URINARY TRACT INFECTION

HASYIM KASIM

2020
 Introduction
• Urinary tract infection (UTI) is a frequent clinical
problem confronting the physician.
• Any site in the urinary tract may be involved,
including the urethra, prostate, bladder, ureter,
kidney and perinephric space.
• Bacterial infection is most common, but fungi
(primarily yeast), chlamydia, viruses, and
parasites may be responsible in some patients.
 Prevalence of UTI

Ratio
Age group % (male:female)

Neonatal 1 3:2
Preschool 2-3 1:10
School age 1-2 1:30
Reproductive age 2-5 1:50
Elderly 20-30 1:10
Pathogenesis
 Bacterial infections of the UTI
• Cystitis
• Acute pyelonephritis
• Chronic pyelonephritis
• Recurrent urinary tract infections
• Asymptomatic bacteriuria
• Catheter associated UTI
 Other Classification

• Upper UTI = Pyelonephritis

• Lower UTI = Cystitis

• Complicated UTI
• Uncomplicated UTI
 I. Uncomplicated urinary tract infection

• Occurs in individuals with structurally and functionally normal

genitourinary tracts
• Most common bacterial infection that occurs in women, but is
uncommon in men
• May involve the bladder or the kidneys and may be symptomatic
or asymptomatic

II. Complicated urinary tract infection

• As acute or chronic parenchymal infection associated with
a functional or structural urinary tract abnormality
 Underlying factors associated
with ‘complicated’ urinary tract infection

Systemic Conditions
Diabetes mellitus
Papillary necrosis (e.g. analgesic nephropathy)
Immunodeficient states (including immunosuppressive
drug therapy e.g. transplant recipient)

Abnormal drainage of urine

Renal calculi
Obstruction at any site in the urinary tract (extra/intra)
Vesicoureteric reflux
Foreign body in the urinary tract (stent, catheter)
Pregnancy
UTI in men
The diagnosis approach in a patient suspected
of having UTI aims to answer three questions:

1. Is infection present?
2. Does the patient have an upper or lower urinary
tract infection?
3. Is there an anatomic abnormality that
predispose to the development of infection?
1. Symptoms :
• Lower UTI
• Upper UTI

2. Urinalysis
•The presence of  5-10 WBC / high-power field sediment
midstream urine

3. Culture

4. Radiological evaluation
• Ultrasound
• Plain abdominal radiography
• Intravenous urography
• CT scanning
 Clinical features of acute lower and
upper urinary tract infection in adult

Lower UTI Upper UTI

Dysuria Systemically unwell
Frequency Fever – rigors
Suprapubic pain Loin pain and tenderness
Malodorous urine Nausea and vomiting
Haematuria Hypotension and shock
Normal temperature Features of lower urinary
tract infection
 Cystitis

1.Typical symptom are dysuria, frequency, and urgency.

2.Onset is abrupt
3.Lower abdomen heaviness and/or lower back pain may
be present
4.Urine may be turbid, sometimes foul smelling.
5.Occasionally, it shows a bloody tinge or its frankly
bloody
 Acute pyelonephritis

1. Syndrome that consists of localized flank or

back pain combined with systemic symptoms
(fever, chills, and prostration)

2.Caused by infection of the renal parenchyma

and collecting system

3.Often complicated by bacteremia

 Chronic pyelonephritis

1. Cannot be defined in terms of a clinical syndrome.

2. It refers to a spesific pathologic appearance of the kidney.
3. Occurs as a result of recurrent UTIs: progressive inflammation
of the renal interstitium and tubules.
4. This pathology is not specific and is commonly found in association
with other renal diseases, such as chronic obstruction, uric acid
nephropathy, analgesec abuse, and hypokalemic nephropathy.

To avoid the implication that chronic pyelonephritis indicates

infection, many authors suggest that the term chronic interstitial
nephritis be used to describe this pathologic condition of the kidneys.
 Urinalysis

• Bacteriuria, pyuria, and in patients with pyelonephritis,

white blood cell cast are the major urinary findings, in UTIs.
• Hematuria also may be present and may on occasion be
macroscopic.
• Bacteria can be identified on an unspun clean catch urine
specimen (preferably a first morning void) or in the urine
sediment, examined either directly or after a gram stain
has been performed.
• Although helpful, examination of the urine for bacteria does
not obviate the need to confirm the diagnosis by urine
culture.
• Pyuria is not, by itself, diagnostic of
urinary tract infection or an indication
for antimicrobial therapy.

however

The absence of pyuria has a high

negative predictive value to exclude
UTI
 Bacteriuria : Presence of bacteria in the urine.

Bacterial etiology of urinary tract infection

 Criteria for diagnosis of significant bacteriuria

Symptomatic women :
•  102 coliform organisms/ml urine plus pyuria, or
•  105 of any pathogenic organism/ml urine, or
• Any growth of a pathogenic organism from urine obtained by
suprapubic aspiration

Symptomatic men :
•  103 pathogenic organism/ml urine

Asymptomatic patients :
•  105 pathogenic organism/ml urine in two consecutive samples
Indication of Radiological evaluation

• All cases of UTI except simple cystitis

in young women
 Treatment
Desired outcome
• Prevent or treat systemic
consequences of infection
• Eradicate the invading organism
• Prevent reoccurrence of infection
 Treatment
Management includes
• Initial evaluation
• Selection of an antibacterial product
• Selection of duration of therapy
Clinical Classification of Urinary Tract Infection

1. Acute uncomplicated cystitis in women

2. Acute uncomplicated pyelonephritis in women
3. Complicated UTI in both sexes
4. Recurrent infections in women
5. Asymptomatic bacteriuria
6. Catheter associated UTI
 Acute uncomplicated cystitis in women

Single dose or 3-day course of treatment

Follow-up urine culture 7-14 days later

Cured Failure or relapse Reinfection

(sterile urine) (identical pathogens) (new pathogen)

Ultrasonography urinary tract

No investigation KUB radiograph

Treatment for 2 weeks

Empiric antibiotics can be prescribed using a
first-line agent for a 3-day course without
further evaluation

• Women younger than 55

• No other comorbidities
• Not postmenopausal
• Not pregnant
• No recent UTI
• No vaginitis or cervicitis symptoms
• Presence of increased urinary frequency
• Presence of dysuria.
 Antimicrobial therapy for
uncomplicated cystitis

Drug of Choice:
• Nitrofurantoin
• TMP-SMX
• Quinolon (Ciprofloxacin, Levofloxacin)

Abbreviations: TMP-SMX, trimethoprim-sulfamethoxazole.

Clinical Classification of Urinary Tract Infection

1. Acute uncomplicated cystitis in women

2. Acute uncomplicated pyelonephritis in women
3. Complicated UTI in both sexes
4. Recurrent infections in women
5. Asymptomatic bacteriuria
6. Catheter associated UTI
Acute uncomplicated pyelonephritis in women

Severe illness
Moderate severity

Outpatients and oral Hospitalization with initial

therapy possible parenteral therapy Urologic evaluation

No resolution
Resolution
No resolution in 5 days
in 5 days
in 5 days

Radiologic evaluation
Treatment 14 days Oral treatment 14 days or
longer as required
 Antimicrobial therapy for
uncomplicated pyelonephritis

Drug of Choice:
• Quinolon (Ciprofloxacin, Levofloxacin)
• TMP-SMX
• Amoxicillin/clavulanate

Abbreviations: TMP-SMX, trimethoprim-sulfamethoxazole.

Clinical Classification of Urinary Tract Infection

1. Acute uncomplicated cystitis in women

2. Acute uncomplicated pyelonephritis in women
3. Complicated UTI in both sexes
4. Recurrent infections in women
5. Asymptomatic bacteriuria
6. Catheter associated UTI
 Complicated UTI in both sexes
Hospitalize, urine culture, blood culture

Empiric therapy with parenteral regimen

Significant clinical improvement

Yes No
5 Days

Switch to or continue Review antimicrobial susceptibility pattern

oral regimen Radiologic & urologic evaluation
For total 2 weeks Correct reversible risk factors

Review treatment plan as appropriate,

treat for total 2 weeks or longers if necessary

Follow-up urine culture after treatment

Clinical Classification of Urinary Tract Infection

1. Acute uncomplicated cystitis in women

2. Acute uncomplicated pyelonephritis in women
3. Complicated UTI in both sexes
4. Recurrent infections in women
5. Asymptomatic bacteriuria
6. Catheter associated UTI
 Recurrent UTI
Reinfection :

Reccurence of bacteriuria with an organism different from that originally isolated.

1. Tend to occur more than 2 weeks after completion of therapy. Response well to therapy,
2. Most likely represent infections of the bladder, occur weeks to months after
treatment of the previous infection, usually associated with a normal urinary tract

Relapse :

Reccurence of bacteriuria with the same organism as originnally isolated.

1. Often recur within 2 weeks after antimicrobials have been discontinued.
2. Usually represent infection of the kidney or prostat.
3. Anatomic abnormalities or renal insuficiency are more common.
4. A long course of antimicrobials or surgery may be required if the urine is to be
permanently sterilized

Reinfection may occur with an organism identical to the original strain,

cannot be distinguished from relapse.
 Recurrent infections in women
Reccurent UTI in women

Relapse Diagnosis Reinfection

Conventional antibiotic ≥ 3  year ≤ 2  year

therapy 2-6 weeks

Sexually active Conventional antibiotic

Postmenopausal therapy 3-7 days

Estrogen substitution
Antibiotic therapy :
(oral & topical)
On demand or
Postcoital or
Longterm prophylaxis
Antibiotic therapy :
On demand or
Longterm prophylaxis
Drug regimens for long-term, low-dose prophylaxis of
recurrent urinary tract infection

Drug Dose*
Nitrofurantoin 50 mg

Trimethoprim 100 mg

Co-trimoxazole 0.24 g

Norfloxacin 200 mg

Ciprofloxacin 125 mg

Cephalexin 125 mg
( useful if renal insufficiency)
Hexamine hippurate 1 g

* Treatment is effective if taken each night, alternate nights, three times a week,
or just after intercourse
Clinical Classification of Urinary Tract Infection

1. Acute uncomplicated cystitis in women

2. Acute uncomplicated pyelonephritis in women
3. Complicated UTI in both sexes
4. Recurrent infections in women
5. Asymptomatic bacteriuria
6. Catheter associated UTI
 Asymptomatic bacteriuria

Significant bacteriuria in a patients without

symptoms attributable to the urinary tract.
 Indication for the treatment of patients with
asymptomatic bacteriuria

Definitive Possible Not indicated

Pregnancy Diabetes mellitus Elderly

Before an invasive Short-term School girls and

genitourinary procedure indwelling premanopausal women
catheterization

Intermittent Children with reflux

catheterization
Renal transplant Long-term indwelling Patients with abnormal
catheter urinary tract
Clinical Classification of Urinary Tract Infection

1. Acute uncomplicated cystitis in women

2. Acute uncomplicated pyelonephritis in women
3. Complicated UTI in both sexes
4. Recurrent infections in women
5. Asymptomatic bacteriuria
6. Catheter associated UTI
• Prevention of bacteriuria: keep the closed catheter
system closed and remove the catheter as soon as
possible.
• Irrigation of the catheter and bladder with antibacterial
solutions has not curtailed bacteriuria.
• Asymptomatic bacteriuria need not be treated as long as
catheter short term or long-term, remains in place.
EXCEPTIONS :
1. For patients who may be at high risk of serious
complications (e.g. granulocytopenic patients, solid
organ transplant patients, and pregnant women)
2. Patients undergoing urologic surgery
• In case of symptomatic catheter
associated UTI it may be reasonable to
replace or remove the catheter before

• Starting antimicrobial therapy if the

indwelling catheter has been in place for
more than 7 days
T H A N K
Y O U