Introduction

A urinary tract infection (UTI) is a condition in which one or more parts of the urinary system (the kidneys, ureters, bladder, and urethra) become infected. UTIs are the most common of all bacterial infections and can occur at any time in the life of an individual. Nearly 95% of cases of UTIs are caused by bacteria that typically multiply at the opening of the urethra and travel up to the bladder. Much less often, bacteria spread to the kidney from the bloodstream.

The male and female urinary tracts are similar except for the length of the urethra. The Urinary System. The urinary system helps maintain proper water and salt balance throughout the body and also expels urine from the body. It is made up of the following organs and structures:

The two kidneys, located on each side below the ribs and toward the middle of the back, play the major role in this process. They filter waste products, water, and salts from the blood to form urine. Urine passes from each kidney to the bladder through thin tubes called ureters. Ureters empty the urine into the bladder, which rests on top of the pelvic floor. The pelvic floor is a muscular structure similar to a sling running between the pubic bone in front to the base of the spine. The bladder stores the urine. When the bladder becomes filled, the muscle in the wall of the bladder contracts, and the urine leaves the body via another tube called the urethra. In men the urethra is enclosed in the penis. In women, it leads directly out.

Defense Systems Against Bacteria. Infection does not always occur when bacteria are introduced into the bladder. A number of defense systems protect the urinary tract against infection-causing bacteria:

Urine itself functions as an antiseptic, washing potentially harmful bacteria out of the body during normal urination. (Urine is normally sterile, that is, free of bacteria, viruses, and fungi.) The ureters join into the bladder in a manner designed to prevent urine from backing up into the kidney when the bladder squeezes urine out through the urethra. The prostate gland in men secretes infection-fighting substances. The immune system defenses and antibacterial substances in the mucous lining of the bladder eliminate many organisms. In healthy women, the vagina is colonized by lactobacilli, beneficial microorganisms that maintain a highly acidic environment (low pH) that is hostile to other bacteria. Lactobacilli produce hydrogen peroxide, which helps eliminate bacteria and reduces the ability of Escherichia coli (E. coli) to adhere to vaginal cells. (E. coli is the major bacterial culprit in urinary tract infections.)

Risk factors for urinary tract infections include:

Being female. UTIs are common in women, and many women experience more than one infection. Women have a shorter urethra than men do, which cuts down on the distance that bacteria must travel to reach a woman's bladder. Being sexually active. Sexually active women tend to have more UTIs than do women who aren't sexually active. Using certain types of birth control. Women who use diaphragms for birth control also may be at higher risk, as may women who use spermicidal agents. Completing menopause. After menopause, UTIs may become more common because the lack of estrogen causes changes in the urinary tract that make it more vulnerable to infection. Having urinary tract abnormalities. Babies born with urinary tract abnormalities that don't allow urine to leave the body normally or cause urine to back up in the urethra have an increased risk of UTIs.

Having blockages in the urinary tract. Kidney stones or an enlarged prostate can trap urine in the bladder and increase the risk of UTI. Having a suppressed immune system. Diabetes and other diseases that impair the immune system the body's defense against germs can increase the risk of UTIs. Using a catheter to urinate. People who can't urinate on their own and use a tube (catheter) to urinate have an increased risk of UTIs. This may include people who are hospitalized, people with neurological problems that make it difficult to control their ability to urinate and people who are paralyzed.

Signs and symptoms: Urinary tract infections don't always cause signs and symptoms, but when they do they may include:

A strong, persistent urge to urinate A burning sensation when urinating Passing frequent, small amounts of urine Urine that appears cloudy Urine that appears red, bright pink or cola-colored a sign of blood in the urine Strong-smelling urine Pelvic pain, in women Rectal pain, in men

Acute urinary tract infections are relatively common in children, with 8 percent of girls and 2 percent of boys having at least one episode by seven years of age. The most common pathogen is Escherichia coli, accounting for approximately 85 percent of urinary tract infections in children. Renal parenchymal defects are present in 3 to 15 percent of children within one to two years of their first diagnosed urinary tract infection. Clinical signs and symptoms of a urinary tract infection depend on the age of the child, but all febrile children two to 24 months of age

with no obvious cause of infection should be evaluated for urinary tract infection (with the exception of circumcised boys older than 12 months). Evaluation of older children may depend on the clinical presentation and symptoms that point toward a urinary source (e.g., leukocyte esterase or nitrite present on dipstick testing; pyuria of at least 10 white blood cells per highpower field and bacteriuria on microscopy). Increased rates of E. coli resistance have made amoxicillin a less acceptable choice for treatment, and studies have found higher cure rates with trimethoprim/sulfamethoxazole. Other treatment options include amoxicillin/clavulanate and cephalosporins. Prophylactic antibiotics do not reduce the risk of subsequent urinary tract infections, even in children with mild to moderate vesicoureteral reflux. Constipation should be avoided to help prevent urinary tract infections. Ultrasonography, cystography, and a renal cortical scan should be considered in children with urinary tract infections. DIAGNOSTIC TESTS Dipstick tests for UTI include leukocyte esterase, nitrite, blood, and protein. Leukocyte esterase is the most sensitive single test in children with a suspected UTI. The test for nitrite is more specific but less sensitive. A negative leukocyte esterase result greatly reduces the likelihood of UTI, whereas a positive nitrite result makes it much more likely; the converse is not true, however. Dipstick tests for blood and protein have poor sensitivity and specificity in the detection of UTI and may be misleading. Accuracy of positive findings is as follows (assumes a 10 percent pretest probability)13:

Nitrite: 53 percent sensitivity, 98 percent specificity, 75 percent probability of UTI Bacteria on microscopy: 81 percent sensitivity, 83 percent specificity, 35 percent probability of UTI Leukocytes on microscopy: 73 percent sensitivity, 81 percent specificity, 30 percent probability of UTI Leukocyte esterase: 83 percent sensitivity, 78 percent specificity, 30 percent probability of UTI Leukocyte esterase or nitrite: 93 percent sensitivity, 72 percent specificity, 27 percent probability of UTI Blood: 47 percent sensitivity, 78 percent specificity, 19 percent probability of UTI Protein: 50 percent sensitivity, 76 percent specificity, 19 percent probability of UTI

Complications of UTIs may include:

Recurrent infections, especially in women who experience three or more UTIs Permanent kidney damage from an acute or chronic kidney infection (pyelonephritis) due to an untreated UTI, especially in young children Increased risk of women delivering low birth weight or premature infants Treatment Although amoxicillin has traditionally been a first-line antibiotic for UTI, increased rates of E. coliresistance have made it a less acceptable choice, and studies have found higher cure rates with trimethoprim/sulfamethoxazole (Bactrim, Septra). Other choices include amoxicillin/clavulanate (Augmentin) or cephalosporins, such as cefixime (Suprax), cefpodoxime, cefprozil (Cefzil), or cephalexin (Keflex).10 Table 1 lists commonly used antibiotics, with dosing information and adverse effects. Physicians should be aware of local bacterial resistance patterns that might affect antibiotic choices.