3. EPIDEMIOLGY
UTI are the most common bacterial infection
Additionally , UTI is the most common cause of
nosocomial infection
Women make a significant proportion of UTI suffer”s
with annual incidence of 12.1%
Peak incidence of UTI in women occurs between the
ages of 20-40 yrs
20-30% of women who have a UTI will have recurrent
UTI(RUTI)
4. Epidemiology
RUTI results in significant discomfort & have a high
impact on ambulatory health care cost as a result of
OPD visits, diagnostic tests & prescriptions.
RUTI is more common in post menopasal females due
to residual urine after voiding, which often associated
with bladder or uterine prolaspe
In addition, the lack of estrogen causes marked
changes in vaginal microflora, including a loss of
lactobacilli & increased colonization of E.Coli.
5. DEFINATION
UTI is diagnosed in women by presence of at least
100,000 colony forming units (cfu)/ml in pure culture
of voided clean catch urine.
RUTI are caused by either re-emergence of bacteria
from a site within the urinary tract (bacterial
persistence) or new infections from bacteria outside
the urinary tract (reinfection).
RUTI is defined as three episodes of culture confirmed
UTI in the last 12 mths or 2 episodes in last 6 mths.
6. RISK FACTORS
Women
Infections tend to recur.
Short urethra
Frequent sexual intercourse
Spermicidal cream
Diaphragm
7. .
RISK FACTORS
Menopausal females have decrease in
estrogen, which leads to thinning of lining
of the urinary tract, which increases
susceptibility to bacterial infections.
Pregnancy does not increase the risk of
getting UTI but it can increase the risk of
developing a serious infection that could
potentially harm the mother & fetus
8. PATHOGENESIS
The interaction between bacterial virulence & host
defense factors can ultimately results in UTI
More virulent bacteria are necessary to infect
healthy hosts with normal urinary tract, whereas
less virulent bacteria may easily infect
compromised hosts
The cause of UTIs in women is usually
colonization of the vagina & urethera with bacteria
from the intestinal tract
9. BACTERIAL VIRULENCE
The initial step in pathogenesis of UTI is bacterial
adherence to urothelium by pilli.
Pilli are filamentous adhesvie organelles in
Uropathogenic strains of E.coli (UPEC)
Bacterial colonization causes a host inflammatory
response, which includes neutrophil influx,
followed by apoptosis & exfoliation of the
bladder”s epithelial cells in an effort to rid the
bladder of bacteria.
12. HOST RISK FACTORS IN PATHOGENESIS
Genetic, anatomic, functional, & behavioral
factors that affect the host susceptibility to
uropathogens & its ability to overcome them.
Anatomical/Functional
Congenital Abnormalties
Urinary Obstruction
Urinary Incontinence
Calculi
Residual Urine
Cathers or Foreign Bodies
Atrophic Vaginitis
Genetic
Blood group Antigen
Nonsecretor status
Density of adhesin
receptors
Behavioral
Sexual activity
Diaphragm use
Spermicide Use
Antimicrobial use
13. Risk Factors differ in Pre & Post
Menopausal
In sexually active pre-menopausal risk factors are:
Frequency of sexual intercourse
Spermicide Use
Age of First UTI (< 15 yrs of age indicates > risk of
RUTI)
H/O UTI in the Mother (genetic factor or long
term environmental exposures)
In Post menopausal risk factors are:
Vesical Prolaspe
Incontinence
Post Voiding residual Urine
15. Initial Evaluation of Females with
RUTI
Most women with RUTI do not have anatomic
abnormalities & do not need a X Ray
Assesment should include
History & physical Exam that include a pelvic
exam
Pelvic USG for residual urine
Urine C/S for documenting that UTI is the cause of
symptoms (typically , frequency, dysuria, &
Haematuria)
16. Specialized Evaluation for RUTI
Congenital Abnormalities -
Either CT scan or IVP should be done
Prior Pelvic Surgery –
USG for checking HDN HU because of ureter
may be caught in scarring due to stitch or clip
during prior surgery
Cystoscopy to check the bladder for stitches
which can form a nidus for stone or infection
17. Specialized Evaluation for RUTI
UTI with Klebsiella, Pseudomonas or
Proteus bacteria – USG KUB is done because
these bacteria have urease splitting enzyme
that can alkalinize urine & may cause
formation of struvite stones
Kidney Stones – check NCCT for stones,
evidence of urinary obstruction.
Pyelonephritis – diagnosed by positive urine
C/S , back pain and High fever
18. DIFFERENTIAL DIAGNOSIS OF RUTI
Not all women with frequency, dysuria &
haematuria have UTI
In the case of RUTI, especially with negative
cultures; a urogical & gynaecological evaluation
should be performed in order to exclude
Bladder cancer
Obstructive problems
Detrusor failure
Vaginal infections
Genital infection
Interstitial cystitis
Neurogical disease
19. Complications of RUTI
Acute Papillary necrosis
Overwhelming sepsis syndrome with shock
due to
Loss of vasomotor tone
Capillary Leak
Impaired myocardial performance
Perinephric abscess
20. TREATMENT of RUTI
Primary Tt for RUTI should be guided by C/S
Commonly used antimicrobials that act on gram
negative uropathic organism include
Trimethoprim (TMP) & Co-trimoxazole (TMP-SMX)
Fluroquinolones (ciprofloxacin, levofloxacin, norfloxacin,
ofloxacin, moxifloxacin)
Nitrofurantin
Beta–Lactams penicillins (amoxycillin, ampicillin-like
compounds, cefadroxil, cefuroxime, cefpodoxime)
Duration of Tt of 7-10 days increases rate of eradication
& minimize resistance to drugs
22. PREVENTION OF RUTI
Approaches proposed for the prevention:
Non Pharmacological therapies,
Local estrogens for post menopausal
females
Antimicrobial prophylaxis therapy: given
regularly or postcoital prophylaxis in
sexually active women
Immunoactive Prophylaxis
23. NON PHARMACOLOGICAL THERAPIES
Non Pharmacological therapies have
doubtful role & include:
Adequate fluid intake
Voiding after sexual intercourse
Ingestion of cranberry juice
Eating yogurt ( lactobacilli Cultures)
Vaginal application of lactobacilli
Avoiding constipation
25. CONTINUOUS PROPHYLACTIC
ANTIMICROBIAL THERAPY
One effective approach for Mgmt is the prevention of
infection by use of long term, prophylactic
antimicrobials taken on a regular basis at bedtime
It is not known
Which antibiotic schedule is best
Optimal duration of prophylaxis
Incidence of adverse events
Recurrence of infections after stopping prophylaxis
Treatment compliance
26.
27. CHOICE OF ANTIBIOTIC
TMP, Co-trimoxazole or nitrofurantin can
still be considered as the standard regimen.
In cases of Breakthrough infection due to
resistant pathogens, low doses of
flouroquinolones may be used
During pregnancy an oral first – generation
cephalosporin is recommended
28. POST COITAL ANTIMICROBIAL THERAPY
It is an alternative prophylactic approach for
women in whom episodes of infection are
associated with sexual intercourse
Same drugs can be used in the same doses as
recommended for continous prophylaxis
29. SELF START ANTIMICROBIAL THERAPY
Suitable for mgmt in well informed women
in whom the rate of recurrent episodes is
not too common
This is not prophylaxis but early treatment
It has emerged in an effort to decrease
overall antibiotic usage
It relies on pt’s intelligence and
recognization of UTI
Pt takes same antibiotics for 2-3 days
30. EFFICACY & SIDE EFFECT OF
PROPHYLACTIC THERAPY
Number of pts with RUTI decreased by
eightfold after prophylaxis
UTI episode /pt year is reduced by 95%
during prophylaxis
However, prophylaxis does not appear to
modify the natural history of RUTI or exert
a longterm effect on the baseline infection
rate
31. EFFICACY & SIDE EFFECT OF
PROPHYLACTIC THERAPY
After stopping prophylaxis even after
extended periods, approximately 60 % of
women will become re–infected within 3-4
mths
Side effects of prophylactic antimicrobials
include vaginal & oral candidiasis and GI
symptoms
32. RUTI IN PREGNANCY
Women with bacteria in urine during
pregnancy should be put on prophylaxis till
delivery (penicillin or first generation
cephalosporin)
Other options for pts whom are allergic is
NFT or TMP-SMX
Women with bacteria with no symptoms and
whom are not pregnant do not need to be
treated with antibiotics
33. CRANBERRY
Cranberry (Botanical name - Vaccinium macrocarpon)
is a small evergreen shrub grown in bogs in damp
forests and open ponds. It requires wet, boggy, acidic
soil
34. CRANBERRY
Cranberry is a North American native
Cranberry was a popular Tt of UTI prior to
the introduction of antibiotics, & continues
to be used widely for this purpose.
Cranberries (Proanthocyanidin) can inhibit
the attachment of bacteria to the epithelial
lining of the urinary tract.
In vitro studies have observed potent
inhibition of bacterial adherence of E.coli &
other gram-negative uro-pathogens.
35. CONCLUSIONS FROM STUDIES
Cranberry has direct antibacterial activity
Cranberry may offer an alternative
methodology to antibiotic prophylaxis.
Effect on type P-fimbriated E. coli was
observed to be specific to cranberry
400 mg / day of shows reduction in RUTI
In one uncontrolled study, more than 50%
of pts had a positive clinical response in UTI
36. D-MANNOSE
D-Mannose is a sugar monomer of the
alsohexose series of carbohydrates. Mannose
is a C-2 epimer of glucose.
D-mannose prevents binding of type 1-
piliated E. coli to the human bladder cell line
& reduces both adhesion & invasion of the
E.coli.
It significantly reduce bacteriuria within 1
day
Pts who were treated daily with D-Mannose,
94% reported symptom improvement.
37. THE RIGHT COMBINATION
‘ALTERNATIVE MEDICINE REVIEW’
suggests the use for Cranberry & D-
Mannose as a natural option for the
mgmt of UTI. At the same time,
Potassium salts are suggested to
alkalize the urine and reduce
dysuria.
39. INPATIENT CARE FOR RUTI
Necessity of admission depends upon Age, Host
factors, Risk of complicated infection, Likelihood of
morbidity with failed OPD treatment
Pts with
Structural abnormality ( eg, calculi, Urinary tract
abnormality , indewelling catheter , obstruction)
Metabolic disease ( eg, DM, CKD)
Impaired Host defense ( eg, HIV, Current
chemotherapy, underlying active
40. INPATIENT CARE FOR RUTI
Pts with uncomplicated Pyelonephritis
should be admitted
Pts unable to maintain oral hydration,
shock, fever unresponding to antipyretic
therapy
Pts with deblitating pain or dehydration that
cannot be corrected in OPD
Pts with inadequate home care or resources
to comply with medical regimen
41. TAKE HOME MESSAGE
RUTI are a major issue for many women because
they are common, costly, & cause considerable
morbidity
Pts with RUTI should be properly investigated
by Lab & radiological techniques to exclude
complicated causes or gynecological problems.
Prophylactic therapy proved efficacy with
decrease rate of recurrence, minimal side
effect & drug resistance but without alteration
in natural history of disease
