Urinary tract infection

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Urinary tract infection
Classification and external resources

Multiple white cells at urinary microscopy from a

patient with urinary tract infection.

Urinary tract infection (UTI) is a bacterial infection that affects any part of the urinary tract.
Symptoms include frequent feeling and/or need to urinate, pain during urination, and cloudy
urine.[1] The main causal agent is Escherichia coli. Although urine contains a variety of fluids,
salts, and waste products, it does not usually have bacteria in it.[2] When bacteria get into the
bladder or kidney and multiply in the urine, they may cause a UTI.

The most common type of UTI is acute cystitis often referred to as a bladder infection. An
infection of the upper urinary tract or kidney is known as pyelonephritis, and is potentially more
serious. Although they cause discomfort, urinary tract infections can usually be easily treated
with a short course of antibiotics with no significant difference between the classes of antibiotics
commonly used.[3]

Epidemiology
Bladder infections are most common in young women with 10% of women getting an infection
yearly and 60% having an infection at some point in their life.[4] Pyelonephritis occurs between
18–29 times less frequently.[4]

According to the 1997 National Ambulatory Medical Care Survey and National Hospital
Ambulatory Medical Care Survey, urinary tract infection accounted for nearly 7 million office
visits and 1 million emergency department visits, resulting in 100,000 hospitalizations.[22]

Nearly 1 in 3 women will have had at least 1 episode of urinary tract infections requiring
antimicrobial therapy by the age of 24 years. The risk of urinary tract infection increases with
increasing duration of catheterization. In non-institutionalized elderly populations, urinary tract
infections are the second-most-common form of infection, accounting for nearly 25% of all
infections.[22]

The condition rarely occurs in men who are younger than 50 years old and who did not undergo
any genitourinary procedure. However, the incidence of urinary tract infections in men tends to
rise after the age of 50.

According to statistics from 1990, the prevalence of urinary tract infections in pre-school and
school girls was 1% to 3%, nearly 30-fold higher than that in boys.[23] Also, the statistics from the
same year show that approximately 5% of girls will develop at least one urinary tract infection in
their school years.

In what concerns the symptoms of the condition, bacteriuria appears to increase in prevalence with age
in women, still being 50 times greater than the one in males. It is estimated that bacteriuria will be
experienced by 20 to 50% of older women and 5 to 20% of older men.

Signs and symptoms

The most common symptoms of a bladder infection are burning with urination (dysuria),
frequency of urination, an urge to urinate, no vaginal discharge, and no significant pain.[4] An
upper urinary tract infection or pyelonephritis may also present with flank pain and a fever.
Healthy women have an average of 5 days of symptoms.[4]

The symptoms of urinary tract infections may vary with age and the part of the urinary system
that was affected. In young children, urinary tract infection symptoms may include diarrhea, loss
of appetite, nausea and vomiting, fever, and excessive crying that cannot be resolved by typical
measures.[5] Older children on the other hand may experience abdominal pain, or incontinence.
Lower urinary tract infections in adults may manifest with symptoms including hematuria (blood
in the urine), inability to urinate despite the urge, and malaise.[5]

Other signs of urinary tract infections include foul-smelling urine and urine that appears cloudy.
[6]

Depending on the site of infection, urinary tract infections may cause different symptoms.
Urethritis, meaning only the urethra has been affected, does not usually cause any other
symptoms besides dysuria. However, if the bladder is affected (cystitis), the patient is likely to
experience more symptoms, including lower abdomen discomfort, low-grade fever, pelvic
pressure, and frequent urination, all together with dysuria.[7]

Whereas in newborns the condition may cause jaundice and hypothermia, in the elderly,
symptoms of urinary tract infections may include lethargy and a change in mental status, signs
that are otherwise nonspecific.
Risk factors
Intercourse

In young sexually active women, sex is the cause of 75–90% of bladder infections, with the risk
of infection related to the frequency of sex.[4] The term "honeymoon cystitis" has been applied to
this phenomenon of frequent UTIs during early marriage. In post menopausal women sexual
activity does not affect the risk of developing a UTI.[4] Spermicide use, independent of sexual
frequency, increases the risk of UTIs.[4]

Gender

Women are more prone to UTIs than men because, in females, the urethra is much closer to the
anus and shorter than in males, and women lack the bacteriostatic properties of prostatic
secretions.[8] Among the elderly, UTI frequency is roughly equal in women and men. This is due,
in part, to an enlarged prostate in older men. As the gland grows, it obstructs the urethra, leading
to increased frequency of urinary retention.

Urinary catheters

Urinary catheters are a risk factor for urinary tract infections. The risk of an associated infection
can be decreased by only catheterizing when necessary, using aseptic technique for insertion, and
maintaining unobstructed closed drainage of the catheter.[9][10][11]

Others

A predisposition for bladder infections may run in families.[4] Other risk factors include
diabetes[4]. While ascending infections are, in general, the rule for lower urinary tract infections,
the same is not necessarily true for upper urinary tract infections like pyelonephritis, which may
originate from a blood-born infection.

Pathogenesis
The most common organism implicated in UTIs (80–85%) is E. coli,[4] while Staphylococcus
saprophyticus is the cause in 5–10%.[4]

The bladder wall, in common with most epithelia is coated with a variety of cationic
antimicrobial peptides such as the defensins and cathelicidin which disrupt the integrity of
bacterial cell walls.[12] In addition, there are also mannosylated proteins present, such as Tamm-
Horsfall proteins (THP), which interfere with the binding of bacteria to the uroepithelium. As
binding is an important factor in establishing pathogenicity for these organisms, its disruption
results in reduced capacity for invasion of the tissues.[clarification needed] Moreover, the unbound
bacteria are more easily removed when voiding. The use of urinary catheters (or other physical
trauma) may physically disturb this protective lining, thereby allowing bacteria to invade the
exposed epithelium.
During cystitis, uropathogenic Escherichia coli (UPEC) subvert innate defenses by invading
superficial umbrella cells and rapidly increasing in numbers to form intracellular bacterial
communities (IBCs).[13] By working together, bacteria in biofilms build themselves into
structures that are more firmly anchored in infected cells and are more resistant to immune-
system assaults and antibiotic treatments.[14] This is often the cause of chronic urinary tract
infections.

Prevention
The following are measures that studies suggest may reduce the incidence of urinary tract
infections.

 A prolonged course (six months to a year) of low-dose antibiotics (usually nitrofurantoin or

TMP/SMX) is effective in reducing the frequency of UTIs in those with recurrent UTIs. [4]
 Cranberry (juice or capsules) may decrease the incidence of UTI in those with frequent
infections. Long-term tolerance, however, is an issue. [15] Subsequent research has questioned
these findings. [16]
 For post-menopausal women intravaginal application of topical estrogen cream can prevent
recurrent cystitis.[17] This however is not as useful as low dose antibiotics. [4]
 Studies have shown that breastfeeding can reduce the risk of UTIs in infants. [18]

A number of measures have not been confirmed to affect UTI frequency including: the use of
birth control pills or condoms, voiding after sex, the type of underwear used, personal hygiene
methods used after voiding or defecating, and whether one takes a bath instead of a shower.[4]

Diagnosis

Multiple bacilli (rod-shaped bacteria, here shown as black and bean-shaped) shown between white cells
at urinary microscopy. This is called bacteriuria and pyuria, respectively. These changes are indicative of
a urinary tract infection.

In straight-forward cases, a diagnosis may be made and treatment given based on symptoms
alone without further laboratory confirmation.[4] In complicated or questionable cases,
confirmation via urinalysis, looking for the presence of nitrites, leukocytes, or leukocyte esterase,
or via urine microscopy, looking for the presence of red blood cells, white blood cells, and
bacteria, may be useful.[4]

Urine culture showing a quantitative count of greater than or equal to 103 colony-forming units
(CFU) per mL of a typical urinary tract organism along with antibiotic sensitives is useful to
guide antibiotic choice.[4] However, women with negative cultures may still improve with
antibiotic treatment.[4]

Most cases of lower urinary tract infections in females are benign and do not need exhaustive
laboratory work-ups. However, UTI in young infants may receive some imaging study, typically
a retrograde urethrogram, to ascertain the presence/absence of congenital urinary tract anomalies.

Differential

If the urine culture is negative:

 Symptoms of urethritis may point at Chlamydia trachomatis or Neisseria gonorrheae infection.

 Symptoms of cystitis may point at interstitial cystitis.
 In men, prostatitis may present with dysuria.

The presence of bacteria in the urinary tract of older adults, without symptoms or signs of
infection, is a well-recognized phenomenon that may not require antibiotics. This is usually
referred to as asymptomatic bacteriuria. The overuse of antibiotics in the context of bacteriuria
among the elderly is an issue of concern.

Treatment
Uncomplicated

Uncomplicated UTIs can be diagnosed and treated based on symptoms alone.[4] Oral antibiotics
such as trimethoprim, cephalosporins, nitrofurantoin, or a fluoroquinolone substantially shorten
the time to recovery. All are equally effective for both short and long term cure rates.[3] About
50% of people will recover without treatment within a few days or weeks.[4] The Infectious
Diseases Society of America recommends a combination of trimethoprim and sulfamethoxazole
as a first-line agent in uncomplicated UTIs rather than fluoroquinolones.[19] Fluoroquinolones are
not recommended first line due to their cost and concern that over use will increase resistance
and thus decrease the utility of this class for those with severe infections.[19] Resistance has
developed in the community to all of these medications due to their widespread use.[4]

A three-day treatment with trimethoprim, TMP/SMX, or a fluoroquinolone is usually sufficient,

whereas nitrofurantoin requires 7 days.[4] Trimethoprim is often recommended to be taken at
night to ensure maximal urinary concentrations to increase its effectiveness. While
trimethoprim/sulfamethoxazole was previously internationally used (and continues to be used in
the U.S. and Canada), the addition of the sulfonamide gives little additional benefit compared to
the trimethoprim component alone. However, it is responsible for a high incidence of mild
allergic reactions and rare but potentially serious complications. For simple UTIs, children often
respond well to a three-day course of antibiotics.[20]

Pyelonephritis

Pyelonephritis is treated more aggressively than a simple bladder infection using either a longer
course of oral antibiotics or intravenous antibiotics. Regimens vary, and include SMX/TMP and
fluoroquinolones. In the past, they have included aminoglycosides (such as gentamicin) used in
combination with a beta-lactam (such as ampicillin or ceftriaxone). These are continued for 48
hours after fever subsides.

If there is a poor response to IV antibiotics (marked by persistent fever, worsening renal

function), then imaging is indicated to rule out formation of an abscess either within or around
the kidney, or the presence of an obstructing lesion such as a stone or tumor.[21]

Recurrent

Women with recurrent simple UTIs may benefit from self-treatment upon occurrence of
symptoms with medical follow-up only if the initial treatment fails.[4] Effective treatment can
also be delivered over the phone.[4]

In children
Children with recurrent UTIs may be treated with preventative antibiotics that decrease the rate
of microbiological recurrence but not symptomatic recurrence.[24] These conclusion must be
viewed in light of the poor quality of evidence available.[24]

In pregnancy
Urinary tract infections are more concerning in pregnancy. If urine testing shows signs of
infection even in the absence of symptoms (known as asymptomatic bacteriuria) women are
treated.[25] Treatment is typically with cephalexin or nitrofurantoin[25] as while there are no
adequate studies of these antibiotics in pregnant women, many women have safely used them
during pregnancy.
References
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"Antimicrobial agents for treating uncomplicated urinary tract infection in women". Cochrane
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