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Urinary Tract Infections
The document provides a comprehensive overview of urinary tract infections (UTIs), discussing their types, common pathogens, risk factors, clinical presentations, diagnosis, complications, management, and prevention strategies. UTIs primarily affect women and can lead to serious complications if untreated, necessitating appropriate antimicrobial therapy based on the classification of the infection. Preventive measures include proper hygiene, adequate hydration, and potential use of cranberry products.
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Urinary Tract Infections
- 1. URINARY TRACT INFECTIONs ArwaM. Amin Mostafa PhD, M.Pharm Clinical Pharm, Dip Mangt, B.Pharm.
- 2. Arwa M. Amin WHATWE WILL DISCUSS TODAY? • What are Urinary Tract Infections (UTIs)? • What are the routes of UTIs? • What is the pathogenesis of UTIs? • What are the common pathogens of UTIs? • What are the risk factors of UTIs? • What are the Clinical Presentations of UTIs? • How to diagnose UTIs? • What are the complications of untreated UTIs? • How to manage UTIs? • How to prevent UTIs?
- 3. Arwa M. Amin URINARYTRACT INFECTIONS (UTIs) UTIs are infections which affect the Urinary system (Kidneys, Ureters, Urinary Bladder, Urethra) and adjacent structures (e.g. Prostates). UTIs include: Upper UTIs: • Pyelonephritis • Infection affecting the Kidneys Lower UTIs: • Cystitis • Infection affecting the Urinary Bladder • Urethritis • Infection affecting the Urethra • Prostatitis • Infection affecting prostates
- 4. Arwa M. Amin URINARYTRACT INFECTIONS (UTIs) UTIs are infections which affect the Urinary system (Kidneys, Ureters, Urinary Bladder, Urethra) and adjacent structures (e.g. Prostates). UTIs include: Upper UTIs: • Pyelonephritis • Infection affecting the Kidneys Lower UTIs: • Cystitis • Infection affecting the Urinary Bladder • Urethritis • Infection affecting the Urethra • Prostatitis • Infection affecting prostates Most common UTIs & Mostly affecting women
- 5. Arwa M. Amin URINARYTRACT INFECTIONS (UTIs) • UTIs are commonly caused by Bacterial pathogens. • Some UTIs are caused by fungal pathogen (but Rare). • Most UTIs are caused by single organism. • Hospitalized patients and patients suffering from predisposing Renal Disease may suffer from multiorganisms UTI.
- 6. Arwa M. Amin PATHOGENESISOF UTIs Bacteria may be seeded in the Kidneys from blood Routes of UTIs Ascending Bacteria ascends through the urethra to the urinary bladder & multiplies Hematogenous Most common route e.g. E-coli Less common route e.g. S. aureus E-coli: Escherichia coli, S. aureus: Staphylococcus aureus
- 7. Arwa M. Amin PATHOGENESISOF UTIs • Uropathogen from the bowel contaminates the periuretheral area and enter the urethra. • The pathogen migrates to the urinary bladder. • Colonization of the pathogen in the bladder will cause irritation and inflammatory reaction. • Lower UTIs (e.g. Cystitis) may spread to the kidneys leading to upper UTI such as Pyelonephritis. • Upper UTIs may happen also due to infecting pathogen from blood stream. UTIs in Women
- 8. Arwa M. Amin PATHOGENESISOF UTIs
- 9. Arwa M. Amin COMMONBACTERIAL PATHOGENS OF UTIs • Escherichia coli G (-) • Accounts for 80 – 90 % of UTIs • Klebsiella pneumonia G (-) • Proteus species G (-) • Pseudomonas aeruginosa. G (-) • Coagulase-negative staphylococci (CoNS) (G +) • Staphylococcus Saprophyticus • Enterococcus species (G +) • Staphylococcus aureus (G +) E. coli Pseudomonas aeruginosa Enterococci
- 10. Arwa M. Amin RISKFACTORS OF UTIS • Indwelling urinary catheters • Urinary catheter may introduce infection • Bacteria may colonies the catheter • Woman are at ↑↑ Risk of UTIs • Risk in Women > Men • ↑↑ Risk in Pregnant Women • ↑↑ Risk in sextually active women • ↑↑ Risk after menopause • Genetic/Family history • Immunocompromised patients • Lack of water intake • Holding urine • Use Feminine douches and spray
- 11. Arwa M. Amin RISKFACTORS OF UTIS •Improper Hygiene •Diabetes Mellitus •Renal Disease • Kidney stones • Abnormal normal flow of urine • Vesicoureteral reflux • Chronic Renal Abscess • Recent Urinary procedure •Neurological bladder •Prostatic Hypertrophy
- 12. Arwa M. Amin CLINICALPRESENTATIONS OF UTIs General Signs and Symptoms for UTIs: • Painful burning sensation before, during and after urination. • Lower Abdomenal Pain or Pelvic pain. • Frequent urination with little urine comes out • Dysuria • Persistent urge to Urinate • Leaks of urine • Mild Fever • Fatigue & Malaise • Presence of blood in urine (Pink/cola color urine) • Cloudy Urine • Strong-smelling urine • Nausea & Vomiting (Not frequent)
- 13. Arwa M. Amin SPECIFICCLINICAL PRESENTATIONS OF EACH UTI Specific Signs and Symptoms for main UTIs PyelonephritisUrethritisCystitis • High Fever with Chills • Upper back and side pain • Malaise • Nausea & Vomiting • Burring with urination • Discharge • Pain in the Bladder region • Frequent Urination • Urgency • Painful urination • Lower abdomen discomfort • Dark Urine (Blood in Urine)
- 14. Arwa M. Amin UTISARE PAINFUL & BURNING … YES, UTI STANDS FOR ….
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- 16. Arwa M. Amin DIAGNOSISOF UTIs Diagnosis • Depends on detection of the pathogen in presence of UTIs underlying signs and symptoms. Laboratory Tests: • Standard urine analysis • Urine culture • Using midstream urine • Microscopic examination of the urine • WBCs & RBCs • Gram stain. • CBC • Blood Culture Other Investigations: • Ultrasonography • CT scanCBC: Complete blood count, WBCs: White blood cells, RBCs: Red blood cells, CT: computed tomography scan
- 17. Arwa M. Amin DIAGNOSISOF UTIs Laboratory Findings of UTIs • Bacteriuria • Pyuria (WBC >10/mm3) • RBCs in urine • Nitrite-positive urine (with nitrite reducers) • Indicates nitrite reducing bacteria in the urine (e.g. E. coli) • Leukocyte esterase-positive urine • Rapid test to detect pyuria • Antibody-coated bacteria (ACB) • An indicator of the site of UTI: • Present in urine samples of upper UTI (Pyelonephritis)
- 18. Arwa M. Amin COMPLICATIONSOF UN-TREATED UTIs Un-treated UTIs or improperly treated UTIs may lead to serious complications: • Recurrence of UTIs (2 or more in 6 months or 4 or more in one year) • Permanent kidney damage from pyelonephritis. • High risk of early delivery in pregnant ladies (Premature infant or low weight infant). • Urethral narrowing in men. • Prostatitis. • Urosepsis. • Sepsis • Spread of the infection to the blood stream. • Sepsis is Life threatening condition
- 19. Arwa M. Amin MANAGEMENTOF UTIs Goals of UTIs Therapy: To provide symptomatic and supportive treatment. To eradicate pathogenic infection. To prevent and treat recurrence. To Identify and treat predisposing risk factors. Symptomatic and supportive treatment: • Drinking plenty of Water to increase the frequency of emptying the urinary bladder. • Encourage frequent emptying of urinary bladder. • Antipyretic if fever present. • Urinary Analgesic if burning and urinary pain are present: Phenazopyridine
- 20. Arwa M. Amin MANAGEMENTOF UTIS Systematic Approach to Manage UTIs Management of UTIs includes the following steps: Initial Evaluation of the UTI and patient’s condition. Selection of Antimicrobial agent & duration of Therapy based on: Severity of signs & symptoms Site of infection; upper UTI or lower UTI? Categorizing UTI type: Complicated or un-complicated? Microorganism is drug sensitive or drug resistant Selection of AB should be based on Local resistance rates of E. coli Follow-up Evaluation.
- 21. Arwa M. Amin MANAGEMENTOF UTIS Categorization of UTIs for proper Antimicrobial selection • Proper Management of UTIs is achieved by categorizing the UTI in one of six UTIs categorizes Acute Un-complicated Cystitis Symptomatic Abacteriuria (Urethral Syndrome) Asymptomatic Bacteriuria Recurrent Infections Prostatitis Complicated UTIs
- 22. Arwa M. Amin MANAGEMENTOF UTIS Asymptomatic Bacteriuria • Transient and resolves without AB treatment. • Can resolve within one week • Treat with AB if Pregnant woman. Symptomatic Abacteriuria (Urethral Syndrome) • Symptomatic & supportive treatment • Some studies showed that AB is effective. • As Urethral Syndrome can be due to Low Estrogen, it can be treated with hormonal replacement.
- 23. Arwa M. Amin MANAGEMENTOF UTIs • Cephalosporins • Ceftriaxone, Cephalexin, Ceftazidime, Cefepime • Cephalexin active against E. coli, Proteus & Kelibsella • Penecillins • Amoxicillin-clavulanates • Ampicillin-sulbactam • Aminoglycosides • Gentamicin, Tobramycin & Amikacin • Adjust dose for renal impairment Commonly used Antimicrobials for UTIs: • Nitrofurantoin • Most active antimicrobial against E. coli. • Avoid if CrCl < 30 mL/min • Doesn’t cover Proteus infections • Trimethoprim-sulfamethoxazole • Don’t use if resistance is suspected • Renal dose adjustment and Avoid if CrCl < 15 mL/min • Fluoroquinolones • Ciprofloxacin, Levofloxacin • Fosfomycin • Active against E. coli & Enterococcus CrCl: Creatinine Clearance
- 24. Arwa M. Amin MANAGEMENTOF UTIs Empiric Antimicrobial Therapy for UTIs Antimicrobial TreatmentType of UTI 1st line: Nitrofurantoin: 100 mg PO, BID for 5 days Or Trimethoprim-sulfamethoxazole: 160/800 mg DS PO bid for 3 days Fosfomycin: 3 g, OD, for 1 day 2nd line: (particularly, if Pyelonephritis is suspected): Fluoroquinolones: Ciprofloxacin 250 mg PO, BID for 3 days or Levofloxacin 250 mg PO, OD for 3 days Acute uncomplicated Cystitis Ceftriaxone 250 mg IM + either Azithromycin 1 g PO once Or doxycycline 100 mg PO BID for 7 days Urethritis Long-term Prophylaxis: Nitrofurantoin: 50 mg PO, OD for 6 months Or Trimethoprim-sulfamethoxazole: ½ (80/400 mg) SS PO OD for 6 months Recurrent Infections (Prophylaxis) DS: double strength, SS: single strength
- 25. Arwa M. Amin MANAGEMENTOF UTIs Empiric Antimicrobial Therapy for UTIs Antimicrobial TreatmentType of UTI 1st line: Fluoroquinolones: Ciprofloxacin 500 mg PO, BID Or Levofloxacin 250 mg PO, OD, for 7-10 days 2nd line: Trimethoprim-sulfamethoxazole: 160/800 mg DS PO bid for 14 days Acute un- complicated Pyelonephritis Amoxicillin-Clavulanate: 500/125mg, TID, for 14 days Fluoroquinolones: Ciprofloxacin 500 mg PO, BID Or Levofloxacin 250 mg PO, OD, for 7-10 days or Aminoglycosides: Gentamicin 7.5mg/kg IV q24h (adjust dose based on renal function) In serious cases patient may require hospitalization & IV treatment Acute complicated Pyelonephritis Trimethoprim-sulfamethoxazole: 160/800 mg po BID for 4-6 weeks Fluoroquinolones: Ciprofloxacin 500 mg PO, BID, 4-6 weeks Prostatitis
- 26. Arwa M. Amin MANAGEMENTOF UTIS IN PREGNANCY • UTI during Pregnancy should be treated to avoid UTIs complications in Pregnancy. • AB should be with Minimum adverse effect • AB can be used for 7 days treatment course: • Cephalexin • Amoxicillin • Amoxicillin-Clavulanate • Contraindicated UTI AB during Pregnancy: • Tetracyclines, why? • Teratogenic • Sulfonamides; particularly in the 3rd trimester, why? • Possible development of Hyperbilirubinemia & Kernicterus • Fluoroquinolones, why? • They may inhibit cartilage & bone development in Newborns
- 27. Arwa M. Amin MANAGEMENTOF UTIS IN CHILDREN • The recommended initial ABs for children with UTIs** are as the following for 3 or 5 days course: • Trimethoprim/sulfamethoxazole 6-12 mg/kg/day, divided q 12 h • Contraindicated in infants < 6 weeks • Alternative ABs • Amoxicillin/clavulanate (particularly if acute pyelonephritis is diagnosed). • 20-40 mg/kg/day divided q 8 h • Cephalosporins, such as • Cephalexin 50-100 mg/kg/day divided q 6 h Or • Cefixime 8 mg/kg/day divided q 24 h **Note: Nitrofurantoin 5-7 mg/kg/day PO divided q 6 h can be used, however it is contraindicated in infants < 3 months
- 28. Arwa M. Amin MANAGEMENTOF UTIS IN CATHETERIZED PATIENTS Asymptomatic Bacteriuria in short-term catheterized patient (<30 days): • Remove the catheter as soon as possible • Don’t provide AB Symptomatic Bacteriuria: • Remove the catheter • Treat as complicated UTIs It is NOT recommended to routinely use Prophylactic AB therapy to prevent UTIs in catheterized patients. • It may lead to emergence of resistant organisms.
- 29. Arwa M. Amin PREVENTINGUTIs in Adults • Drinking plenty amounts of water daily. • Drinking water will ↑↑ urination which will help to flush bacteria before causing infection. • Don’t Hold • Urinate as soon as needed. • Proper Hygiene. • Taking shower is better than taking tube bath. • Wipe from front to back after urination, particularly women.
- 30. Arwa M. Amin PREVENTINGUTIs in Adults • Avoid using irritating feminine douches and sprays. • Drink un-sweetened Cranberry juice. • Using Lactobacillus probiotics • It helps in ↓↓ vaginal pH → ↓↓ E. coli colonization • Wear Loose clothes to promote air-circulation.
- 31. Arwa M. Amin PREVENTINGUTIs • The American College of Obstetrics and Gynecology suggested that Cranberry Un-sweetened Juice & Cranberry Supplements may help to prevent UTIs. • The dose and duration of using Cranberries for UTI prevention are nor yet well established. • Suggested Mechanism of action: • Cranberries acidifies urine making it unfriendly environment for E. coli. • Cranberries prevent bacteria from sticking to the wall of UT. Cranberry Un-sweetened Juice
- 32. Arwa M. Amin PREVENTINGUTIs Limitations of using Cranberries Supplements for UTI prevention: • Contains ↑↑ Oxalate salts; they may lead to kidney stones formation in susceptible people. • Drug-Interactions with warfarin → bleeding Cranberry Un-sweetened Juice
- 33. Arwa M. Amin PREVENTING UTIsin Children Figure source: How to Treat and Prevent Urinary Tract Infections (UTIs) in Children, https://www.top10homeremedies.com/how- to/how-to-treat-and-prevent-urinary-tract- infections-utis-in-children.html
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