Urinary Tract Infections (UTIs)

Microbiological Investigation

3MED666 Laboratory 1
Investigation of UTIs
 Predisposing factors
• Sexual activity in females
• Elderly males: prostatic hypertrophy
• Young children with inherited defect, e.g.
vesico-uretic reflux
• Pregnancy
• Catheterisation
• Surgery, e.g. prostatectomy
• Diabetes mellitus
3MED666 Laboratory 2
Investigation of UTIs
Genito-Urinary tract

3MED666 Laboratory 3
Investigation of UTIs
Human kidney

3MED666 Laboratory 4
Investigation of UTIs
 Types of UTI
• Non- sexually transmitted!
• Cystitis: inflammation of bladder wall;
accompanied by dysuria and frequency
• Cystitis is much the commonest,
discomforting but not serious
• Upper tract infections, e.g. pyelonephritis,
are much more serious
• Accompanied by fever and risk of
complications
3MED666 Laboratory 5
Investigation of UTIs
 Causative agents: mainly faecal bacteria

• COMMUNITY - • HOSPITAL –
ACQUIRED ACQUIRED
• Escherichia coli • Pseudomonas
• Proteus mirabilis aeruginosa
• Klebsiella • Candida albicans
pneumoniae • AND
• Enterococcus faecalis Mycobacterium
• Staphylococcus tuberculosis (renal TB
species – will be a ‘sterile
pyuria’

3MED666 Laboratory 6
Investigation of UTIs
 Investigation: the specimen
• Mid-stream Urine (MSU) is the specimen
of choice
• Suprapubic urine
• Catheter urine
• In all cases, urine must be examined
immediately or stored at 4oC
• Contamination of urine is a big problem!!

3MED666 Laboratory 7
Investigation of UTIs
 Standard procedures
• Investigation of UTI involves the detection
of bacteriuria together with evidence of an
inflammatory response
• Microscopy for pyuria and haematuria (can
also reveal other structures, e.g. crystals,
other cells, casts
• Culture for detection of bacteria
• Sensitivity testing to advise on antibiotic
treatment
3MED666 Laboratory 8
Investigation of UTIs
 Microscopy
• Not always performed as it is time
consuming
• The finding of a rise in WBCs (pyuria)
should be linked to a bacteriuria
• May also see RBCs (haematuria); this is
potentially an important finding
• Microtitre plate and an inverted
microscope enables many urines to be
simply screened
3MED666 Laboratory 9
Investigation of UTIs
 Automation
• Looking for particles suspended in a fluid
• In the same way platelets and white cells
can be automatically estimated in blood,
so, too, can urine be analysed for its
cellular content
• Faster, less labour intensive and reliable

3MED666 Laboratory 10
Investigation of UTIs
 White cells in urine
• In normal state, there is a continuous
secretion of WBCs into urine
• In a UTI caused by bacteria, neutrophils
may be secreted in large numbers
• Labs may report >200/µl (>200 x 103/ml)
and will suggest this as significant pyuria
• Lower numbers: < 103/ml are regarded as
not significant
3MED666 Laboratory 11
Investigation of UTIs
 Culture: procedure
• Cystitis is usually caused by a single
species of bacterium present at >105/ml
• Standard loopful of urine is streaked onto
a selective medium, e.g. CLED
• Typically 1µl
• Incubate overnight and count the colonies
• If a genuine UTI, should see >100
colonies; this = >100 bacteria/µl or >105/ml
3MED666 Laboratory 12
Investigation of UTIs
 Culture: interpretation
• >105/ml of a single species strongly suggests a
UTI
• 104-105/ml of a single species is equivocal –
needs repeat specimen for testing
• <104/ml is regarded as no significant growth
• >1 species in any numbers suggests
contamination
• Catheter and suprapubic urines should be
interpreted differently

3MED666 Laboratory 13
Investigation of UTIs
 Sensitivity testing
• Clinical isolates are tested against antibiotics
that a) are filtered by kidneys and b) are usually
effective against common agents
• Since UTIs are common, drugs should be
cheap!
• Typical course of treatment: 5-7 days orally,
resulting in sterile urine
• Nitrofurantoin, nalidixic acid, trimethoprim,
ampicillin + gentamicin, cephalosporins

3MED666 Laboratory 14
Investigation of UTIs
Antibiotic sensitivities

3MED666 Laboratory 15
Investigation of UTIs