Urinary tract infection in nutshell as ppt

1. Urinary Tract Infection:
Dr Ajit Joshi
Associate Prof Medicine
DYPES Medical collage
Kolhapur

2. Urinary Tract Infection
 Urinary tract infection—most common
source of bacteremia, a dangerous
systemic infection in long-term care
facilities
 Bacteremia—40 times more likely to occur
in catheterized than non-catheterized
patients
 Bacteremia leads to significant morbidity
and mortality in the vulnerable elderly

3. Urinary Tract Infection
Lower
urethritis
cystitis
prostatitis
Upper
pyelonephritis
intrarenal and perinephric abscess

4. Also categorized into
Non-catheter associated (community acquired)
Catheter associated (hosp. acquired)
Any category may be symptomatic or
asymptomatic

5. Urinary Tract Infection
Pathogenic microorganisms in urine, urethra,
bladder, kidney, prostate
Usually growth > 105 organisms per milliliter
From midstream “ clean catch” urine sample
If from catheter specimen can be significant with
102 or 104 organisms per mL

6. Etiology
 Most common is Gram neg. bacteria
 E. coli - 80% of uncomp. acute UTI
 Proteus – assoc. with stones
 Klebsiella – assoc. with stones
 Enterobacter
 Serratia
 Pseudomonas

7. Etiology
 Gram positive cocci
 Staphylococcus saprophyticus 10-15 % acute UTI in young females
 Enterococci – occas. in acute uncomplicated cystitis
 Staphylococcus aureus – assoc. with renal stones, instrumentation,
increased susptebility of bacteremic kidney infection

8. Etiology
 Urethritis from chlamydia, gonorrhea, HSV – acute symptomatic,
sexually active female with sterile pyuria
 Ureaplasma urealyticum
 Candida or other fungal species – commonly assoc. with catheter or
DM
 Mycobacteria

9. Pathogenesis
 Usually ascent of bacteria from urethra to bladder to kidney
 Vaginal introitus, distal urethra colonized by normal flora
 Gram negative bacilli from bowel may colonize at introitus,
periurethra

10. Age-Related Changes Men Women
Decreased bladder capacity and increased
urine production (especially at night)
Decreased voided volume
Decreased estrogen menopause leads to
thinning of vaginal & urethral mucosa
Decreased lower urinary tract sensory
threshold
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Physiologic Changes with age

11. Age-Related Changes Men Women
Problems of urinary storage & emptying
↑incidence of overflow incontinence from
urethral obstruction or stricture
Decreased estrogen levels leads to pH
changes in vagina, favoring colonization of
E. coli, ↑risk of UTI
Prostatic enlargement can lead to urinary
obstruction, increased residual urine &
infection
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UTI - Physiologic Changes

12. Age-related Risk Factors for UTI
 Advanced Age
 Fecal incontinence/impaction
 Incomplete bladder emptying or neurogenic bladder
 Vaginal atrophy/estrogen deficiency
 Pelvic uterine prolapse/cystocele
 Insufficient fluid intake/dehydration
 Indwelling foleys catheter or urinary catheterization or
instrumentation procedures

13. Age-related Risk Factors for UTI
 Diabetes or immunosuppression
 Benign prostatic hypertrophy
 Bladder or prostate cancer
 Urinary tract obstruction
 Spinal cord injury

14. Predisposing conditions to UTI
Female
 Short urethra, proximity to anus, termination beneath
labia
 Sexual activity
Pregnancy
 2-3% have UTI in pregnancy 20-30% with
asymptomatic bacteriuria  may lead to pyelo
 Increased risk of pyelo = decreased ureteral tone,
decreased ureteral peristalsis, temporary
incompitance of vesicoureteral valves

15. Predisposing conditions
 Neurogenic bladder dysfunction or bladder diverticulum
(incomplete emptying)
 Age - Postmenopausal women with uterine or bladder prolapse
(incomplete emptying), lack of estrogen, decreased normal
flora, concomitant medical conditions such as DM
 Vesicoureteral reflux
 Bacterial virulence
 Genetics
 Change in urine nutrients, DM, gout

16. Complicated vs Uncomplicated UTI
UTI’s in elderly men are always considered
complicated
UTI’s in women are complicated when:
Recurrent UTI
Secondary to structural abnormalities
Catheters
Stones
Urinary retention
Abscess formation or urosepsis
Primary diagnostic and treatment focus in research
studies have been related to the elderly female
population

17. Complicated vs Uncomplicated UTI
Recurrent UTI’s — culture-confirmed UTI’s
>3 in 1 year or
> 2 in 6 months
Relapse UTI — occurs within 2 weeks of Rx
of an earlier UTI
same pathogen
Re-infection UTI — occurs >4 weeks after earlier UTI
different pathogen

18. Age/Type Specific Pathogens -
Younger patients, rare in elderly—Staphylcoccus,
saprophyticus (gram pos.) – 10-15%
Elderly diabetics
Klebsiella species (gram neg.) most common
Elderly
E. coli ~ 30%
Proteus species (part of host flori in GI tract) ~ 30%
Staphylcoccus aureus, Klebsiella, Pseudomonas (gram neg.)
and Enterococcus (gram pos.) ~ 40%

19. Symptomatic vs Asymptomatic Bacteriuria
Asymptomatic Bacteriuria (ASB)
 Defined as the presence of bacteria in urine of patients who do
not have dysuria, urinary frequency, urgency, fever, flank pain,
or other symptoms related to irritation of the urethra, bladder, or
kidney
 Strictly defined—exists when 2 urine cultures done with clean-
catch specimens are positive in a patient who has no urinary
tract symptoms

20. Symptomatic vs. Asymptomatic Bacteriuria (
cont’d)
Most ASB in the elderly is associated with
complicating factors such as:
Hormonal: post-menopausal women
Anatomical: prostatic obstruction in men, cystocele in women
Functional: CNS, i.e., P.D. & dementia
Metabolic:diabetics (ASB females with Type 2 diabetes—29%)
Immunological: ↑’s in inflammatory mediators (cytokines, acute
phase proteins)
Instrumental: indwelling catheter→always bacteriuric
symptoms

21. UTI Signs and Symptoms -
Very difficult to assess and recognize, even when present in the
older adult.
Signs & Symptoms that indicate further evaluation-
 New or increased urgency, frequency, dysyuria:
> in younger patients, still can be present in elderly
These complaints can be common & chronic without
bacteriuria
 Requires careful interpretation—may not be due to UTI
 Change in character of urine
 Cloudy, bloody, or malodorous urine in >85% symptomatic
UTI’s

22. Signs and Symptoms -
 Clarity of urine
 Clear → no bacteria; cloudy, milky or turbid → bacteriuria
Cloudiness, however, can occur in normal urine—mucus, epithelial cells
Cloudy character, alone or with (+) dipstick analysis → further lab
analysis
Study by Loeb et al. (2001) as consensus criteria—cloudy urine not an
indication for antibiotics
 Bloody
 Hematuria not always indicative of infection; possibly
irritation or medication related
 Malodorous
 Not a valid indicator—may be caused by bacteria, but
could be hygiene-related
 Often considered an indicator.

23. Signs and Symptoms -
 Elevated temperature—(vital signs)
Elderly require > time to present with fever, may not have any
increase in temperature → may even be hypothermic
Elderly at ↑’d risk for masked or absent fever response due to
antipyretics, corticosteroids, chemo Rx, alcoholism,
hypothyroidism, malnutrition and renal insufficiency
Fever is a marker for serious infection & most important
clinical indicator for antibiotic treatment
Not always due to UTI—consider differential diagnoses:
pulmonary or skin infections
Lack of fever may delay diagnosis

24. Signs and Symptoms -
 Pain
Despite limitations of assessment in the elderly, suprapubic,
flank or CVA pain can indicate UTI
(abdominal, rectal & vaginal exam)
Agitation, irritability, restlessness, decreased appetite,
increased confusion, or even falls may indicate pain
(Neuro & GI exam)
Cultural differences in interpretation of pain, symptoms
 Incontinence
May be caused by UTI or the altered mental status that
that occurs with the elderly
Commonly caused by other conditions
Symptom and a risk factor of UTI

25. Signs and Symptoms -
 Decline or Sudden Change in Mental Status
Hallmark symptom of UTI in elderly in most studies
Altered mental status, lethargy & confusion are the most common
indicators of bacteremia in elderly UTI
 Falls
Not specific to UTI, but may indicate a change in status, evaluate
clinical picture
 Appearance—(general survey)
Vague assessment
General decline in status
Listen to family and staff that know the patient well

26. Signs and Symptoms -
 Other Possible Signs & Symptoms of UTI
Signs of sepsis other than fever -
 Hypotension
 Tachycardia
 Tachypnea
 Rales
 Respiratory distress
 Anorexia, nausea, vomiting
 Abdominal tenderness

27. Diagnostic Criteria -
Pyuria
 A host response to infecting bacteria causing an increase of
white blood cells or pus in the urine
 Associated with presence of both symptomatic and
asymptomatic UTI’s
 Level of pyuria is ↑ when infected with a gram negative
organism
 This is so common that it has questionable value in UTI
detection and as an indicator for Rx in the absence of clinical
symptoms.

28. Urethritis
 Acute dysuria, frequency
 Often need to suspect sexually transmitted pathogens esp. if
symptoms more than 2 days, no hematuria, no suprapubic pain, new
sexual partner, cervicitis

29. Cystitis
 Symptoms: frequency, dysuria, urgency, suprapubic pain
 Cloudy, malodorous urine (nonspec.)
 Leukocyte esterase positive = pyuria
 Nitrite positive (but not always)
 WBC (2-5 with symptoms) and bacteria on urine microscopy

30. Pyelonephritis
Fever
chills, diarrhea, tachycardia, gen. muscle
tenderness
Renal angle tenderness with deep abdominal
tenderness
Possibly signs of Gram neg. sepsis

31. Pyelonephritis
Leukocytosis
Pyuria with leukocyte casts, and bacteria and
hematuria on microscopy
Complications: sepsis, papillary necrosis, ureteral
obstruction, abscess, decreased renal function if
scarring from chronic infection, in pregnancy –
may increase incidence of preterm labor

32. Catheter-Associated
Urinary Tract Infections
 10-15% of hosp. patients with indwelling catheter develop
bacteriuria
 Risk of infection is 3-5% per day of catheterization
 UTI after one-time bladder cath approx. 2%
 Gram neg. bacteremia most significant complication of cath-
induced UTI
 Greater antimicrobial resistance

33. Diagnosis of UTI
History
Physical exam
Lab
 Urinalysis with micro = WBC, bacteria
 Urine culture
 Sensitivities of culture for tailored antibiotic therapy
 May dx acute uncomp. cystitis based on hx, Phy
exam and U A alone, no need for culture to treat

34. Diagnosis
 Urinalysis
 Leuk. Esterase pos. = pyuria
 Nitrite pos. from urea prod. bact. (but not always)
 Micro – WBC (even 2-5 in patient with symptoms)
 Micro – Bacteria

35. Diagnosis
 Urine culture
 Once 105 colonies per mL considered standard for dx but misses up to
50%
 Now, 102 to 104 accepted as significant if patient symptomatic
 Needed in upper UTI, comp. UTI, and in failed treatment or reinfection
 Sensitivities for better tailoring of tx

36. Asymptomatic Bacteriuria
1. ASB Dx based on results of a culture from clean-catch
specimen (* important to minimize contamination)
 Women: bacteriuria = 2 consecutive voided urine samples
,isolation of same strain in cfu/mL >100,000
 Men: bacteria = single, clean-catch specimen with 1
bacterial species isolated in > 100,000 cfu/mL
 Both: single catheterized urine specimen with 1 bacterial
species isolated in a count of > 1,000 cfu/mL

37. Asymptomatic Bacteriuria -
2. Pyuria accompanying ASB not an indication for
antimicrobial Rx (A-2)
3. Pregnant women should be screened in early pregnancy,
at least once & treated if positive (A-1)
4. Screening of ASB & Rx if positive before these urological
procedures:
 Transurethral resection of prostate (A3)
 Procedures anticipated to cause possible mucosal
bleeding (A-3)

38. Asymptomatic Bacteriuria
5. No screening for ASB: (A-1 & A-2 strongly
recommended)
 Pre-menopausal, non-pregnant women (A-1)
 Diabetic women (A-1)
 Community older adults (A-2)
 Institutionalized elderly (A-1)
 Spinal cord injury (A-2)
 Indwelling-catheterized patients (A-1)
6. Antimicrobial Rx of asymptomatic women with
catheter-acquired bacteriuria persisting 48 hrs after
removed, should be considered
7. No screening or Rx of ASB → renal transplant or
solid organ transplant recipients

39. Asymptomatic Bacteriuria
 Treatment failures: repeat tx based on sensitivities for 1 week, then
prophylactic therapy for remainder of pregnancy
 Prophylaxis: Nitrofurantoin, Ampicillin, TMP/SMX

40. Indwelling catheter present:
two of the following must be met Catheter is not present:
three of the following must be met
 Fever (>38°C/100.4°F) or increase of
1.5°C (2.4°F) above baseline
temperature.
 Chills
 New costovertebral angle tenderness
 New suprapubic pain, flank pain or
tenderness
 Decreased mental or functional status
(delirium)
 New-onset hematuria, foul-smelling
urine, or amount of sediment
 Acute dysuria alone (key indicator) or
fever (>38°C/100.4°F) or increase of
1.5°C (2.4°F) above baseline temperature
 Chills
 Frequency
 Urgency
 New costovertebral angle tenderness
 Decreased mental or functional status
(may be new or increased incontinence
related) *
 New-onset hematuria, foul-smelling urine
or (+) sediment
 New suprapubic pain, flank pain or
tenderness

41. Treatment Plan
 Early detection/Rx → goal is to prevent systemic infection,
bacteremia
 Initiation of antibiotic treatment is recommended for a clinically-
diagnosed UTI. Adjust medication when urine C&S is final
 Selection of antibiotic must be individualized and consider:
Side effect profile
Cost
Bacterial resistance
Likelihood of compliance (convenience, fewer pills/day ↑’s compliance)
Effect of impaired renal function on dosing
Possible adverse drug reactions ↑ in elderly (multiple drugs, co-morbidities.

42. Treatment Plan
 Anti biotic Rx for at least 10 days for institutionalized
elderly, as short-term therapy may not be as effective.
 10 -14 days, if indicated, for complicated UTI.
(recommended for males)
 Conventional regimen of 7-10 days duration is
usually recommended.

43. Treatment
Uncomplicated cystitis with less than 48 hours of
symptoms, non-pregnant, usually 3 days tx
sufficient
 Bactrim DS, Septran DS
 Cipro or other FQ (avoid in preg.)
 Nitrofurantoin (7 days)
 Augmentin
 Bladder analgesis, Pyridium

44. Treatment
 Uncomp. cystitis in pregnant patient
 Requires longer tx of 7-14 days
 Cephalosporin, nitrofurantoin, augmentin, sulfonamides (do not use near
term, inc. kernicterus)

45. Treatment Recurrent uncomp. UTI
3 or more episodes in one year, 2 in 6 months
Bactrim DS ( or septran DS) QD for 3-6 months
once infection eradicated, self-admin. Single dose at
symptom onset or one DS tab post-coitus
Measures for prevention: voiding after intercourse,
good hydration, frequent and complete voiding

46. Treatment of Pyelonephritis --
Outpatient
Uncomp. Nonpreg pyelo
Primary – any FQ x 7 days, cipro
Alt. -- Augmentin, TMP/SMX, or oral
Cephlosporin for 14 days

47. Treatment of
Pyelonephritis – Inpatient ?
 Treat IV until patient is afebrile 24-48 hours. Then, complete
2 week course with PO medications.
 Use FQ or amp/gent or ceftriaxone or piperacillin
 If no improvement on IV, consider imaging studies to look
for abscess or obstruction
 All pregnant patients with pyelo get inpatient tx, appropriate
IV antibiotics immediately

48. Treatment of Complicated UTI
 Catheter related
 Amp/gent or ticaricillin/clav or imipenem or meropenem x 2-3
weeks
 Switch to PO FQ or TMP/SMX when possible
 Rule out obstruction
 Watch out for enterococci and pseudomonas

49. Treatment Plan
Treatment Dosage/Duration Bacterial
Coverage/
Resistance
Common
Side Effects
Compliance/
Convenience
Cost
I/E
Men Wome
n
Sulfonamide
Trimethoprim-
Sulfamethoxazole
TMP-SMX
160/800 mg po bid x 3-14*
days
*available in a syrup
If CrCl <15-30 mL/min, ↓in half
(E. coli 20%)
↑ resistance
Less effective
nausea, rash Fair/Good
longer duration of bid ↓
compliance
I √ √
Fluoroquinolones
Ciprofloxacin (2nd
gen)
Levofloxacin (3rd
gen)
100- 250 mg po bid x 3-14*
days
If CrCL <30mL/min ↓ by half
250 mg po daily x 10 days
(complicated upper and lower
UTI)
gram (-) effective
gram (+) only fair
headache,
dizziness,
nausea, diarrhea
Good/Good
bid, longer duration ↓
compliance
Excellent
E √ √
Fosfomycin 3 g powder, dissolved in water
*single dose
gram (-) effective
gram (+) less
effective
diarrhea,
vaginitis, nausea,
rhinitis
Excellent VE,
often
not on
formula
ries
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Nitrofurantoin
(Macrobid)
100 mg po bid x 7 days
If CrCL <40 mL/min
not recommended
Narrow spectrum
gram (-) effective
gram (+) effective
nausea, vaginitis,
diarrhea
↑ rate of severe
pulmonary &
hepatotoxicity
Fair
7-day regimen &
bid, ↓ compliance
I Prostat
itis
NR
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Miscellaneous
Beta Lactam AB’s:
Cephalosporins (Cefuroxime, cefpodoxime)
Penicillins (ampicillin), Carbapenems (imipenem)
Phenazopyridine (Pyridium)—not appropriate
for elderly or patients with renal insufficiency
↑ resistance 2°
Beta Lactamase
enzymes in
resistant bacteria
2nd/3rd gen
Cephalosporins
>resistant to beta
lactamase
PCN-anaphylaxis
Abdominal
cramping
diarrhea
Fair for bid dosing I Prostat
itis
NR
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50. Prevention & Treatment Plan
Recommendations/Considerations/Prevention
Indwelling-Catheterization
Foley catheterization should be avoided if at all possible
Most effective means of UTI prevention is limitation of chronic
indwelling catheters.

51. Prevention & Treatment
Recommendations/Considerations/Prevention
 Post-menopausal women w/recurrent infection may
require estrogen replacement to restore atrophic
vaginal mucosa, ↓ vaginal pH (topical creams)
 Always adjust antibiotic dosage for renal
impairment/insufficiency using the Cockcroft-Gault
equation or eGFR.
Ensure adequate hydration
Recommended 2.5 L/day in patients with recurrent UTI
Often signs & symptoms similar to UTI in elderly are actually
caused by dehydration

52. Alternative Therapies in UTI Prevention
Cranberry (Vaccinium macrocarpon,
fruit)
Leading cranberry juice cocktail:
juice sweetener, water & added Vit.
C
Central in folk medicine beneficial effects on
urinary tract health.
Longstanding Rx for UTI prophylaxis
Well-tolerated, key factor with older adults
Mechanism Cranberry prevents bacterial (E. coli & other
gram-negative uropathogens) binding to host
cell surface membranes
1984—Sobota demonstrated a mode of
action in cranberry juice that interferes with
the adherence of E. coli and other bacteria to
uroepithelial cells
Scientific Rationale E. coli & other bacteria have different types
of adhesins on their fimbriae that allow the
organism to adhere to epithelial cells &
proliferate. Cranberries unique compound,
proanthocyanidins (PAC’s) adhesins inhibit
this process

53. Cranberry Therapy -
Interactions No significant herb-drug reactions reported
Dosage Varies. Cranberry extract tablets/capsules: 1 tablet
(300-400mg) twice daily. CranMax—500mg once daily
(potent cranberry supplement)
Cost Tablets
Unsweetened juice: varies
*Safe botanical alternative, effective in UTI prophylaxis
Other Alternative Therapies in UTI Management
Grapefruit
Seeds
Case study by Oyelami et al (2005)—4 middle-aged
patients treated w/seeds x 2 weeks upon dx of UTI.
Concluded: adequate clinical response
5-6 seeds every 8 hrs comparable to antibacterials
Oral Lactulose May reduce rate of UTIs in elderly.
Possible mechanism: increase in fecal Lactobacillus
organisms & avoidance of constipation

54.  Overuse of antibiotics is problematic in UTI management in
elderly
 Careful individualized assessment & evaluation of elder. Must
consider differential diagnoses before treatment, even when urine
culture is positive.
 Identification of subtle, atypical symptoms of UTI is critical. Listen
to family and staff
 UTI most common nosocomial infection to educate staff and
implement preventative measures to ↓ incidence.

 Lack of consensus criteria related to UTI management in
emphasizes need for urinary health promotion.
 Be proactive!

55. Thank you