A complete knowledge of UTI urinary tract infection

1. URINARY TRACT INFECTION
Dr . PRATEEK SINGH
PGY1 MEDICINE

2. INTRODUCTION
 first documentation in the Ebers Papyrus in
egypt dated to 1550 BC
 About 150 million people per year
 more common in women than men.
 m/c form of bacterial infection in women

3.  Half of women having at least one infection
at some point in their lives
 Most frequent in female 20-36
 Risk increases after menopause
 20-40 % have recurrenUp to 10% of women
have UTI in a given year

4. HOSPITAL ACQUIRED UTIs
 600k / year
 40% of hospital acquired infections
 CAUTIs – 80 % of hospital acquired UTIs
 Catheterization increases risk by 10 fold
 Pyelonephritis common in pts catheterized
over a month.

5. GENDER AND SEX DIFFERENCES
 Neonate : M > F
 Adolescent to menopause : F > M
 Older age : M=F
 Female : short urethra , sexual contact and
spermicidal
 Male : prostate infections , circumcision ,
homosexuals , anatomical defects

6. Classification of UTI
 Location
 Upper ( pyelonepritis , interrenal and peri-
nephric abscess )
 Lower ( cystitis , uretheritis )
 Symptoms
 Asymptomatic –bacteriuria in absence of
symptoms
 Symptomatic- bacteruria with symptoms

7.  Recurrences
 Sporadic < 2 /6 months
 Reccurent >_ 2 /6 months or >_3/1year
 Complicating factors
 Uncomplicated-episode of cysto-urethritis following
bacterial colonisation of urethral and bladder mucosa
 Complicated-infection involving parenvchyma
(pyelonephritis or prostatitis.) in obstructive uropathy or
instrumantation
 Setting
 Hospital acquired UTIs

8. ETIOLOGY
Common pathogens of UTI
E. Coli (80 % of outpatient UTIs)
Klebsiella
Proteus
Enterobactor
pseudomonas
Staph. Saphropyticus (5-15% )
Enterococcus
Candida
Staph. Aureus

9. Pathogenesis

10. Pathogenesis of UTI
 Ascending route – m/c
 Initial event – colonisation of uretheral and
peri-uretheral tissues
 Once in bladder – multiplies – pass up ureter
if VUR – renal pelvis and parenchyma
 Healthcare infections – instrumentation
( catheterisation , cystoscopy )

11.  Hematogenous – less frquent ( MTB ,
salmonella )
 Common site of abscess formation in Staph.
aureus bacteremia , less often in candidemia
and rarely with gram negative
 Source of uropathogens – enteric bacteria

13. HOST PROTECTIVE FACTORS IN UTI
 Flushing mechanism (during micturation)
 Acidic pH of urine ( 4.6-6 ) – anti-bacterial
 Acidic vaginal pH(3.5-4.5) – inhibits
colonization
 THF protein –attach to p.fimbre and blocks
E.coli colonisation
 Chemo tactic factors IL-8

15. Bacterial factors in UTI
 E.coli strains expressing O Ag – most of UTI
 Expressing capsular Ag – antiphagocytic –
clinical severity
 P-fimbriae – enhance attachment of E.coli to
uroepithelial cells
 Motility – ascend against urine flow

16.  Proteus – urease producing –NH4 – alkaline
urine - struvite stones
 Endotoxins of Gram negative – decreases
ureteral peristalsis
 Hemolysin – damage tubular epithelium –
promotes invasion
 Aerobactin of E.coli – promote iron
accumulation for bacterial replication

17. Risk factors for UTI
Reduced Urine Flow
 outflow obstruction (BPH , carcinoma, urethral
stricture, foreign body, calculus)
 neurogenic bladder
 inadequate fluid uptake

18. Promote Colonization
 sexual activity – increased inoculation
 spermicide – increased binding
 estrogen depletion – increased binding
 antimicrobial agents – decreased indigenous flora

19. Facilitate Ascent
 catheterization
 urinary incontinence
 fecal incontinence
 residual urine with ischemia of bladder wall

20. TYPES OF UTI AND SOME
RELATEDTERMS

21. Uncomplicated UTI
 OPD visit
 Non-pregnant female
 Anatomically and functionally normal urinary
tract

22. Complicated UTI
 Male
 Pregnant female
 Anatomic or functional abnormality of
urinary tract
 Immuno-compromised host
 Metabolic abnormality
 Instrumentation
 Multi-drug resistant bacteria

23. ASYMPTOMATIC BACTERIURIA
 Positive urine culture( Ucx >_10(5)CFU/ml ) in
the absence of infection
 Investigate and treat only in
 Pregnant women
 Renal transplant pts
 About to undergo urinary tract procedures.

24. Acute uretheral syndrome
 Lower UTI symptoms and pyuria with < 10(5)
bacteria/ml urine
 mos- Chlaymdia trachomatis , ureaplasma
urealyticum , N.gonorrhoea
 If no specific etiology – empirical t/t with
doxycycline 1oo mg PO bd for 7 days or
azithromycin 1 g po single dose

25. Catheter asc. UTI
 Risk of bacteriuria is 5%/day , 25%/wk and
100%/month.
 40% of nosocomial infections
 m/c source of gram negative bacteremia.
 Dx : 10(2) CFU/ml
 mo – E.coli , proteus , enterococcus ,
enterobactor , serratia ,pseudomonas , candida
.

26. RECURRENT UTI
 27% of young women
>_ 3 episodes/year
>_ 2 episodes/6 months
 Identify organism by culture
 RELAPSE : infection with same organism
 RECURENCE : infection with different
organisms

27. PREVENTION :
1. Frequent and complete voiding
2. Avoidance of spermicide and/or diaphragm
3. Immediate voiding after intercourse
4. Good hydration
5. Low dose antibiotic prophylaxis

28. Recommendations for recurrent
UTI
1. Urinalysis and midstream urine culture and
sensitivity should be performed with the first
presentation of symptoms in order to establish a
correct diagnosis of recurrent UTI
2. Patients with persistent hematuria or persistent
growth of bacteria aside from Escherichia coli
should undergo cystoscopy and imaging of the
upper urinary tract.
SOGC CLINICAL PRACTICE GUIDELINE 1088 NOVEMBER JOGC
NOVEMBRE 2010

29. 3. Sexually active women suffering from
recurrent UTI and using spermicide should be
encouraged to consider an alternative form
of contraception.
4. Prophylaxis for recurrent UTI should not be
undertaken until a negative culture 1 to 2
weeks after treatment has confirmed
eradication of the urinary tract infection.

30. 5. Continuous daily antibiotic prophylaxis using
cotri- moxazole, nitrofurantoin, cephalexin,
trimethoprim, trimethoprim-
sulfamethoxazole, or a quinolone for recurrent
UTI
6.Women with recurrent UTI associated with
sexual intercourse should be offered post-
coital prophylaxis as an alternative to
continuous therapy in order to minimize cost
and side effects

31. 7. Acute self-treatment should be
restricted to compliant and motivated
patients in whom recurrent UTI have
been clearly documented.
8. Vaginal estrogen should be offered to
postmenopausal women who experience
recurrent UTI.
9. Cranberry products are effective in reducing
recurrent UTI.

32. 10. Acupuncture may be considered as an
alternative in the prevention of recurrent UTI in
women who are unresponsive to or intolerant
of antibiotic prophylaxis.
11. Probiotics are of no proven therapy for
recurrent UTI
12. Pregnant women at risk of recurrent UTI should
be offered continuous or post-coital prophylaxis
with nitrofurantoin or cephalexin, except during
the last 4 weeks of pregnancy

34. Acute prostatitis
 Fever with chills, dysuria, and a boggy, tender
prostate on examination
 Diagnosis - physical exam and urine Gram
stain and culture.
 Enteric gram negatives are the usual
causative organism

35. Chronic prostatitis
 low back pain, perineal, testicular, or penile
pain, dysuria, ejaculatory pain, recurrent UTIs
with the same organism, or hematospermia
 frequently abacterial
 Dx- quantitative urine cultures before and
after prostatic massage
 TRUS if abscess suspected.

36. Acute epididymitis
 unilateral scrotal ache with swollen and
tender epididymis on exam
 Causative org.
- N. gonorrhoeae or C. trachomatis in sexually
active young men
- gram-negative enteric organisms in older
men

37. PYELONEPHRITIS
 Fever with chills and rigors
 N/V , diarrhoea ,tachycardia
 CV or renal angle tenderness
 Leucocytosis
 Urine microscopy : pyuria +WBC casts +
hematuria
 Gram negative sepsis

38. COMPLICATION :
1. Sepsis
2. Papillary necrosis
3. Abscess
4. Ureteral obstruction
5. Impaired function if scarring
6. Pregnany – preterm labour

39.  Rapid increase in Sr. Creatine may indicate
PAPILLARY NECROSIS ( sickle cell ds , DM,
analgesic nephropathy )
 INTRAPARENCHYML ABSCESS s/b
suspected when pt has continued fever and
bacteremia despite antibiotic therapy .

40. EMPHYSEMATOUS PYELONEPHRITIS
 Severe acute necrotizing parenchymal renal
infection caused by gas-forming bacteria.
 Much higher mortality .
 No specific symptoms and signs, and can be
present in the absence of a septic physiology.

41.  EPN should be suspected in patients who are
 not responding to therapy
 unexplained abnormal gas formation in the
body, especially in diabetic patients with poor
glycemic control.
 High-dose antibiotic therapy alone or with
percutaneous drainage in contrast to bilateral
nephrectomy may be a preferable approach to
salvage kidney function

43. EPN classification by Huang and
Tseng
Class Description
Class I Gas in collecting system only
Class II Parenchymal gas only
Class III a Extension into perinephric tissue
Class III b Extension into pararenal space
Class IV EPN in solitary kidney , or bilateral
disease

44. XANTHOGRANULOMATOUS PYELONEPHRITIS
 Rare ,serious, chronic inflammatory disorder
characterized by destructive mass that invades
renal parenchyma.
 Defect in microbial processing
 Deposition of lipid laden macrophages
 Middle aged women with recurrent UTI
 Mo : E.coli , proteus , kliebsella , pseudomonas ,
E. fecalis
 t/t : iv antibiotics , partial/total neprectomy
 Consider RCC (XGP share characteristics with,
radiographic appearance, and ability to involve
adjacent structures

45. Xanthogranulomatous
pyelonephritis

47. DIAGNOSIS OF UTI
 History
 Physical examination
 Urine-analysis
 Imaging

49. Clinical symptoms of UTI
 CYSTITIS - dysuria ,urgency , frequency ,
suprapubic pain , cloudy urine , strangury
 PYELONEPHRITIS – fever with chills , N/V ,
flank pain , CV tenderness
 UROSEPSIS – + shock

50. Physical Exam:
CVA tenderness ( pyelonephritis )
Urethral discharge ( urethritis)
Tender prostate on DRE (
prostatitis)

51. Urinalysis
 Leukocyte esterase
 Nitrites
More likely gram-negative rods
 WBCs ( >_ 10 /HPF )
 RBCs ( stones , obstructive lesions ,
mallignancy )
 C/S

52. Collecting urine sample
 MSU
 Samples from urinary bags and bed-pans
should not be used
 Suprapubic puncture – most reliable
 Urine in bladder > 4 hrs

54. Dx-Interpretation
Urine culture
 10(5) CFU/ml – standard
 10(3) -10(4) significant if symptomatic
 Several strains – likely contamination

55. Indications for Radiologic
Imaging with UTI
 non responsive to treatment
 with predisposing factors
 Imaging modalities
 X-ray KUB
 USG abdomen and pelvis
 Non-contrast CT abdomen and pelvis
 Cystoscopic or ureteroscopic evaluation of
the urinary tract (rarely )

57. DIAGNOSTIC
FLOWCHART
FOR UTI

60. Differential diagnosis
 Herpes genitalis (HSV)
 N. Gonorrhoeae
 Chlamydia
 Trichomonas
 Vaginitis
 Prostatitis
 Nephrolithiasis
 Trauma
 Urinary tract tuberculosis
 Urinary tract neoplasm
 Intra-abdominal abscess
 Sepsis – source other than GU system
 Overactive bladder

61. MANAGEMENT
 Principles of management :
 hydration
 relief of urinary tract obstruction
 removal of foreign body or catheter if
feasible
 correctable cause of GU abnormalities and
metabolic abnormality
 judicious use of antibiotics

63. ANTIBIOTICS
 Highest mean urine concentration (from
highest to lowest):
Cabrenicillin > Cephalexin > Ampicillin >
TMP/SMX > Ciprofloxacin > Nitrofurantoin

64. Uncomplicated UTI (cystitis, some
pyelonephritis)
 Nitrofuratoin 100 mg BID x 5 days or a 3 day
course of oralTMP/SMX - 95% effective
 IfTMP/SMX resistance is > 10 – 20% -
consider fluoroquinolones.
 Only use fluoroquinolones or beta-lactams if
one of these recommended antibiotics
cannot be used due to availability, allergy, or
tolerance

65. Other Uncomplicated UTI
7 – 10 day antibiotic course
 diabetes
 symptom duration before treatment of > 7
days
 pregnancy
 age >65 years
 past history of pyelonephritis
 UTI with resistant organisms

69. Antibiotic therapy for
recurrent UTI

70. Take home message
 Accurate diagnosis
 Correct treatment to prevent antimicrobial
resistance

71. REFERENCES
 Davidson’s Principles and Practice of Medicine
22E
 Harrison’s Principles of Internal Medicine 20E
 THEWASHINGTON MANUAL OF MEDICAL
THERAPEUTICS 34E
 American society of urology 2016

72.  THANKYOU