Management of uti

Javed Iqbal
FCPS, FRCS,
Professor Of Surgery
Quaid-e-Azam Medical College, &
Iqbal Minimal Invasive Surgery Center
Bahawalpur
www.facebook.com/surgeonjaved
e-mail:
surgeonjaved@hotmail.com

Urinary tract infections
(Complicated)

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Introduction
Most common type of bacterial infections

Although the urinary tract, unlike the
respiratory tract or the gastrointestinal
tract, is not exposed to the outside
world, and is normally sterile.

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Definition

Urinary tract infection is diagnosed
when bacteria and pus cells are
recovered from the urine with or
without symptoms.

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UTI
 Women during the reproductive years

 Old age

 Post-operative period

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“complicated” UTI
 Long-term foreign bodies such as indwelling
urinary catheters and stents.
 Urinary tract stones.
 Congenital or anatomic anomalies.
 Obstructive uropathy
 Vesicoureteric reflux, or structural urologic
abnormalities, including surgically created
structural changes, such as ileal loops;
 Neurogenic bladder disorder
 Renal transplantation.
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Why is the Concept of
'Complicated' Urinary
Tract Infections Useful in
Practice?

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Complicated UTI
 More chances of infection with bacteria
that are resistant to first-line antibiotics
 Less likely to respond to a short course
(<7 days) of antibiotics; and
 More likely to require microbiologic
laboratory testing, follow-up
assessment, and consideration of imaging
procedures

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Pre-menopausal
Women

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Premenopausal Women
 Nosocomial pathogens --recent hospitalization
 Diabetes mellitus
 Pregnancy
 Recent instrumentation or surgery
 Uremia from renal causes
 Anatomic abnormalities of the urinary tract
 Urinary tract stones
 Urinary stents or other foreign bodies
 Immunocompromised or
immunosuppressed, including from the use of
immunosuppressive drugs; and a history of renal
transplantation.
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Why are Women so Prone
to Urinary Tract
Infections?

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 Short urethra.
 Close proximity to the anus, vulva and
perineal area.
 In adults the UTIs have been shown to be
strongly and independently associated
with recent sexual activity

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Pediatric Patients

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In infants below the age of three
months
hematogenous spread

After this age
The route of entry of pathogens is by
ascending through the urethra, as in
adults
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The organism most
commonly associated with
UTI in children, as in
adults, is E. coli

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 Diagnosis is not always as straightforward
as in adults, especially in neonates and
very young children;
 The risk of recurrence is relatively high
 The risk of complications, or long-term
sequela is relatively high, a risk that can
be significantly reduced with timely
diagnosis and prompt treatment.
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 More extensive diagnostic investigations
 Greater emphasis on prompt and
appropriate treatment
 Longer follow-up after apparent cure

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What is Required for the
Diagnosis of a Pediatric
Urinary Tract Infection?

Urine Culture is must

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Elderly Patients

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Again, women outnumber
men as far as incidence is
concerned

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Urinary Tract Infections in
the Elderly should always
be Considered
'Complicated'
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1

Non-specific, vague, or
atypical clinical presentation

Decline in mental status
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2
The sensitivity of standard
urinalysis for leukocyte esterase
as a marker of infection is low.

Urine cultures
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3

Non-first-line antibiotics

short-course antibiotic therapy is
much less likely to be effective.

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4

Wide variety of both Gram-negative and
Gram-positive bacteria, and polymicrobial
infection is relatively common.

E. coli accounts for less than 50% of
bacterial isolates in the elderly

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Treatment failures and
recurrences, despite what would
be considered appropriate and
adequate therapy, are common
in the elderly

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Why elderly are more prone to UTI
 Oestrogen
 Anatomical changes due to
gyaenacological surgery
 Some degree of BOO in male
 Debilitating diseases resulting in
decreased immunity

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Asymptomatic
Bacteriuria

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More than 100,000 colony-
forming units (CFU)/mL of
voided urine in a person
with no symptoms of UTI

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Asymptomatic
Bacteriuria in elderly
The current view is that it should
not be treated

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Pregnant Patients

1. asymptomatic bacteriuria
2. symptomatic lower UTIs
3. pyelonephritis

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Asymptomatic bacteriuria
 Itshould be treated
 E-coli is the common bug
 First line treatment is the choice
 Duration should be short
 Recurrence should be monitored

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Patients with Anatomic
Abnormalities of the
Urinary Tract

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 Patients with congenital developmental or
anatomic anomalies;
 Patients with surgically created anatomic
changes in the urinary tract;
 Patients with any kind of obstructive uropathy;
 Patients with urinary tract stones; and
 Patients with long-term foreign bodies in the
urinary tract, such as stents or indwelling
catheters
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 Infected with a wider range of bacteria
 They sustain renal damage and scarring
as a result of infection
 They have a high risk of poor response to
antibiotic therapy.

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Catheter-related Urinary
Tract Infection

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Risk Factors
 longer duration of catheterization
 female sex
 poor catheter care
 inadequate use of antibiotics

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Can Urinary Tract Infection be Prevented in
Catheterized Patients?

 Minimal duration
 Close system
 Intermittent cathetrization
 Supra-pubic cystostomy

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Should Asymptomatic
Bacteriuria in
Catheterized Patients be
Treated?

NO
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Chronic (Bacterial)
Prostatitis
Chronic Pelvic Pain Syndrome

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TREATMENT

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UTI was first treated with
sulfonamides during the
Second World War in 1939
by the Nobel Prize Winner
Gerhard Domagk
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Non specific therapies
 Hydration and increased fluid intake;
E. coli do not grow in a low osmolar
(dilute) urine.
 Alkalinization of the urine: dissolves urate
and oxalates crystals and less growth of
E.coli
 Urination after intercourse.
 Analgesia.
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Antibiotics

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General Considerations
 Concentration in the urine
 Concentration in vaginal secretions
 Spectrum of activity against infecting
organisms
 Half-life
 Safety and adverse effect profile
 Cost

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Traditional First-line Agents for
Uncomplicated Urinary Tract
Infections
 Amoxicillin
 Ampicillin
 Trimethoprim
 Trimethoprim–sulfamethoxazole

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First-line Agents
 No role in Complicated UTI
 Very little role when the isolate is E-Coli

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Oral Cephalosporins

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Extended-spectrum
Agents

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Aminoglycosides

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Nitrofurantoin

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Fluoroquinolones

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 Classification of Fluoroquinolones

 Whatis the Anti-bacterial Activity of the
Fluoroquinolones?

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Which Fluoroquinolones
are Suitable as First-line
Agents for Treatment of
Complicated Urinary
Tract Infections?

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Antipyretic Therapy

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THANK YOU VERY
MUCH

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Management of uti

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