Urinary Tract Infection and focus on its management

1. Urinary Tract Infection and
focus on its Management
Dr. Santosh Ramesh Achwani
Access Clinic, DIP – 2, Dubai
Monday, 17th of May, 2021, 9:00 PM
Online Live Webinar

2. Index
1. Definition
2. Classification *Insight: when to refer or start higher abx t/t
3. Etiology *Reason & prevent recurrence or re-infection
4. Risk Factors *Correctable measures
5. Pathogenesis *Understand dz process and progression
6. Symptomatology (Bg info for making firm diagnosis)
7. Diagnosis
8. Treatment (Empirical & Specific)
9. Spectrum of Levofloxacin
10. Life-style modifications & home remedies for UTI
11. Complications
12. Prevention (Educate pts for their UTIs)
13. Summary

3. 1. Definition of UTI
3
Infection of
1. Urinary stream
2. S/s of excretory organ that is
associated with it
- Kidneys (Pyelonephritis)**AKI
- Ureters (Uretritis)
- Bladder (Cystitis)**MC
- Prostate (A/c or C/c Prostatitis)
- *Urethra (Urethritis) 
- Balanitis (STI)
- Balanoposthitis (DMT2: Fungal)
Orchitis
Epididymitis
(>105 CFU/ml, Isolatable & Cultured)

4. 4
1. Anatomical Classification: (Location)
Upper UTI: Above Bladder (Pyelonephritis, Ureter-itis)**
Lower UTI: Upto Bladder (Cystitis, Prostatitis, Urethr-itis)** MC
2. Clinical Classification: (Followed in clinical practice)
A. Simple UTI: Uncomplicated infection in health patients (1. No underlying structural or
functional abnormality of UT, 2. Non pregnant patients, 3. Pts with no significant comorbidities)
B. Complicated UTI: Child, Pregnant patient or Any of 3 (1. Underlying structural or functional
abnormality of UT + obstruction to urine flow, 2. Comorbidity that increases risk of acquiring
infection or resistance to treatment: DMT2, CKD, Ca Chemotherapy, IMC, IMS therapy, HIV,
AIDS, 3. Recent instrumentation or Sx)
C. Recurrent UTI: Multiple symptomatic infections with asymptomatic periods
Terms:
1. Asymptomatic Bacteriuria: MC: Elderly, Bacteriuria > 105 CFU/ml of urine (T/t: Vulnerable)
2. Symptomatic Abacteruria: S/s UTI, but bacterial load < 105 CFU/ml (MC: Dysuria)
3. Count < 105 CFU/ml, but still infection +: Concurrent abx + tt, rapid urine flow, low urine pH
2. Classification of UTI

5. 5
3. Etiology of UTI

6. 6
3. Etiology of UTI
Uropathogenic E. Coli

7. 4. Risk Factors
7
(Easily attached)
Route / Nidus for infection
Opportunity for bac. growth
More time for
bacterial proliferation
Urinary retention
+
promoting bacterial growth
Weakened
Defense mechanisms
In each patient: Every time: Multiple factors overlap

8. 4. Risk Factors
8
1. Category 1:
- Manoeuvres that help bacteria get easily attached onto urinary tract epithelium
2. Category 2:
- Things that allows more time for bacterial proliferation (E.g.: Dehydration,
Constipation in children, BPH, Urethral stricture, Holding urine for long times, wet damp
nappies in neonates)
- Acts that introduce and implant bacteria into uro-epithelium (E.g.: Kidney stones,
Anatomical abnormalities, Intra – abdominal growth causing kinking of ureters)
3. Category 3:
- Manoeuvres that favour urinary retention & promoting bacterial growth and help in
infection ascension further along the urothelium
4. Category 4:
- Weakened defence mechanisms (DMT2, Ca, Chemotherapy)
5. Miscellaneous: Infection spreading from other areas (Unclean genital area: Anus 
Vagina), Non accidental Injuries in children, Post menopausal women with thinner + drier
vulval tissue (increases the risk of irritation or abrasions that encourage infection)

9. 9
5. Pathogenesis of UTI
- Kidney damage
- Infection into kidney parenchyma /
surrounding tissues etc.
- Extension of pathogens towards the kidneys
and to other organs nearby
- Penetration into the organ tissue
- Accumulation of bacterial load in urine

10. 6. Symptomatology
10
Adult: (Classical S/s)
- Dysuria *MC
- Frequency
- Urgency *Tricky
- Nocturia *Subtle
- Discharge *STI
- Dyspareunia *Tricky
- Suprapubic pain
± Back pain
± Hematuria
± Cloudy urine
± Enuresis
Babies: (Special S/s)
- Lethargy
- Poor feeding
- Fever or Hypothermia
- Vomiting +/- Diarrhea
- Strong smelling urine (Odour)
- Irritable + Cranky child
- Crying inconsolably
- Crying when peeing
Elderly: (Non Classical S/s)
- Malaise
- Weakness, tiredness
- Nausea +/- Vomiting +/- Dizziness
± Fever or hypothermia
± Confusion
± hypotension
± urine retention

11. 6. Symptomatology
11
Symptomatology: Helps in **Only gives idea + purpose of description **Non-reliable
− Localizing the organ infected
− Urgency of need of treatment (Complicated, Simple UUTI, Recurrent)
Upper UTI: Higher: More Systemic S/s: Kidneys (Pyelonephritis), Ureters (Uretritis)
High Grade Fever, Chills, Myalgia, Arthralgia, Loin (Flank) pain, Nausea, Vomiting, Blood
Stream related changes (Elevated: Pulse, WBCs, CRP, Low: BP) **Urgency of t/t **Hospitalizn
Lower UTI: Lower: Local S/s: Dysuria, Urgency, Dyspareunia, Frequency, Hesitancy,
incomplete urination, Hematuria, Cloudy urine, Supra-pubic pain **Non-urgent: OPD care
- Bladder (Cystitis): Low back pain, Pelvic pressure, Lower abdominal discomfort, Hematuria,
Urgency, Supra-pubic pain, Frequency
- Prostate (Prostatitis): Recurrent Dysuria, A/c urinary retention, Severe deep pelvic pain,
unable to sit
- Urethra (Urethritis): Dysuria, Cloudy urine, pain at base of penis, Pyuria, discharge

12. 7. Diagnosis
12
Urine Testing: 1: Clean Catch, 2: Morning 1st Urine sample, 3: Mid-stream
1. ***Urine R/M (e/o Infection: Pus cells, RBCs)
2. ***Urine Dipstick (e/o Infection: Nitrates +, Leucocyte Esterase +)
3. ***Urine C/S  To obtain MIC Values and antibiotic susceptibility for treatment
4. UGT Imaging Techniques  for evaluating details of Complicated & Recurrent UTI (Further
evaluation and management)
**If STD (Urethritis with discharge) is suspected then a urethral swab should precede urine sample.
Specimen:
1. Clean Catch Urine (Clean voided specimen: CVS)
2. Minicath for menstruating females
3. Perineal bag / Suprapubic tap: babies
4. Straight cath male (8 to 10 French catheter): only if unable to void

13. 13
Diagnosis of Infection (Urine-analysis):
- Turbid Urine
- ***Leucocyte esterase +
- ***Nitrites +
- ***WBCs +
- ***Bacteria +
Urine-analysis: Dipstick & R/M

14. Urine Culture Sensitivity & MIC values
1. MIC = 1
1 Standard Dose of
abx is required to
kill all bacteria.
2. MIC >= 2
2x the normal dose
of abx will be
required to kill the
bacterial load
3. MIC <= 0.5
½ abx dose
4. Lower MIC
values = Higher
potency of abx
***Minimal Inhibitory concentration (MIC) values ***

15. 15
 Main treatment: Antibiotics + Home remedies + Symptomatic treatment
 Choice of antibiotics: May differ from country to country according to local health protocol
 Simple UTI: 5-7 days course
 Complicated/Severe UTI: Hospital admission + IV antibiotics
 Recurrent UTI: Prolonged treatment + meticulous follow - up
 Generally: MC Drugs used for UTIs include:
1. Ampicillin, Amoxy-Clavulanate
2. Trimethoprim/Sulfamethoxazole (TMP-SMX)
3. Nitrofurantoin
4. Cephalexin
5. Ceftriaxone
6. Quinolones***(Levofloxacin, Moxifloxacin, Ciprofloxacin)
7 Fosfomycin (New, Resistant bacteria, Single dose therapy)
 Increasing rates of antibiotic resistance + high recurrence rates  leads us to use simpler
forms of antibiotics first and then step up therapy is unsuccessful, also to avoid the development
of resistance in UTI causing bacteria.
8. Treatment of UTIs
*LUTI, Classical / Simple UTI, 5 - 7 days
*UUTI, Complicated UTI / Recurrent, Prophylaxis, Long Term t/t
*High Risk patients, Hospital acquired, Disseminated Infection

16. Other
Aerobic Gram-Positive
bacteria
Bacillus anthracis
Staphylococcus aureus methicillin-
susceptible
Staphylococcus saprophyticus
Streptococci, group C and G
Streptococcus agalactiae
Streptococcus pneumoniae
Streptococcus pyogenes
Chlamydophila pneumoniae
Chlamydophila psittaci
Chlamydia trachomatis
Legionella pneumophila
Mycoplasma pneumoniae
Mycoplasma hominis
Ureaplasma urealyticum
Anaerobic
bacteria
Pepto streptococcus
Aerobic Gram-Negative
bacteria
Eikenella corrodes
Haemophilus influenzae
Haemophilus para-influenzae
Klebsiella oxytoca
Moraxella catarrhalis
Pasteurella multocida
Proteus vulgaris
Providencia rettgeri
9. Levofloxacin Broad Spectrum Coverage
1

17. 60%
80%
40%
20%
0%
92%
88%
80%
Levofloxacin is a good choice for empiric treatment of acute Pyelonephritis (UUTI)
Clinical
Cure
rate
(%
)
Levofloxacin
250 mg OD*
Ciprofloxacin
500 mg BD*
Lomefloxacin
400 mg OD*
Levofloxacin shows proven efficacy compared with Ciprofloxacin and Lomefloxacin.1
Two randomized, multicenter trials to evaluate Levofloxacin compared with Ciprofloxacin and Lomefloxacin for efficacy and safety in treating acute
pyelonephritis. We enrolled a total of 186 patients with bacteriologically proved infection. Of these, 89 patients in both trials combined received Levofloxacin 250
mg once daily; 58 received Ciprofloxacin 500 mg twice daily in the first trial (double- blind); and 39 received Lomefloxacin 400 mg once daily in the second trial
(open-label). Microbiologic response of patients evaluable for microbiologic efficacy was the primary efficacy variable, and clinical response of microbiologically
evaluable patients was the secondary efficacy variable in both studies.1
Clinical response rates among microbiologically evaluable patients1
100%
Adapted from ref 1
1. Richard GA, Klimberg IN, Fowler CL, et al. Levofloxacin versus ciprofloxacin versus lomefloxacin in acute pyelonephritis. Urology. 1998;52(1):51-55. 2. Levofloxacin 500 mg Summary of Product Characteristics. Abbott. Last
revision date 14 Oct 2016.
The once-daily oral administration, proven efficacy, and good tolerability make Levofloxacin an
excellent choice for empiric treatment of acute pyelonephritis.1
Levofloxacin should be administered 500 mg once daily for 7-10 days.2

18. 6%
8%
4%
2%
0%
Levofloxacin is a good choice for empiric treatment of acute Pyelonephritis vs.
Ciprofloxacin & Lomefloxacin with less adverse events
8%
2%
Levofloxacin
250 mg OD*
Lomefloxacin
400 mg OD
Ciprofloxacin
500 mg BD*
Adverse
events
The once-daily oral administration, proven efficacy, and good tolerability make Levofloxacin an excellent
choice for empiric treatment of acute pyelonephritis.1
Adapted from ref 1
1. Richard GA, Klimberg IN, Fowler CL, Callery-D’Amico S, Kim SS. Levofloxacin versus ciprofloxacin versus lomefloxacin in acute pyelonephritis. Urology.
1998;52(1):51-55. 2. Levofloxacin 500 mg Summary of Product Characteristics. Abbott. Last revision date 14 Oct 2016.
Two randomized, multicenter trials to evaluate Levofloxacin compared with Ciprofloxacin and Lomefloxacin for efficacy and safety in treating acute
pyelonephritis. We enrolled a total of 186 patients with bacteriologically proved infection. Of these, 89 patients in both trials combined received Levofloxacin 250
mg once daily; 58 received Ciprofloxacin 500 mg twice daily in the first trial (double-blind); and 39 received Lomefloxacin 400 mg once daily in the second trial
(open-label). Microbiologic response of patients evaluable for microbiologic efficacy was the primary efficacy variable, and clinical response of microbiologically
evaluable patients was the secondary efficacy variable in both studies.1
Levofloxacin should be administered 500 mg once daily for 7-10 days.2
5%

19. 90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
84%
43%
Levofloxacin shows higher urinary excretion rate compared with Ciprofloxacin
*EAU: The European Association of Urology
**c-UTI: Complicated urinary tract infection
Levofloxacin Ciprofloxacin
Urinary
Excretion
(%)
Urinary excretion of Levofloxacin andCiprofloxacin1
Adapted from ref 1
EAU* guidelines for empiric therapy of c-UTI** Advise the use of fluoroquinolones
with mainly renal excretion when empiric therapy is necessary 1
1. McGregor JC, Allen GP, Bearden DT. Levofloxacin in the treatment of complicated urinary tract infections and acute
pyelonephritis. Ther Clin Risk Manag. 2008;4(5):843-853.

20. Fluoroquinolones, such as Levofloxacin, are considered drugs of choice for treatment of
chronic bacterial prostatitis, because of their favourable pharmacokinetic properties, their
generally good safety profile, and antibacterial activity against Gram-negative pathogens,
including P. aeruginosa. In addition, Levofloxacin is active against Gram-positive and atypical
pathogens, such as C. trachomatis and genital mycoplasmas.2
Levofloxacin is recommended for Urological Infections according to…
American Academy of Family Physicians1
Levofloxacin is recommended as First-line treatment for Chronic Bacterial Prostatitis.1
1.Sharp VJ, Takacs EB, Powell CR. Prostatitis: diagnosis and treatment. Am Fam Physician. 2010;82(4):397-406.
2.Grabe (Chair) M, Bartoletti R, Bjerklund Johansen TE, et al. Guidelines on Urological Infections. European Association of Urology. 2015;1-86. Available at:
https://uroweb.org/wp-content/uploads/19-Urological-infections_LR2. pdf Accessed on April, 2018.
3.Rees J, Abrahams M, Doble A, Cooper A; Prostatitis Expert Reference Group (PERG). Diagnosis and treatment of chronic bacterial prostatitis and chronic
prostatitis/chronic pelvic pain syndrome: a consensus guideline. BJU Int. 2015;116(4):509-525.
The quinolones (e.g. Levofloxacin) are considered the antibiotics of choice
because of their favorable pharmacokinetic properties for treatment of
chronic bacterial prostatitis (CBP).3
BJUI
BJU*
Interntional
*British Journal of Urology

21. Levofloxacin once daily for 7-10 days is recommended in
mild and moderate uncomplicated pyelonephritis. 1
1. Grabe (Chair) M, Bartoletti R, Bjerklund Johansen TE, et al. Guidelines on Urological Infections. European Association of Urology. 2015;1-86. Available at:
https://uroweb.org/wp-content/uploads/19-Urological-infections_LR2. pdf Accessed on April, 2018.
EAU Guidelines
Levofloxacin is recommended for Urological Infections according to…

22. Infection of urinary tract, including your kidneys or bladder
1. Levofloxacin 500 mg Summary of Product Characteristics. Abbott.Last revision date 14 Oct 2016.
Levofloxacin Dosing
o Pyelonephritis:
One tablet of Levofloxacin 500 mg once a day for 7 - 10 days1
o Complicated urinary tract infections:
One tablet of Levofloxacin 500 mg once a day for 7 – 14 days1
o Chronic bacterial prostatitis:
One tablet of Levofloxacin 500 mg once a day for 28 days treatment1

23. Life Style modifications recommended:
• Drink plenty of water: Water helps to dilute urine and flush out bacteria.
• Avoid drinks that may irritate the bladder: (tend to aggravate s/s)
• Coffee, Alcohol, Carbonated drinks
• Drinks containing citrus juices, Caffeine
• Use a heating pad: Apply a warm, heating pad to abdomen to minimize
bladder pressure or discomfort.
• Topical Estrogen therapy: markedly reduces the incidence of recurrent UTIs
in post-menopausal women with atrophic vaginitis or atrophic urethritis
23
Life Style Modification and
Home remedies

24. Complications of UTI
24
• Recurrent: >= 2 UTIs in 6m OR >= 4 UTIs in 1 year
• Permanent kidney damage: AKI. CKD (MCC: Pyelonephritis, untreated UTI)
• Increased risk in pregnant women: Pre term Labor  LBW / Premature baby
• Urethral stricture: Men > women, d/t: Recurrent urethritis and instrumentation
(gonococcal urethritis)
• Urosepsis: Infection spreading from urine  blood  Other organs of body via blood

25. Prevention of UTIs
25
• Stay hydrated: Drink plenty of water (MOA): Dilute your urine + excrete non concentrated
urine more frequent  timely excretion of waste products + bacteria prevents building of
bacterial load and crystals.
• Drink cranberry juice: Studies inconclusive, drinking juice does more good than harm anyways
• Tissue Wipers: Wipe from front to back: helps prevent bacteria in the anal region from
spreading to the vagina and urethra (especially females)
• Wear cotton underwear and loose-fitting pants: Avoid synthetic clothes (absorbs sweat)
• Empty bladder after intercourse: To flush away the bacteria entering urethra from vault after
intercourse.
• Avoid potentially irritating products: Using deodorant sprays or other artificial products (E.g.:
douches, powders, in the genital area can irritate the urethra)
• Change birth control method: Diaphragms, spermicide-treated condoms, can all contribute to
bacterial growth
• Go to the toilet as soon as you feel the urge to urinate, rather than holding on
• Treat vaginal infections quickly (Thrush, Trichomonas)
• Avoiding Constipation / Diarrhea

26.  Always refer infant < 3 months with UTI
 T/t children >=3 months with simple medications using Amoxicillin/
Augmentin, send C/S + consider request for USG
 T/t all non-pregnant women with UTI: Nitrofurantoin
 T/t asymptomatic bacteruria (ASB) in pregnant women
 Rule out STI (Urethritis, Prostatitis) in male patients
 Do not give prophylaxis for adult with catheter (Colonization >
Infection) and do not treat asymptomatic bacteruria (ASB) otherwise
unless IMC/IMS.
26
Special Considerations

27. 1. Suspect (with S/s) + Localize (Using S/s)
2. Diagnose (Using tests)  Categorize patient for treatment
3. Simple UTI: T/t in OPD  Complicated UTI/Recurrence: Meds + Refer
4. Start Empirical treatment  Change to definitive treatment (MIC, C/S)
5. Give:
 Home remedies
 Patient education
 Risk Factor explanation
 Preventative measures explanation
6. Follow – up + Rule out complications
27
Summary (Take Home Message)

28. 28
Thank you
Dr. Santosh Ramesh Achwani
Access Clinic, DIP – 2, Dubai
Monday, 17th of May, 2021, 9:00 PM
Online Live Webinar