Prof. M.C.BansalFounder Principal & Controller Jhalawar Medical College &Hospital Jhalawar.Ex. Principal & controller Mahatma Gandhi Medical College andHospital , Sitapura ; Jaipur.
Urinary tract infections have been described since ancient times. First documented description in the Ebers Papyrus dated to c. 1550 BC. It was described by the Egyptians as "sending forth heat from the bladder". Effective treatment did not occur until the development and availability of antibiotics in the 1930s before which time herbs, bloodletting and rest were recommended.
Urinary tract infection (UTI) is an infection of urethra, bladder, ureters, or the kidneys, which comprise the urinary tract. Urethritis (urethral infection), cystitis (bladder infection), ureter infection, and pyelonephritis (kidney infection).
Between 1 year and ~50 years of age, UTI and recurrent UTI are predominantly diseases of females. Are 10 times more common among women than men. as 50–80% of women in the general population acquire at least once atime; UTI during their lifetime—uncomplicated cystitis in most cases The urethra is much shorter (4cm) and closer to the anus. . Colonization of the vaginal introitus and perirurethral area with organisms from the intestinal flora (usually E. coli) is the critical initial step in the pathogenesis of UTI. Escherichia coli is more likely to colonize the glans and prepuce of clitoris; and subsequently migrate into the urinary tract . Sexual intercourse is associated with an increased risk of vaginal colonization with E. coli and thereby increases the risk of UTI . Honey moon Cystitis may persist as chronic UTI. As a womans estrogen levels decrease with menopause, her risk of urinary tract infections increases due to the loss of protective effect of estrogen .
The genetic background of the host influences the individuals susceptibility to recurrent UTI, at least among women . A familial disposition to UTI and to pyelonephritis is well documented. Women with recurrent UTI are more likely to have had their first UTI before age 15 years and to have a maternal history of UTI.
A new sex partner or multiple partners More frequent or intense intercourse Use of irritating contraceptives, such as diaphragms and spermicide Episode of UTI in the previous 12 months, diabetes, and pregnancy Maternal h/o UTI Any condition that permits urinary stasis or obstruction predisposes the individual to UTI. . Foreign bodies such as stones or urinary catheters provide an inert surface for bacterial colonization and formation of a persistent biofilm. Vesico ureteral reflux, ureteral obstruction , neurogenic bladder , incomplete voiding, spinal cord injury, Anterior vaginal prolapse ( cysto –urthrocele)and urinary diversion surgery create an environment favorable to UTI.
The most common causes of UTI infections (75-90%) are E. coli , a gram negetive bacteria that usually inhabit the colon. Staphylococcus saprophyticus for 5–15%, Klebsiella, Pseudomonas, Enterobacter, Proteus, Staphylococcu s, Mycoplasma, Chlamydia, Serratia and Neisseria spp.).-5-10% Fungi (Candida and Cryptococcus spp.) and Parasites (Trichomonas and Schistosoma) Klebsiella and group B streptococcus infections are relatively more common in patients with diabetes, and Pseudomonas infections are relatively more common in patients with chronic catheterization. Proteus mirabilis i s a c common uropathogen in patients with indwelling catheters, spinal cord injuries, or structural abnormalities of the urinary tract.
Asymptomatic Bacteriuria:-- patient does not have local or systemic symptoms referable to the urinary tract. screening urine culture:--bacteriuria Cystitis The typical symptoms of cystitis are dysuria, urinary frequency, and urgency. Nocturia, hesitancy, supra pubic discomfort, and gross hematuria . Unilateral back(lumber/ renal angle ) or flank pain is generally an indication that the upper urinary tract is involved. Fever is also an indication of invasive infection of either the kidney , Pyelonephritis.
Mild pyelonephritis :-low-grade fever with or without lower-back or costo vertebral-angle pain. severe pyelonephritis :--High fever--resolves over 72 hrs of therapy Rigors, nausea, vomiting, and flank and/or loin pain. Symptoms are generally acute in onset . Altered mental status. Bacteremia develops in 20–30% of cases of pyelonephritis Emphysematous pyelonephritis is a particularly severe form of the disease that is associated with the production of gas in renal and peri nephric tissues and occurs almost exclusively in diabetic patients Xanthogranulomatous pyelonephritis occurs when chronic urinary obstruction (often by stag horn calculi), together with chronic infection, leads to suppurative destruction of renal tissue
Uncomplicated UTI refers to acute cystitis or pyelonephritis in non pregnant outpatient women without anatomic abnormalities or instrumentation of the urinary tract Complicated UTI presents as a symptomatic episode of cystitis or pyelonephritis in a man or woman with an anatomic predisposition to infection, with a foreign body in the urinary tract, or with factors predisposing to a delayed response to therapy.
urine test:-presence of urinary nitrites, white blood cells (leukocytes), or leukocyte esterase. Mid stream urine sample should be collected after cleaning the Vulva with soap and water / catheter spaceman . urine microscopy, looks for the presence of red blood cells, white blood cells, or bacteria. Urine culture is positive; if it shows a bacterial colony count of greater than or equal to 103 colony-forming units per ml of a typical urinary tract organism in symptomatic pt / > 1lack bacteria count /ml. 105 colony-forming units per mL is consistent with a diagnosis of UTI in asymptomatic patients. Antibiotic sensitivity can also be tested with these cultures, making them useful in the selection of antibiotic treatment. However, women with negative cultures may still improve with antibiotic treatment.
For uncomplicated UTI :-- ANTIBIOTICS:--Nitrofurantoin—100 mg bad -5 days TMP-SMX DS(160/800) --1 bad ----3 days Fluoroquinolones—Norflox 400-800mg /day Pylonephritis:--IV ciprofloxacin / oral ciprofloxacin 500mg bd –7 days. Oral TMP-SMX (one double-strength tablet twice daily for 14 days. Blactam +b lactamase inhibitor---ampicillin+sulbactum,ticarcillin +clavulanate,piperacillin+tazobactum – are prescribed in complicated cases IV ceftriaxone
Drug should be present in (high bacteriolethal concentration as an blood ) all fluids of urinary tract e.g. Glomerular filtrate, interstitial space, Intra cellular space , extra cellular space ,affernt and efferent blood vessels of glomerular capsule . So that its effctive against all bacteri present in any part of renal system. No residual infection persists even after caesation of antibiotic therapy. Drug should not be altered in its efficacy / detoxified by liver and kidney it self. Drug shold not be nephrotoxic. Drug should be present in same bacterio lethal concentration in urine when passing down in ureters and stored in bladder for variable time (4-6hrs ) before it bring voided. Drug should be broadly effective against all common bacteria cuasing urinary tract infection . The efficacy of drug should not be much influenced / altered by change in PH of blood as well as that of urine . Drug should not cause crystalization / nidus formation for development of calculus . Drug should have wide marhin of safety ---its bacterio lethal effect and toxicity to patient perticularly pregnant women and fetus in utero. Easy to administer -----Oral or/ and parentral Dose schedule should be simple ---od / bid .. Bactria should not be able to develop their resistance too early and too frequently.
Catheter-Associated UTI;--bactriuria & symptoms in a cathetarised pt.,either localized or to UTI or systemic such as fever Bacteriuria:-10 3-10 5 cfu/ml. Candiduria:--The appearance of Candida in the urine is an increasingly common complication of indwelling catheterization, particularly for patients in the intensive care unit, those taking broad-spectrum antimicrobial drugs, and those with underlying diabetes mellitus. C. albicans is still the most common isolate, although C. glabrata and other non-albicans species are also isolated frequently. The clinical presentation varies from an asymptomatic laboratory finding to pyelonephritis and even sepsis. In asymptomatic patients, removal of the urethral catheter results in resolution of candiduria in more than one-third of cases.
Treatment is recommended for patients who have symptomatic cystitis or pyelonephritis and for those who are at high risk for disseminated disease. High-risk patients include those with neutropenia, those who are undergoing urologic manipulation, and low-birth-weight infants. Fluconazole (200–400 mg/d for 14 days) achieves high levels in urine and is the first-line regimen for Candida infections of the urinary tract oral flucytosine and/or parenteral amphotericin B are preferably given toresistance cases.
Causative agent:--Neisseria gonorrhoeae ; a Gram neg. Inra cellulardiplococci .Sites of infection:--endocervix ,urethra , skenes gland , bartholinesgland,Symptoms:--urinary symptoms—dysuria , frequency of micturition andPID .SIGNS:-Externa urethral meatus –congestedOn squeezing the urethra—purulent discharge present .Diagnosis:--secretions—Grahm staining & culture:--Grahm negetive,intracellular diplococcic.Culture:--Thayer martin medium:-definitive
Single dose treatment--- Drugs:- inj. Ceftriaxone , ciproflox:--500 mg , oflox:-400 mg , cefixime -400 mg , levoflox—250 mg , Kenamycin / streptomycin 2gm injection / 5gm single injection of spiramycin . Note ---Simultaneous treatment of sex partner is must.
One of the common causes of urethritis. T/T:--Azithromycin:--1 gm single dose. Doxycycline:--100 mg bd -7 days. Ofloxacin:--200 mg bd –7 days. Erythromycin:-500 mg—7 days. Sexual partner should be treated at the same time.
Recurrent UTIs:--Are symptomatic UTIs that follow resolution of an earlier episode, usually after appropriate treatment. Recurrent UTIs include relapses (i.e., symptomatic recurrent UTIs with the same organism following adequate therapy) and Reinfection (i.e., recurrent UTIs with previously isolated bacteria after treatment and with a negative intervening urine culture, or A recurrent UTI caused by a second bacterial isolate). Most recurrent UTIs are thought to represent reinfection with the same organism. Recurrent UTIs are common among otherwise healthy young women with anatomically and physiologically normal urinary tracts.
Risk Factors The strongest risk factor for recurrent UTIs in young women is frequency of sexual intercourse. Antimicrobial prophylaxis has proved effective in reducing the risk of recurrent UTIs in women with two episodes of infection in the previous year. Continuous prophylaxis for six to 12 months reduces the rate of UTIs during the prophylaxis period Postcoital prophylaxis may be preferable in women with UTIs temporally related to intercourse. Cranberry products seem to notably reduce the recurrence of symptomatic cystitis. Use of topical estrogen may reduce the incidence of recurrent UTIs in postmenopausal women. Treatment of complicated UTIs should begin with broad-spectrum antibiotic coverage, with adjustment of antimicrobial coverage guided by culture results.
urinary tract disorders- commonly encountered in pregnancy. Some precede pregnancy— example nephrolithiasis. pregnancy-induced changes may predispose to development or worsening of urinary tract disorders- There is the markedly increased risk of pyelonephritis. complications are unique to pregnancy such as pre eclampsia. Prmaturity, PROM.
With good prenatal control / erradication of UTI or early detection in ANC followed by complete and appropriate therapy, most women with these disorders will be least likely to develop any long-term serious consequences.
Significant changes in both structure and function Urinary tract during pregnancy. The kidneys become larger. dilatation of the renal calyces and ureters –Urine content increases > 10ml. Dilatation develops before 14 weeks and likely is due to progesterone-induced relaxation of the muscular layers. More marked dilatation is apparent beginning in mid pregnancy because of ureteric compression, especially on the right side (dextra rotation of uterus ) . There is also some increased vesicoureteral reflux during pregnancy.*all these changes predisposes pregnant women to UTI
refers to persistent, actively multiplying bacteria within the urinary tract in an asymptomatic women. Its prevalence in non pregnant women is 5 to 6 percent and depends on parity, race, and socioeconomic status The highest incidence is in African-American multi paras with sickle-cell trait, and the lowest incidence is in affluent white women of low parity.. The incidence during pregnancy is similar to that in non pregnant women and varies from 2 to 7 percent. Bacteriuria is typically present at the time of the first prenatal visit, and if an initial positive urine culture is treated, fewer than 1 percent of women develop urinary infection . A clean-voided specimen containing more than 100,000 organisms per ml is diagnostic . It may be prudent to treat when lower concentrations are identified, because pyelonephritis develops in some women with colony counts of 20,000 to 50,000 organisms/ml.
If not treated, approximately 25 percent of infected women will develop symptomatic infection during pregnancy. overt bacteriuria has been reported to be associated with preterm or low-birth weight infants . Bacteriuria that persists or recurs after delivery has been associated with pyelographic evidence of chronic infection, obstructive lesions, and congenital abnormalities. The American Academy of Pediatrics and the American College of Obstetricians and Gynaecologists (2007), as well as a U.S. Preventative Task Force (2006), recommends screening for bacteriuria at the first Anenatal visit,
Amoxicillin 500 mg three times daily Ampicillin 250 mg four times daily Cephalosporin 250 mg four times daily Ciprofloxacin 250 mg twice daily Levofloxacin 250 mg daily Nitrofurantoin 50 to 100 mg four times daily; 100 mg twice daily Trimethoprim-sulfamethoxazole 160/800 mg two times daily
Nitrofurantoin 100 mg four times daily for 10 days Nirofurantoin 100 mg twice daily fo 7 days Nitrofurantoin 100 mg at bedtime for 10 days
Treatment failures Nitrofurantoin 100 mg four times daily for 21 days Suppression for bacterial persistence or recurrence Nitrofurantoin 100 mg at bedtime for remainder of pregnancy
Bacteriuria responds to empirical treatment with any of several antimicrobial . selection based on in vitro susceptibilities, empirical oral treatment for 10 days with nitrofurantoin macrocrystals, 100 mg at bedtime, is usually effective. regardless of regimen given, the recurrence rate is approximately 30 percent. For recurrences, nitrofurantoin, 100 mg orally at bedtime for 21 days For women with persistent or frequent bacteriuria recurrences, suppressive therapy for the remainder of pregnancy can be given.
most common bacterial infections during pregnancyOrganisms that cause urinary infections are those from thenormal perineal flora. Most Common bacteria:--E .coli.
puerperium-several risk factors exist that predispose a woman to urinary infections. Bladder sensitivity to intravesical fluid tension is decreased as a consequence of the trauma of labor as well as conduction analgesia Sensation of bladder distension diminishes by discomfort caused by an episiotomy, periurethral lacerations, or vaginal wall hematomas. Normal postpartum diuresis may worsen bladder over distension. Catheterization to relieve retention and distension commonly leads to urinary infection (usually no long-term sequelae ) Operative and instrumental delivery delays early mobilization of patient. Retention of urine is also common as in pearly pregnancy .
Cystitis is characterized by dysuria, urgency, and frequency, but with few associated systemic findings. Pyuria and bacteriuria are usually found. Microscopic hematuria is common, and occasionally there is gross hematuria from hemorrhagic cystitis . usually uncomplicated, but the upper urinary tract may become involved by ascending infection Lower urinary tract symptoms with pyouria accompanied by a sterile urine culture may be from urethritis caused by Chlamydia trachomatis.
Women with cystitis respond readily to any of several regimens. Most of the three-day regimens listed previously are usually 90-percent effective . Single-dose therapy is less effective, and if it is used, concomitant pyelonephritis must be confidently excluded. Mucopurulent cervicitis usually coexists- erythromycin therapy is effective
Renal infection is the most common serious medical complication of pregnancy Increased risk in second trimester, nullipara and young age It is usually unilateral in most of cases . Right-sided in more than half of cases. Bilateral in one fourth cases.
pyelonephritis - one of the leading cause of septic shock during pregnancy urosepsis may be related to an increased incidence of cerebral palsy in preterm infants(prematurity and birth trauma to prmature head , asphyxia are the contributory factors ) . Fortunately, there are no serious long-term maternal sequelae .
abrupt onset of fever shaking chills aching pain in one or both lumbar regions. Anorexia nausea and vomiting(leads to dehydration). Tenderness in one or both costovertebral angles.
respiratory insufficiency from endotoxin-induced alveolar injury(may lead to) frank pulmonary) edema In some cases, pulmonary injury may be so severe that it causes acute respiratory distress syndrome (ARDS)
Bacteraemia demonstrated in 15 to 20 percent patients. Incidence-E. Coli( isolated from urine or blood) in 70 to 80 percent of infections. Klebsiella pneumoniae in 3 to 5 percent Enterobacter or Proteus in 3 to 5 percent gram-positive organisms including group B Streptococcus in up to 10 percent of cases.
Hospitalize the patient. Obtain mid stream catch of urine for culture and sensitivity. Send blood also for culture. Evaluate hemogram, serum creatinine, and Serum electrolytes. Monitor vital signs frequently, including urinary output—consider indwelling catheterization. Establish urinary output to 50 mL/hr with intravenous crystalloid. Administer intravenous antimicrobial therapy . Obtain chest radiograph if there is dyspnea or tachypnea. Repeat hematology and blood chemistry studies after 48 hours. Change to oral antimicrobials when patient becomes afebrile. Discharge when patient remain afebrile for 24 hours, continue same antimicrobial therapy for 7 to 10 days Repeat urine culture 1 to 2 weeks after antimicrobial therapy is completed.
To start with antimicrobial therapy is usually empirical, ampicillin 500-100mg IV 6hrly plus gentamycin 80mg IM bid / cefazolin or ceftriaxone or an extended- spectrum antibiotics give response in 95-percent cases.
If there is no clinical improvement by 48 to 72 hours, then USG is done to look for urinary tract obstruction indicate by presence of abnormal ureteric or pyelocaliceal dilatation . some women may have calculi. If stones are strongly suspected despite a non diagnostic USG examination, a plain abdominal radiograph should be performed ; it identifies nearly 90 percent stones, single X-Ray exposure is usually not hazardous to fetus. others-Intravenous pyelography . The modified one-shot pyelogram—a single radiograph obtained 30 minutes after contrast injection—almost always provides adequate imaging .It is to be done after discussing the pross and cons of benefit to mother and Xray exposure hazard to fetus ----as exposuredoes and duration both are > simple Xray. Magnetic resonance urography may be used safely . Other causes of persistent infection are an intra renal or peri nephric abscess or phlegmon
Obstruction can be relieved by cystoscopic placement of a double-J ureteral stent . these stents tend to become encrusted, percutaneous nephrostomy - a better option as the stents are easier to replace. Surgical removal of stones may be required in some cases.
Recurrent infection—either covert or symptomatic—is common and develops in 30 to 40 percent of women following completion of treatment for pyelonephritis Nitrofurantoin, 100 mg orally at bedtime, is given for the remainder of the pregnancy. this regimen reduces recurrence of bacteriuria.
chronic interstitial nephritis that classically was thought to be due chronic pyelonephritis. radiologicaly identified scarring is frequently accompanied by ureteric reflux with voiding-hence it is termed reflux nephropathy. Long-term complications include hypertension, which may be quite severe if there is demonstrable renal damage. After surgical correction, half of these women have bacteriuria when pregnant . Maternal and fetal prognosis depends on the extent of renal destruction.