 Guidelines on Urological Infections, European
Association of Urology 2015-2016
 Pharmacotherapy, physiological approach, 10 ed, 2017,
Chapter 94
 Applied therapeutics, 2013, Chapters 68