1 LE Urinary tract infection 2 The urinary tract infection (UTI) are becoming increasingly important for two ma in reasons

: the first is purely epidemiological (in Italy each year are diagnose d almost two million cases of UTI) and they are second only to the apparatus res piratory and represent the most common type of infection acquired in hospitals. The second is strictly clinical and prognostic interest and the frequency with w hich these forms of disease, far from being a separate nosological entity evolvi ng almost always beneficial, are rather unique event or at least the most obviou s sign of severe anatomical abnormalities functional urinary tract, such as join t piel ureteral stenosis, bladder neck stricture, prostatic hyperplasia, the inf ected computer. With urinary infections affect more than one frequency in both s exes and different ages of life, are alone 25% of the pathology of the first two years of life and 16% of all childhood diseases. This ratio decreases on into a dulthood and becomes less than 6-7% for the prevalence of cardiovascular disease in old age, cancer, metabolic and chronic degenerative diseases. We define urin ary tract infection the finding of a significant bacteriuria with or without cli nical symptoms. Bacteriuria is significant when the microbial count is greater t han or equal to 10 colonies for the fifth ml of urine. This limit was proposed b y Kuss in 1959 and subsequently accepted by all. However, with the proliferation of antibiotic drugs, their use in various morbid situations has become so frequ ent and so large that interfere with bacterial flora and pathogenic organism is residing in different districts. Thus it is that the value established by Kuss h as been revised and now mostly is considered significant count of 10,000 bacteri a per milliliter of urine. AETIOLOGY Pseudomonas environmental aeruginosa bacterium Etiologic agents of urinary infections are common schizomiceti in almost all cas es. Other organisms have been isolated from the urine but do not appear to be pa thogenic for the urinary tract. Schizomiceti common among those who are isolated most frequently (80-90%) were Gram-negative. Until now, Escherichia coli was th e 3 species frequently isolated from infected urine, in particular serotypes 0, l, 2, 4, 7 and 75. In recent years we are witnessing, in complicated infections, a change in the etiological panorama. In particular there is an increase in oppor tunistic infections by bacteria (Pseudomonas, Proteus, Serratia) and Gram-positi ve. These microorganisms are present in the environment in general and particula rly in the skin, their ubiquity makes them significantly affect infections acqui red in hospitals, often favored by instrumental maneuvers. Infections to chronic trend is also not uncommon to find a mixed bacterial flora, and this is mainly due to the frequency with which this type of infection is treated, ie, with prol onged and repeated cycles of antibiotic therapy in an attempt to their final era dication. Bacterial more PATHOGENESIS Because the infection is determined, a bacterial flora must: 1) to reach the uri nary tract, 2) be able to multiply in the environment 3) be able to compete with these defense mechanisms. The urine is usually sterile. Bacteria can come from

various locations in the urinary tract of the body via the blood (kidney, prosta te and testicles), the route for lymphatic circulation enterourinario (from the cervix and intestine and kidney to the bladder), the route ascending (from the b ladder to the kidney or prostate urethra and bladder), in proximity (direct exte nsion intestinal bladder). 4 In normal urinary dynamics, the persistence of these microorganisms in the uri nary tract is so short that they are eliminated with the urine flow before, mult iplying, can achieve significant load from becoming pathogenic. This can only oc cur: 1) when in the urinary tract conditions are particularly conducive to rapid bacterial growth associated with slow flow of urine from the kidney to the blad der and then outside, and 2) when for various pathological conditions there is a reduction powers of local defense and / or systemic, 3) when the bacteria reach es the urinary tract is of such significance in itself be primitive pathogenic. The factors predisposing the occurrence of UTI are distinguished: a) physiologic al b) pathologic c) iatrogenic. Physiological factors In the short female urethra and its location are undoubtedly responsible for an increased susceptibility to urinary infections. In this anatomical situation, in fact, entry into the bladder of living organisms is a vaginal nell'introitus ea sy occurrence to happen spontaneously, and even more during intercourse (cystiti s "Honeymoon"). In a further risk factor for pregnancy is the reversible uretera l stasis due to the reduction of the normal ureteral peristalsis hormonally indu ced (progesterone) and by mechanical compression of the ureter by the uterus in the last months of pregnancy. With age gradually decreases the ability of immune surveillance system on infectious agents, while increasing the incidence of met abolic diseases and hypertension in turn responsible for immunodeficiency. Furth ermore, with aging appear very frequently due to voiding disorders in men with p rostate disease, and a woman pluripara cystocele. Finally, remember how the part icular biochemical characteristics of bone marrow (poor blood flow, high pH, hyp erosmolarity) neutralizing some complement factors and inhibiting leukocyte chem otaxis, reduce the immune response, thus favoring the persistence and chronicity of infection in this forum. Pathological factors 5 active peristalsis e the most effective al factors intrinsic consequently hinder ction. of the urinary tract and a regular and complete emptying ar means of defending urinary tract infections. Any pathologic or extrinsic to that system that also cause obstruction and the flow and stagnation of urine promotes the onset of infe

Pathological factors extrinsic humans: in humans the major route of spread dell' IVU is ascending through the urethra. Contrary to the situation of women, the ex ternal urethral meatus is neither near the anal orifice, is adjacent to a mucosa l surface (vagina) that can be colonized by bacteria. Furthermore, the prostate secretes a potent antibacterial substance that is probably a natural defense mec hanism against ascending UTI. This substance is zinc. In men with bacterial pros tatitis is absent or in reduced quantities. The 'chronic bacterial infection of the prostate appears to be the main cause of UTI in humans applicant. Pathologic al factors inherent in man: a number of intrinsic factors influencing susceptibi lity to bladder both men and women with UTI. Bacteria introduced into the bladde rs of volunteers were promptly removed after urination, with no treatment. There fore, an efficient bladder emptying alone can be a defense mechanism against inf ection bladder. The bladder dysfunction on neurological basis, the residual urin e and the presence of foreign bodies increase susceptibility to infection. Urete ral and renal factors: in addition to factors related to host susceptibility, th ere are many factors that influence the spread due to ascending from the bladder to the urinary tract high, up to the kidney: the presence or absence of vesicou

reteral reflux, quality of ureteral peristalsis and its susceptibility to infect ion of the renal medulla. An obstructive uropathy, diminishing blood flow to the kidney, primary renal disease and renal or ureteral foreign bodies may increase susceptibility to UTI In fact, these conditions a bacteria, also came in the urinary tract, although m inor, growing exponentially, quickly reaches values such that frankly infectious to overcome the defense mechanisms. The urinary stones is undoubtedly the most common disease that causes UTI, obstruction involving the trauma sull'urotelio i n addition, all malformations of the urinary tract and upper urinary tract 6 below, acquired neoplastic and non-executives of impaired urodynamics and with stagnation of urine, are events throughout the disease for which the infectious disease complications is the rule. From this it follows that in the presence of recurrent urinary infection or chronic trend, particularly in children, is nece ssary to identify all cases the integrity of anatomical or functional urinary tr act. Iatrogenic factors Assessing anatomic or functional urinary tract endoscopic explorations often req uire a sometimes simple and easy, such as uretrocistoscopia sometimes more compl ex, such as uretero-pieloscopia. As these operations are carried out gently, and the equipment used is thoroughly sterilized€endoscopy of the urinary tract is not infrequently complicated by UTI. The microtrauma, small erosions of the epit helium, the inevitable transport of the bacterial flora normally present in the distal urethra, within the urinary tract, irrigation pressure with removal of no n-physiological surface glycosaminoglycans, are important Risk factors for the r ealization of phenomena secondary infections. The problem becomes even more seri ous during endoscopic maneuvers obtained for therapeutic purposes, as the risk f actors mentioned above becomes inevitable and, in most cases of this magnitude, the secondary infection becomes the rule. It is evident from the above the impor tance of implementing more during endoscopic maneuvers, particularly if carried out for therapeutic purposes, all possible precautions to prevent this type of c omplications, in addition to complete sterility of the instrument provides adequ ate coverage antibiotic prophylactic and postoperative. Diagnosis In case of cystitis, the elimination of urine outside can cause pain or burning urination. There may be urgent urination, followed by elimination of urine and l ittle feeling of not completely emptying the bladder (bladder tenesmus). In some cases, possible discoloration or odor of urine with haematuria. It 'also possib le to read a tenderness to the lower abdomen, while it is rare that there is fev er. In case of pyelonephritis is rather high fever with chills, they may also ha ve nausea, vomiting and flank pain, back or groin area. And 'then you may notice blood in urine or purulent urine, and usually there are problems with urination characteristic of cystitis .. 7 The clinical symptoms is not always sufficient for a diagnosis of urinary infe ction, it is often necessary to use laboratory and instrumental investigations i n order not only to detect the presence of UTI, but the factors contributing to seek, to define the clinical form and assess the risk of complications. These su rveys are: Examination of urine. The examination of urinary sediment shows a Leu kocyturia above physiological values (200.000/ho 5 per field): this is an indica tion of general inflammation of the urinary tract, but not always of infection. The presence of a leukocyte cilindruria, representing the cylinder mold greater or lesser extent of the renal tubule, is a sign of inflammation that affects not only the urinary tract but also the renal parenchyma. Conversely, the mere pres ence of low cell exfoliation and / or upper respiratory indicates exclusive or p redominant involvement of the urinary tract. The presence of bacteria without ev idence of inflammation is not always sign of infection, could be the result of p

oor storage of the sample, from the beginning harvest container hygienically ina ppropriate. Instead proteinuria and hematuria, although almost always present du ring infection, are not shown unless they are found associated with the findings mentioned above. The presence of nitrite but is a very indicative sign, as thes e are a product of the metabolism of these germs are most frequently responsible for infection. Urine culture. The diagnosis of urinary infection is based on co nclusive evidence of a significant number of microorganisms in the urine bladder . The urine culture allows an accurate determination of the total number of micr oorganisms per milliliter of urine, and allows the identification of bacterial s pecies. The sample in question, because the urine culture results, should be col lected in suitable container for sterility and characteristics and the amount al located in ways that ensure no contamination by bacteria commonly found in the u rethra, the external genitalia and perineum. The urine is taken from the subject with: 1) MITTO intermediate (in almost all cases), 2) suprapubic puncture (in s elected cases, especially in children), 3) catheter (in the immunologically and / or carriers of catheter) . Bacteriuria is significant when: a) the count is> 1 00,000 col / ml for urine taken with MITTO intermediate or catheterization, wher eas lower values but strongly suspect, b) the count is> 10 col / ml for urine ta ken by puncture suprapubic . The cultural examination must be performed no more than 30 'from the collection of samples, not to have altered results. The colony count becomes meaningless if the patient takes antibacterial drugs. 8 Location of the infection (UTI diagnosis Headquarters). Determine if the patie nt is suffering from urinary tract infection high or low, and if there is parenc hymal involvement or not, is extremely important for clinical,€prognostic and t herapeutic involved. This distinction is not always possible based on clinical e vidence alone, although the presence of high fever and pain will favor the diagn osis of acute pyelonephritis. To highlight the site of infection have been propo sed both direct methods, invasive and possible side effects, both indirect metho ds. Among the first remember the bacterial culture on urine collected by cathete rization of the ureters (Stamey test) or after bladder washing with disinfectant solutions (test Farley). Among the indirect methods are the most reliable resea rch enzimuria (LDH, lysozyme, NAG, beta2-microglobulin) index of damage or tubul ar necrosis, specific serum antibodies and research in the urinary sediment of b acteria coated with antibodies (Antibody Coated Bacteria test or tests of Thomas ). In particular, this last test showed a 80% accuracy in diagnosis of kidney in fection, but may be positive in all situations in which the excess of the urothe lium microorganisms coming in contact with the lymphatic circulation (ulcerative cystitis, prostatitis, etc..) . Diagnostic radiology images can be included amo ng the indirect methods since, noting morphofunctional alterations of one of the districts of the urinary tract, may lean to an infection of the home, or even s howing the absolute integrity of the urinary anatomofunctional more oriented tow ards low seat it. Radiological examinations are necessary in patients with risk factors that may require intervention in addition to the antibacterial treatment . Urinary infection associated with urinary tract obstruction may require furthe r investigation. These are the patients with stones, ureteral tumors, ureteral s trictures, obstructions or congenital genito urinary previous interventions on t he apparatus, such as ureteral reimplantation or measures of urinary diversion, which may have caused obstruction. Some imaging techniques useful in urinary inf ections: a) reno bladder radiography (Rx Direct reno bladder) is useful for the rapid diagnosis of radiopaque stones against kidney or ureter. It is not as spec ific investigation. b) renal ultrasound: is a very important technique for imagi ng due to its non-invasiveness, its ease of implementation and because it does n ot control the patient at risk of radiation or contrast medium. It is particular ly useful in identifying hydronephrosis associated with a urinary tract infectio n, pyonephrosis and perirenal abscesses. c) urography: the IVU is a routine exam ination for the study of patients with complicated infections. Using a contrast medium outlines 9 showing images of the urinary tree minus or plus. It is useful to define the e

xact location and extent of urinary tract obstruction. d) Computerized axial tom ography is able to examine in detail the anatomical details, but for the purpose s of imaging does not appear to be a first choice in UTI, but secondary to a sub sequent study to assess anatomical changes predisposing infection. Anyway, this may already be studied with ultrasound and IVU. Also its high cost prevents its inclusion in most common office procedures. e) renal sequential scintigraphy: is used to study the possible impairment of renal function and reductions in renal perfusion during acute renal infection. After the healing is important for eval uating the restoration of perfusion, excretion and secretion, restoring the stat us quo ante, or in assessing the residual filtration. Classification and symptomatology Of a urinary infection, specify the location (parenchymal, upper respiratory tra ct, lower respiratory tract, prostate), course (acute, chronic, recurrent) and i f it is as simple or complicated, which it means all those cases where the prese nce of concomitant disorders of the urinary tract makes it difficult if not impo ssible dell'IVU resolution. The clinical picture with a urinary infection which manifests itself is extremel y varied and can range from complete absence of symptoms (asymptomatic bacteriur ia) in the presence of only local symptoms (dysuria, frequency, stimulus imperio us stranguria) but are not specific to IVU the presence of general symptoms (fev er, pain) that are characteristic of parenchymal involvement. Depending on the p lace where primitive sets in the infection process, the evolution of the clinica l characteristics and different takes on importance especially in relation to th e interest of the next segments of the urinary tract. If the bladder, a place of relative physiological stasis,€is the point of the urinary tract that most oft en are made conditions ideal for the establishment of an infectious process, is certainly not uncommon that this also leads along the various segments of the ur inary tract high in relation to pathological conditions responsible for a physio logical barrier to the flow of urine. An infectious process involving the primit ive bladder is usually localized to it. The uretero-vesical junction in the abse nce of pathological changes and malformations that alter the anatomical and stru ctural characteristics, is capable of maintaining perfect continence even at hig her pressures and vesicoureteral reflux to intravesical opposing the spread of t he infection process. The infection, directly affect the structure, may cause a temporary modification of the special functional characteristics, and then itsel f be due to reflux, but this rarely occurs in situations of relative immaturity of the junction ureterovescicale or in situations that malformation sun would st ill be insufficient to alter the antireflux mechanisms. The opposite occurs when the infection affects the urinary tract primitively high: at any level is deter mined, in fact, is spreading rapidly around the urinary system and the continuou s and constant flow of urine with high bacterial count is a prerequisite to ' em ergence of a true chronic bladder infection process, particularly in the presenc e of a residue also mild. The upper urinary tract infection also spreads so quic kly to the renal parenchyma with all the consequences in terms of prognosis and therapy. Already mentioned as the infection usually after establishing an anatom ical or functional obstruction of the urinary tract has resulted in a urinary st asis. In the section upstream of the obstacle the high pressures favoring real r eflux of urine from the urinary tract infection to the parenchyma. This leads to the formation of bacterial outbreaks parenchymal and pyelonephritis occurred. I n the presence of infection, therefore we can not under any circumstances regard less of study, the most accurate and complex anatomical and functional state of the urinary tract, in order not to incur the risk of misunderstanding on patholo gical situations such as 'UTI is established and whose complications, more or le ss distant, it can rarely be not only final but also serious enough to jeopardiz e the future life of the patient. Natural history of infection The use of terms such as "chronic" or "persistent", but can lead to inaccuracies and misunderstandings. Stamey in 1980 suggested a new classification is useful

to trace the natural history of each patient and to monitor its clinical evoluti on: 1. Before infection: represented by the first episode of documented UTI 2. B acteriuria is not: cases of UTI in which the infection is not resolved during th erapy for eradication failure. The causes are due to: a. bacterial resistance de veloped during therapy b. reduced patient response to therapy c. rapid developme nt of bacterial resistance despite initial sensitivity d. mixed infections, E. R apid reinfection by a new agent-resistant f. renal insufficiency (BUN) g. kidney infection (die) 3. Bacterial Persistence: When you sterilize the urine during t herapy but still the pabulum that is a. infected computer b. chronic bacterial p rostatitis, c. fistulas and vescicovaginali vescicoenteriche d. obstructive neph ropathy; e. medullary sponge kidney infection 4. Reinfection: those cases of UTI in which there is a new infection with new pathogens, after the cancellation of a previous infectious episode. Complications If at first instance is appropriate to consider the infection as a symptom of ot her disorders of the urinary tract is also true that it is, in itself, a patholo gical event responsible for annoying and disabling symptoms and, if localized to the upper urinary tract of possible irreversible damage to the renal parenchyma . The evolution towards chronic pyelonephritis sclerosis and exclusion of functi onal kidney is the most feared complication. It is a slow process but that its p rogression is accelerated by the presence of obstructive phenomena not resolved swiftly. This is particularly important in children where the infection is almos t always the first sign of malformation un'uropatia more or less important. It i s shown that in patients with UTI secondary to malformations,€Renal functional changes are reversible if corrective surgery is performed within the 1st year of life, remain unchanged if this is achieved between the 1st and 3rd year and are inevitably destined to get worse if the diagnosis and subsequent surgery is del ayed beyond this period. The chronic bilateral pyelonephritis is second only to glomerulonephritis as a cause of chronic renal failure (CRF) in 19.1% of patient s now on dialysis primum movens was obstructed urinary infection or not. Althoug h only unilateral chronic pyelonephritis is a pathological event very serious: i t can lead to hypertension, which if not treated properly in time and is due to vascular compromise of the contralateral kidney, and then on IRC. The presence of infection is one of many conditions, changing the physico-chemic al properties of urine, favoring the precipitation of dissolved salts and theref ore the production of calculations. The UTI acts basically through two mechanism s: 1) changing the urinary pH towards alkalinity (release of ammonia to urea hyd rolysis by urease of bacterial origin) contributes to the conditions that make i t less soluble phosphates and then facilitates an easier form of precipitation o f these crystals, 2) producing organic compounds in significant amounts provides the core of attraction on which the crystals accumulate and aggregate in gallst one formation more voluminous than those calculated up to the realization that s o many racemic have part in the destruction of functional kidney. Finally, pleas e note the danger that UTIs in pregnancy are both the mother and the fetus. Asym ptomatic Bacteriuria also occurring in 10-13% of pregnant women, unrecognized, m ay be responsible for chronic pyelonephritis complicated or not with stones, pre mature birth or gestosis worse with increased perinatal mortality. Every pregnan t woman should be subjected to cultural examination of urine after the third mon th of gestation and be adequately dealt with the first positive test. Therapeutic principles Whereas hitherto this apparent how important it is to establish infection in the presence of a therapeutic program that gives the most extensive guarantees for a definitive cure it. The treatment of urinary infection, however, constitute on e of the most serious medical problems encountered in urological therapy in rela tion to the many factors that oppose it. Three factors hindering the treatment o f urinary infections: 1) urinary employees from the apparatus, 2) dependent on b acterial flora. 3) by employees.

Dependent factors from the apparatus URINARY Regarding the first, first note the stagnation at any level of urinary tract it is determined, even when they should be of interest to one cup. We have already seen the role it takes in determining the infection, no less important is its im portance in thwarting the treatment. The mechanisms through which complicates th e therapy of stasis may be multiple, but the main obstacle is to be realized tha t the rapid turnover of content in that particular sector of the urinary tract, thus defeating one of the best means by in the urinary tract is defended from in fection. The presence of stones is an almost insurmountable obstacle to treatment of infe ction and this primarily because it is almost always due to stagnation, because it is a matter of mechanics and also because of inflammation in the context of g allstone formation is very often present a bacterial flora. Another factor obsta cle to treatment is dependent from the apparatus urinary frequency with which th ey establish parenchymal bacterial outbreaks, particularly in the medullary port ion of the kidney. Here is a physiological hyperosmolarity, the environment is r ich in ammonia and therefore strongly alkaline pH, there is a lack of blood flow and low pressure filtration. All this is opposed to the elimination of bacteria l outbreaks through several mechanisms: first, the hyperosmolarity facilitates t he formation of L forms or protoplasts, namely the dried germs and allows it to survive as a hyperosmolar environment determines whether an obstacle not the arr est of amoeboid movement and therefore of phagocytosis. The alkaline environment also leads to the destruction of some complement components (the fourth in part icular), then inactivated and opposing significantly the mechanism of humoral im munity.€Finally, the low blood flow and low pressure filtration at this level o f kidney medulla is responsible for a low concentration of antibacterial drugs h ere, so that only highly active antibiotics can presumably reach the spinal cord at concentrations above the minimum inhibitory the bacterial flora present. Thi s in turn, offering no guarantee sterilization of bacterial outbreaks, also faci litates the formation of L forms, when the mechanism of action of antibiotics an d capsular type (act by altering the bacterial capsule). The L forms or protopla sts may, with mechanisms and for reasons not yet fully known, regain their origi nal bacterial form and then be responsible for maintaining or at least the recur rent urinary tract infection. Dependent factors BACTERIAL FLORA Among the factors hindering the treatment of infection, most directly dependent on the characteristics of the bacterial flora normally responsible, we must reme mber above all the wide variety of possible bacterial agents. Almost all the flo ra and Gram negative bacteria more than Gram significant positive findings may b e normal in infected urine. Particularly in developed chronic infections, the fr equency of extremely complex polymicrobial makes the choice of medication and be havior therapy. Moreover, the emergence of resistance in the urinary tract is si gnificantly more frequent than in other areas of the body. This may be of a chro mosome, namely the selection of resistant mutants, a phenomenon that occurs in t he course of antibiotic treatment, with the total disappearance of clones sensit ive and so the development of naturally resistant ones, until they are completel y replace the first giving rise to a bacterial population resistant to current t herapy. Other mechanisms of resistance are particularly frequent in the urinary tract are known as genetic combination of phenomena such as transduction, conjug ation and transformation. The transfer of DNA molecules is that it does so by phages, or even by protoplas mic bridges, may be responsible for transferring characters of resistance from o ne species to another. It is obvious that this mechanism occurs with particular frequency where there are polymicrobial infections and that in particular at the intestine and urinary tract. Another mechanism of resistance enormously importa

nt to the urinary tract is the property of most germs to produce, under the stim ulus antibiotic, such as enzymes amidasi, lactamases, esterases, adenyltransfera se, phosphotrasferase, neutralizing the antibiotic itself through a modification of its chemical structure. This mechanism has great practical importance becaus e it means bacteria is Gram positive and Gram negative after antibiotic therapy practiced, can become resistant to many drugs (penicillin, cephalosporins, chlor amphenicol, aminoglycosides). Breaking recent acquisitions in biology concern th e existence of bacterial glycocalyx, that this structure may hinder the treatmen t of a urinary infection. The surface glycocalyx is a formation of bacterial ori gin, containing polysaccharides, which first interacts with the microenvironment of germ and contributes to bacterial virulence. The glycocalyx contributes in d etermining the site of infection, recurrence of UTI and promote the iatrogenic U TI. It actually gives the seed a strong adhesion to surfaces in general, but esp ecially those exogenous as prostheses and catheters, opposes the action of polym orphonuclear cells, antibodies and certain antibiotics and finally protects the seed from the extracellular lytic enzymes. FACTORS BY THE EMPLOYEES Further hinder the treatment of urinary infection are alterations of the patient 's general condition, such as those that may occur for other concomitant disease or simply to physiological age. Of particular value are from this point of view a reduction of defense mechanisms, a more or less marked impairment of liver an d kidney function or even a defective gastrointestinal absorption which reduces the effectiveness of a treatment carried out orally. From what has already said it is clear how difficult it is to establish a treatment program that would give sufficient guarantees for achieving permanent sterilization of the urine. As a first act will provide for the surgical removal of all gallstone formation and t he causes of stasis may be present.€Then it is essential to establish appropria te antibiotic chemo-therapy, however, that gives the greatest guarantee of succe ss. In particular the choice of drug to be used will need to consider a number o f parameters related to the pharmacodynamic characteristics of the various drugs and toxic substances, the data of renal and hepatic function of the patient, an d finally the characteristics of sensitivity of bacterial flora isolated. The choice of drug use is undoubtedly the most important moment of the therapeut ic approach. It is intimately linked to the exact evaluation of the framework an d then the urine culture and bacteriological all'antibiogramma. The urine cultur e through the identification and quantitative assessment of germs or provide acc urate information on the type and severity of infection. The susceptibility then , indicating the range of antibiotics active, allows for a targeted therapy, as well as a choice in more complex cases the combination best suited to the domain of the infection. No less important, in addition to the choice of antibacterial drugs most appropriate adjuvant therapy is represented mainly by the administra tion of substances iperdiuresi antiureasiche, acidifying agents or alkaline urin e. The iperdiuresi also result in a significant decrease in bacterial concentrat ion per ml of urine, involves a more frequent replacement of the contents of the urinary tract. Moreover, it can induce a lowering of renal medullary hyperosmol arity physiological, thus helping to realize here the best conditions for the st erilization of parenchymal bacterial outbreaks. The change of pH is a measure fi nally essential, particularly in relation to the type of drug used. It is known as the antibacterial action of different antibiotics may vary considerably in re lation to pH of the environment in which these drugs carry out their action.