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Urinary Tract Infection 2013
Urinary Tract Infection 2013
Could be...
Uncomplicated UTI
acute cystitis or pyelonephritis in
nonpregnant outpatient women w/o
anatomic abnormalities or
instrumentation of the urinary tract
Complicated UTI
Etiology
uropathogens vary by clinical syndrome &
geography
usually enteric gram-negative rods
acute uncomplicated cystitis in the US, Europe
& Brazil
E. coli: 7590%
Staphylococcus saprophyticus: 515%
( younger women)
Klebsiella sp, Proteus sp, Enterococcus sp,
Citrobacter sp, & other organisms: 510%
The spectrum of agents causing uncomplicated
pyelonephritis is similar; E. coli predominating.
complicated UTI:
E. coli remains the predominant organism
Other aerobic gram-negative rods (Klebsiella
sp, Proteus sp, Citrobacter sp, Acinetobacter
sp, Morganella sp, Pseudomonas aeruginosa)
also are frequently isolated
Gram-positive bacteria (enterococci &
Staphylococcus aureus), & yeasts: also
important pathogens in complicated UTI
Pathogenesis
majority of UTIs: bacteria establish
infection by ascending from the
urethra to the bladder
introduction of bacteria into the
bladder does not inevitably lead to
sustained and symptomatic infection
interplay of host, pathogen, &
environmental factors determines
whether tissue invasion &
Host factors
Genetic background of the host influences the
individual's susceptibility to recurrent UTI
(among women)
A familial predisposition to UTI &
pyelonephritis is well documented.
Women with recurrent UTI: more likely to have
had their 1st UTI before 15 y.o. & have a
maternal history of UTI
Pathogenesis of familial predisposition to
recurrent UTI persistent vaginal colonization
Virulence Factors
P fimbriae
best studied adhesin
hairlike protein structures that interact w/
specific receptor on renal epithelial cells
(blood group antigen P)
important in the pathogenesis of
pyelonephritis & bloodstream invasion from
the kidney
Type 1 pilus (fimbria)
E. coli strains possess but not all E. coli
strains express
Clinical manifestations
Asymptomatic Bacteriuria
considered ONLY when patient does not have local or
systemic symptoms referable to the urinary tract
Cystitis
typical symptoms: dysuria, urinary frequency & urgency
nocturia, hesitancy, suprapubic discomfort, gross
hematuria are often noted
Unilateral back/flank pain indication that upper urinary
tract is involved
Fever indication of invasive infection of the kidney or
prostate
Pyelonephritis
Mild pyelonephritis: low-grade fever with/without
low-back or costovertebral-angle pain
Severe pyelonephritis: high fever, rigors, nausea,
vomiting, & flank &/or loin pain
symptoms are generally acute in onset
symptoms of cystitis may not be present
Fever is the main feature distinguishing cystitis &
pyelonephritis.
Fever high, spiking "picket-fence" pattern,
resolves over 72 h of tx
Bacteremia develops in 2030% of cases
Emphysematous pyelonephritis
severe form
production of gas in renal & perinephric tissues
occurs almost exclusively in diabetic patients
Xanthogranulomatous pyelonephritis
occurs when chronic urinary obstruction (often by
staghorn calculi), together with chronic infection,
leads to suppurative destruction of renal tissue
intraparenchymal abscess formation
suspected when a patient has continued fever &/or
bacteremia despite antibacterial therapy
Prostatitis
infectious & noninfectious abnormalities of
prostate gland
Infections: acute or chronic, almost always
bacterial in nature
far less common than noninfectious
entity of chronic pelvic pain
syndrome (formerly chronic prostatitis)
Acute bacterial prostatitis
Sxs: dysuria, frequency, & pain in the
prostatic, pelvic, or perineal area.
(+) fever & chills, symptoms of bladder
outlet obstruction are common
Diagnostic flowchart
Differential Diagnoses:
dysuria
cervicitis (C. trachomatis, Neisseria
gonorrhoeae)
vaginitis (Candida albicans, Trichomonas
vaginalis)
herpetic urethritis, interstitial cystitis, &
noninfectious vaginal or vulvar irritation
Women with >1 sexual partner & inconsistent
use of condoms high risk for both UTI STD
Diagnostics
Cystitis in Men
Ssx are similar to women
urine culture is strongly recommended
documentation of bacteriuria can
differentiate the less common syndromes
of acute and chronic bacterial prostatitis
from the very common entity of chronic
pelvic pain syndrome
If the diagnosis is unclear, localization cultures
by 2 or 4-glass Meares-Stamey test (urine
collection after prostate massage) should be
done to differentiate b/n bacterial &
nonbacterial prostatic syndromes refer to a
UTI in Men
GOAL: eradicate prostatic infection & bladder
infection
uncomplicated UTI: 7-14-day FQs or TMP-SMX
CAUTI
bacteriuria & symptoms in a catheterized patient
accepted threshold for bacteriuria: 103 cfu/mL to 105
cfu/mL
formation of biofilm (a living layer of uropathogens)
on the urinary catheter is central to the pathogenesis
oOrganisms in a biofilm are relatively resistant to
killing by antibiotics
The best strategy for prevention of CAUTI: avoid
insertion of unnecessary catheters & to remove
catheters once they are no longer necessary
Tx: 7- to 14 days of antibiotics is recommended
Candiduria
Common for patients in the ICU, those taking
broad-spectrum antimicrobial drugs, & those w/ DM
C. albicans: most common isolate
Treatment is recommended for symptomatic
cystitis or APN & for those high risk for
disseminated disease ( neutropenic, those who are
undergoing urologic manipulation, & low-birthweight infants)
Fluconazole (200400 mg/d for 14 days): first-line
TX
oral flucytosine &/or parenteral amphotericin B: for
resistant to fluconazole