UTI CASE

Middle age woman,Malay come with abdominal pain at right loin region and worse
with movement associated with high grade feve and drowsiness.She also complained
about loss of appetite but denied about dysuria and frequency.And she had positive
renal punch.

Causes of Drowsiness in this patient.

1) Infective
Systemic: Sepsis, pyelonephritis
Intracranial: meningitis, encephalitis
2) Fluid and electrolyte imbalance
Hyponatremia
Hypomagnesemia
3) Metabolic

Uremia
Hypercapnia
Hypoxia: shock type 1 respiratory failure
Hypoglycaemia

Patient complaints of right loin pain that worse with movement and positive renal
punch that associated with high grade fever suggesting pyelonephritis. The
infection can lead to septic shock.
Septic shock occur d/t potent bacterial endotoxin which affect cell walls promote the
release of histamine, bradykinin, and cause endothelial damage. Initially there is a
hyperdynamic reaction with high cardiac output, vasodilation, and low peripheral
resistance followed by fluid loss from the vascular compartment as a result of
extensive capillary leakage (by action of histamine).
This leads to hypovolemia, peripheral vasoconstriction and acute circulatory failure.
When oxygen supply to brain reduces, hypoxemia and hypercapnia occur, it can
manifests drowsiness as symptoms.
Drowsiness associated with high grade fever may occur due to intracranial infection
such as meningitis or encephalitis that cause by bacteraemia from site of infection,
pyelonephritis.

Patient also said, she has loss of appetite that may suggest fluid and electrolyte
imbalance that cause the drowsiness, especially, hyponatremia and
hypomagnesemia. Hypoglycaemia may cause drowsiness too.

BACTEREMIA VS SEPTICEMIA VS SIRS

Bacteremia

Systemic inflammatory
response syndrome

Septicemia

Bacteremia is the simple

presence of bacteria in the
blood.

Septicemia is the presence and

multiplication of bacteria in the
blood.

Clinical response to a nonspecific

insult of either infectious or
noninfectious origin.

Bacteremia is not as
dangerous as Septicemia.

Septicemia is a potentially lifethreatening infection.

Life threatening condition , can

lead to death

Less amount of bacteria

are present in blood.

Large amounts of bacteria are

present in the blood.

Does not always present with

bacteria

This may occur through a

wound or infection, or
through a surgical
procedure or injection.

It can arise from infections

throughout the body, including
infections in the lungs, abdomen,
and urinary tract.

SIRS is not always related to

infection.

Toxins are not produced.

Toxins may be produced by

bacteria.

Toxin might or might not present

Bacteremia usually causes

no symptoms or it may
produce mild fever.

It shows symptoms like chills,

fever, prostration, very fast
respiration and/or heart rate.

Fever of more than 38C

(100.4F) or less than 36C
(96.8F)

Heart rate of more than 90

beats per minute

Respiratory rate of more

than 20 breaths per minute or
arterial carbon dioxide tension
(PaCO 2) of less than 32 mm Hg

Abnormal white blood cell

count (>12,000/L or <

4,000/L or >10% immature
[band] forms)

Untreated SIRS will increase

mortality

It can resolve without

treatment.

Untreated septicemia can quickly

progress to sepsis.

Rapidly removed from the

bloodstream by the
immune system.

Antibiotics will be used to treat the Depend on the cause

bacterial infection that is causing
septicemia.

Caused
by Staphylococcus,
Streptococcus,
Pseudomonas,
Haemophilus, E. coli,
dental procedures, herpes
(including herpetic
whitlow), urinary tract
infections,
peritonitis,Clostridium
difficile colitis,
intravenous drug use, and
colorectal cancer.

Staphylococci, are thought to

cause more than 50% of cases of

sepsis. Other commonly

implicated bacteria

include Streptococcus pyogenes,

Escherichia coli, Pseudomonas
aeruginosa, Klebsiella species and

evenCandida spp.

Bacterial sepsis
Burn wound infections
Candidiasis
Cellulitis
Cholecystitis
Community-acquired
pneumonia
Diabetic foot infection
Erysipelas
Infective endocarditis
Influenza
Intra-abdominal infections
(eg, diverticulitis, appendicitis)
Gas gangrene
Meningitis
Nosocomial pneumonia
Pseudomembranous colitis
Pyelonephritis
Septic arthritis
Toxic shock syndrome
Urinary tract infections
(male and female)

noninfectious causes of SIRS:

Acute mesenteric
ischemia
Adrenal insufficiency
Autoimmune disorders

Burns
Chemical aspiration
Cirrhosis
Cutaneous vasculitis
Dehydration
Drug reaction
Electrical injuries
Erythema multiforme
Hemorrhagic shock
Hematologic malignancy
Intestinal perforation
Medication side effect (eg,
from theophylline)
Myocardial infarction
Pancreatitis
Seizure
Substance abuse Stimulants such as cocaine and
amphetamines
Surgical procedures
Toxic epidermal
necrolysis
Transfusion reactions
Upper gastrointestinal
bleeding
Vasculitis

CLINICAL FEATURES OF SEPTICEMIA

The adult patient should have a proven or suspected source of an infection
(usually bacterial) and have at least two of the following problems to be
diagnosed as having sepsis:

Altered mental status (for example, altered consciousness,

mental confusion or delirium)

Fast respiratory rate (> 22 breaths/minute)

Low blood pressure ( 100 mm Hg systolic)

However, patients may have many other signs and symptoms that can occur
with sepsis, such as :

elevated heart rate (tachycardia),

fever,
low body temperature (hypothermia),
a reduced carbon dioxide (PaCO2) level in the blood,
chills,
dizziness,
fatigue,
Shivering ,
facial flushing,
shortness of breath,
low urine production,
skin discoloration,
dysfunction of one or more organs,
shock,
sleepiness.

INVESTIGATION OF SEPTICAEMIA

If time allows and not too ill

o Culture all possible sources before treating
Blood
Sputum
Urine
Faeces
Skin or wound swabs
CSF
Aspirates
Full blood count
o Predict bacterial infection
Though an elevated WBC count is not specific to infection.
In the setting of fever without localizing signs of infection
A white blood cell count higher than 15,000/L or a
neutrophil band count higher than 1500/L has about a
50% correlation with bacterial infection.
WBC counts higher than 50,000/L or lower than 300/L
are associated with significantly decreased survival rates.
o Haemoglobin concentration
Dictates oxygen-carrying capacity in blood, which is crucial in
shock to maintain adequate tissue perfusion.

Although there is no specific haematocrit or haemoglobin target,

keeping the haemoglobin concentration above 7 g/dL and
studies comparing this versus 9 g/dL have shown no increased
survival benefit from either arm.
o Platelets
As acute-phase reactants
Usually increase at the onset of any serious stress and are
typically elevated in the setting of inflammation.
However, the platelet count will fall with persistent sepsis, and
disseminated intravascular coagulation (DIC) may develop.

Coagulation studies
o Prothrombin time (PT)
o Activated partial thromboplastin time (aPTT).
o Patients with clinical evidence of a coagulopathy require additional
tests to detect the presence of DIC.
The PT and the aPTT are elevated in DIC, fibrinogen levels are
decreased, and fibrin split products are increased.
ESR and CRP
o Inflammatory markers
LFT
o Levels of bilirubin
o ALP
o Lipase
o Blood urea nitrogen (BUN) level
o Bilirubin level
o Alkaline phosphatase (ALP) level
o Alanine aminotransferase (ALT) level
o Aspartate aminotransferase (AST) level
o Albumin level
o Important in evaluating multiorgan dysfunction or a potential causative
source (eg, biliary disease, pancreatitis, or hepatitis).
o Increased BUN and creatinine levels can point to severe dehydration or
renal failure.
Serology
Malaria film
Save serum for virology
o Compare with convalescent sample in ~2weeks
Chest xray
o most patients who present with sepsis have pneumonia
o useful in detecting radiographic evidence of ARDS, which carries a high
mortality
MSU or dipstick
o UTI

Clinical features of UTI

- Dysuria
- Frequency and urgency
- Occasional suprapubic tenderness
- Gross hematuria

Common organism in UTI

- Most common : E.Coli (<85%)

- Gram negative Enterobacteriaceae

1) Proteus mirabilis (4%)
2) Klebsiella pneumonia (4%)
3) Enterobacter (2%)
4) Serratia (2%)
5) Pseudomonas group (2%)

- Gram positive bacteria, includes:

1) Staphylococcus saprophyticus
2) S.epidermis
3) S.aureus
4) S.agalactiae
5) Enterococci
6) Citrobacter

CAUSES/RISK FACTORS OF UTI IN MALE & FEMALE

MALE
-

FEMALE

Urethra is much
longer and
further from the
anus.
Uncircumcised
Large prostate

ANATOMY

PHYSIOLOGY

Urethra is shorter and

closer to the anus.

Risk of getting UTI

increases as
estrogen levels
decrease with
menopause due to
loss of protective
vaginal flora
(Lactobacillus sp.)
Post-menopausal
vaginal atrophy
may cause
recurrent UTI

Urinary catheterization
- Diabetes
- Vesicoureteral reflux
Chronic prostatitis may cause recurrent UTI (male)

Complication of UTI

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.
Increased risk in pregnant women of delivering low birth weight or premature
infants.
Urethral narrowing (stricture) in men from recurrent urethritis, previously
seen with gonococcal urethritis.
Sepsis, a potentially life-threatening complication of an infection, especially if
the infection works its way up your urinary tract to your kidneys.
Prostatitis
Kidney failure

Investigation of UTI

Urinalysis :

looking for the presence of urinary nitrites (produced by reduction of urinary nitrates
by bacteria) and elastase (produce by neutrophils).

Analyzing a urine sample.

Your doctor may ask for a urine sample for lab analysis to look for white blood cells,
red blood cells or bacteria. To avoid potential contamination of the sample, you may
be instructed to first wipe your genital area with an antiseptic pad and to collect the
urine midstream.

Growing urinary tract bacteria in a lab.

Lab analysis of the urine is sometimes followed by a urine culture. This test tells
your doctor what bacteria are causing your infection and which medications will be
most effective.

Creating images of your urinary tract.

If you are having frequent infections that your doctor thinks may be caused by an
abnormality in your urinary tract, you may have an ultrasound, a computerized

tomography (CT) scan or magnetic resonance imaging (MRI). Your doctor may also
use a contrast dye to highlight structures in your urinary tract.

Using a scope to see inside your bladder.

If you have recurrent UTIs, your doctor may perform a cystoscopy, using a long, thin
tube with a lens (cystoscope) to see inside your urethra and bladder. The cystoscope
is inserted in your urethra and passed through to your bladder.

TREATMENT OF URINARY TRACT INFECTION

Cystitis
1) 1st choice
- Trimethoprim
2) 2nd choices
- Amoxicillin
- Nitrofurantoin
- Cefalexin
- Ciprofloxacin
3) In
-

pregnancy (avoid trimethoprim & quinolones)

Co-amoxiclav
Cefalexin
Amoxicillin

Prophylactic therapy
1) 1st choice
- Trimethoprim
2) 2nd choices
- Nitrofurantoin
- Co-amoxiclav

Pyelonephritis
1) 1st choice

Co-amoxiclav
Ciprofloxacin

2) 2nd choices
- Gentamycin
- Cefuroxime

Epidemio-orchitis
1) 1st choice
- Ciprofloxacin

Acute prostatitis
1) 1st choice
- Trimethoprim
2) 2nd choice
- Ciprofloxacin

Clinical difference between upper and lower UTI

Upper Urinary tract infection (eg pyelonephritis)
1. Fever,usually high fever (atleast38Cor100.4F)
2. Shivering
3. Vomiting
4. Nausea
5. Diarrhea
6. Pain on the side (flank), upper back or groin - this may become more
uncomfortable when urinating
7. Radiation: abdominal pain
Lower urinary tract infection (eg cystitis, prostatitis, urethritis)
1. Cloudy urine

2. Theurinemayhaveanunpleasantsmell
3. Hematuria-bloodinurine
4. Frequent need to urinate - this may occur during the waking hours,
sleeping hours, or both
5. Holding the urine in may become harder to do
6. Discomfort and sometimes pain when urinating
7. General malaise;generally feeling unwell
8. Tenderness around the pelvic area