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
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
12.
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
14.
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
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
33.
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
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
42.
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
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
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 )
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
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
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