3. Introduction
Common in females~50%
– 80% acquire at least one
UTI during their lifetime
which is mostly
uncomplicated cystitis.
The annual incidence of
pyelonephritis was
approximately 28 per
10,000 women.
Rare in young men.
In the elderly age group,
benign prostatic
hyperplasia has been
implicated as a common
predisposing factor for
UTI.
4. ~ 8% of girls and 2% of boys will have at least
one episode by seven years of age, 12–30%
will experience recurrence within one year
5. Introduction
• Micturition : expulsion of urine from the bladder, hence emptying the
urinary bladder through the urethra to the exterior of the body
• Urinary tract infection is defined as microbial infiltration of the
otherwise sterile urinary tract
• Infection leads to complications such as urethritis, cystitis, prostatitis
and pyelonephritis
6. Contamination organisms are introduced during collection or processing of urine. No health
care concerns
Asymptomatic
bacteriuria
(Colonization)
organisms are present in the urine but are causing no illness or symptoms.
Depending on the circumstances, patient often does not require treatment
Uncomplicated UTI infection in a healthy, non-pregnant, pre-menopausal female patient with
anatomically and functionally normal urinary tract
Complicated UTI infection associated with factors increasing colonization and decreasing
efficacy of therapy
Recurrent UTI occurs after documented infection that had resolved. Defined as 2 or more
infections in 6 months, or > 3 infections in 12 months (JAMA article)
Reinfection UTI a new event with reintroduction of bacteria into urinary tract or by different
bacteria
Persistent UTI UTI caused by same bacteria from focus of infection
8. NATURAL DEFENSES OF URINARY TRACT
Periurethral and
Urethral Region
• Normal flora in these areas form barriers against colonization.
Changes in estrogen, low vaginal pH and cervical IgA affect
colonization by normal flora.
Urine
• High osmolality, high urea concentration, low pH, high organic
acids are protective. Glucose in urine may facilitate infections.
Bladder
• Epithelium expresses Toll-like receptors (TLRs) that recognize
bacteria and initiate immune/inflammatory response (PMNs,
neutrophils, macrophages, eosinophils, mast cells and dendritic
cells). Adaptive immune response then predominates (T and B
lymphocytes). Induced exfoliation of cells also occurs to allow
excretion of bacterial colonization.
Kidney
• Local immunoglobulin/ antibody synthesis in the kidney occurs
in response to infections (IgG, IgA).
9. ALTERATIONS IN HOST DEFENSE MECHANISMS
Obstruction
Key factor in
increasing
susceptibility to
UTI
VUR
Hodson and
Edwards (1960)
described
association of
VUR, UTI, and
eventual renal
scarring.
Underlying Disease
Diabetes mellitus (DM), sickle cell disease (SCD),
nephrocalcinosis, gout, analgesic abuse, aging,
hyperphosphatemia, and hypokalemia.
DM: Glycosuria
may contribute to
severity of
infections due to
immune
compromise.
Majority of
infections (80%)
are in the upper
tracts.
Papillary Necrosis:
due to DM,
pyelonephritis,
obstruction,
analgesics,
transplant rejections,
cirrhosis,
dehydration, contrast
media, renal vein
thrombosis.
HIV: UTIs 5x
more
prevalent in
this population
and they recur
more
frequently.
Pregnancy
Bacteriuria in
pregnancy = 4–
7% and
incidence of
acute clinical
pyelonephritis =
25–35% in
untreated
patients.
Spinal Cord
injury with
High Pressure
Bladder
High morbidity
and mortality
from bacteriuria.
10. • Common Causative Pathogens
• Escherichia coli - 63 – 85%
• Coagulase negative Staphylococcus - up to 15%
• Klebsiella pneumoniae - ~ 8%
• S. aureus - up to 8%
• GBS - 2-7%
• Proteus mirabilis (> in children)
• Staphylococcus saprophyticus (young and sexually active women)
• Enterococcus, Candida (hospitalized patient on CBD – ascending
infection)
12. Investigations
• Urine analysis (UFEME)
a) clean catch midstream voided urine
b) catheterized urine
c) suprapubically aspirated urine
d) Urine bag –paediatric patient
• Urine culture and sensitivity
• Full blood count
• Renal Profile
• Ultrasound KUB
13. Urine bag Clean catch (CCU/MSU) Catheterisation (CSU) Suprapubic aspiration
(SPA)
After careful cleaning of
the perineum, an adhesive
plastic bag is applied to
collect urine
The stream of urine is
caught in a urinary
specimen pot. The risk of
contamination is reduced
by:
•cleansing the perineum
and meatus prior to
collection with anti-septic
solution
•retracting the labia and
foreskin
•collecting a midstream
sample
A midstream urine sample
is collected using in and
out catheterisation
Lignocaine 2% gel aids in
insertion but takes 10
minutes for full analgesic
effect.
Under ultrasound
guidance, a 1.5 inch, 22 G
needle is attached to 5
ml syringe and inserted
into a full bladder (>20
mL or >1 cm in all axes US
scan). The bladder lies
midline approximately 1–
2 cm above the pubic
symphysis. The
procedure is relatively
safe and complications
are rare
19. *post coital prophylaxis: taking a single dose of an effective antimicrobial
(eg, nitrofurantoin 50 mg, trimethoprim-sulfamethoxazole [TMP-SMX]
40/200 mg, or cephalexin 500 mg) after sexual intercourse
20. Cranberries juice (in vitro studies)
Cochrane 2021: group that
consume vs didn’t consume =
similar findings
Non Antibiotic Prevention
OM-89 is an immunomodulatory
drug.
It is effective against Escherichia
coli infections
Women with recurring urinary
tract infections treated with OM-
89 for 6 months had a twofold
reduced further recurrence rate
(67.3% vs. 32.7%)
recommended both by the
European Association of Urology
(EAU) in uncomplicated UTIs in
women (strong evidence, highest
recommendation level, 1a) and by
the Polish Association of Urology
in prevention of recurring urinary
tract infections.
Non-antibiotic
prophylactic treatment –
immunomodulation
21. Other non antibiotic prophylaxis
• bacterial lysate vaccine Strovac®
• Tropaeoli majoris herba (Nasturtium) and Armoraciae
rusticanae radix (Horseradish)
• D-Mannose
• monosaccharide that can inhibit bacterial adhesion to the urothelium after
oral intake
• Bladder irrigation with various agents
• Neomycin
• acetic acid
• sterile saline
25. Case
• 40 years old, G2P1 at 9 weeks POA
• LMP 20/5/23, EDD 24/2/24
• Antenatally:
• Chronic Hypertension
• on T. Methyldopa 250mg TDS and T. Cardiprin 100mg OD
• Diagnosed in 2010
• PE profile taken at 8 weeks : normal
• 1Previous Scar for PE in 2020
• Advance maternal age, planned for detail scan in October 23
26. • Nausea and vomiting for 3/52
• Poor oral intake but able to drink minimally
• Incomplete voiding 3/7
• Dysuria 3/7
• No fever
• No abdominal pain
• No other symptoms
• o/e: Alert, good pulse volume, CRT < 2 sec, coated tongue, pink
• BP 125/74, HR 88
• Systemic exam: unremarkable
• Ix: UFEME: ketone 1+, nitrite +ve, leukocyte 3+, others negative
• TWC 14.1, HB 13.2, PLT 319
• Renal Profile: NA 135, K 3.9, CR 56, Ur 3.1
• Impression??
27. • Imp: UTI in pregnancy
• Treatment: T.Cephalexin 250mg QID 5/7
T.Paracetamol 1G QID
*Urine c+s taken: Klebsiella Oxycota
HVS c+s: NG
28. Resources
• National Antibiotic Guideline 2019
• UTI in Malaysia, MY Portal Health http://www.myhealth.gov.my/en/prime-
years-urinary-tract-infection/
• American Urology Association, Adult UTI
http://www.myhealth.gov.my/en/prime-years-urinary-tract-infection/
• Urinary Tract Infections in Women –Menopause Review Poland
https://www.termedia.pl/Urinary-tract-infection-in-
women,4,43860,1,1.html
• https://www.racgp.org.au/afp/2016/august/paediatric-urinary-tract-
infections-diagnosis-and
• Non-Antibiotic Prophylaxis for Recurrent UTIs in Neurogenic Lower Urinary
Tract Dysfunction (NAPRUN): Study Protocol for a Prospective, Longitudinal
Multi-Arm Observational Study (April 23)
