❖ Sulfonamides: safe in early pregnancy however in near
URINARY TRACT term it can interfere with protein binding bilirubin that
INFECTION
Course Outline
UTI DURING PREGNANCY
ASSESSMENT FOR PREGNANT WOMEN WITH UTI
THERAPEUTIC MANAGEMENT FOR UTI PREGNANCY
UTI DURING PREGNANCY
4% to 10% of nonpregnant women have asymptomatic
bacteriuria. In pregnant women, because of progesterone,
stasis of urine can occur. There is also minimal presence of
glycosuria that also occurs with pregnancy provides an ideal
medium for growth of any organism present.
Asymptomatic infections are potentially dangerous because
they can progress to the kidneys [pyelonephritis] and are
associated with preterm labor and premature ruptured of
membrane. Women with vesicoureteral reflux can develop UTIs
or pyelonephritis.
Escherichia coli are bacteria that is responsible for UTI that is an
ascending infection, while descending infection can also occur.
It begins in the kidneys from the filtration of organisms present
from other body infections.
If streptococcus B is detected, vaginal cultures should be
obtained because it is associated with pneumonia in newborns.
ASSESSMENT FOR PREGNANT WOMEN WITH UTI
 Frequent urine and dysuria.
 Pain in lumbar region especially on the right side that
radiates downward [pyelonephritis].
 The RLR is tender to palpate.
 May have accompanying nausea and vomiting, malaise,
pain, and frequency of urination.
 Temperature may be slightly elevated or 39 degrees to 40
degree Celsius.
 Infection is usually on the right because there’s greater
compression & urinary stasis on the right ureter from the
uterus being pushed that way by the large bulk of
intestine on the left side.
 Urine culture: over 100,000 organisms per milliliter of
urine.
THERAPEUTIC MANAGEMENT
❖ Urine culture and sensitivity
❖ Antibiotics: amoxicillin, ampicillin, and cephalosporins
leads to hyperbilirubinemia.
❖ Tetracyclines: contraindicated because it can cause bone
growth retardation and staining of deciduous teeth.
❖ Promote increased amount of fluid [3 to 4L/day] to flush
out infection.
❖ Promote urine drainage by knee-chest position for 15
minutes morning & evening,
❖ Pyelonephritis: 24-48 hours IV antibiotics, nitrofurantoin
for the remainder of her pregnancy, ascorbic acid.
❖ After birth UTI. Ultrasound to detect urinary tract
abnormality such as vesicoureteral reflux to prevent
future infections.
BACKGROUND
Urinary tract infection is common and painful human illness
that is responsive to modern antibiotic therapy. The most
common manifestation of UTI is acute cystitis because it is
more prevalent among women.
DEFINITIONS OF UTI
UTI may be asymptomatic [subclinical infection] or
symptomatic [disease].
▪ Asymptomatic bacteriuria [ASB] occurs in the absence
of symptoms and usually does not require treatment.
▪ Cystitis – symptomatic infection of the bladder.
▪ Urethritis – inflammation of ureter.
▪ Pyelonephritis – symptomatic infection of the kidneys.
▪ Uncomplicated urinary tract infection – acute cystitis
or pyelonephritis without anatomic abnormalities or
instrumentation of urinary tract.
▪ Complicated UTI – encompasses all other types of UTI
▪ Recurrent UTI – not necessarily complicated; individual
episodes and can be uncomplicated and treated as
such.
▪ Catheter-associated bacteriuria
RISK FACTORS
(1) Females
(2) Neonatal period: males are slightly high risk
(3) Male after 50: prostatic hypertrophy
(4) Recent use of diaphragm with spermicide
(5) Frequent coitus
(6) History UTI
(7) Postmenopausal: sexual activity, DM, incontinence,
history of premenopausal, anatomic factors affecting
bladder emptying, cystoceles, residual urine
 (8) White premenopausal: frequent sex, use of
spermicide, new sexual partner, first UTI before 15
y/o, maternal history of UTI
(9) Urinary obstruction
(10) Lack of circumcision in men
(11) Increase use of insulin and chronic diabetes
(12) Impaired cytokine
(13) Sodium-glucose co transporter 2 inhibitors = glycosuria
ETIOLOGY
ACUTE UNCOMPLICATED CYSTITIS & UNCOMPLICATED
PYELONEPHRITIS
- E. coli accounts 50%-70%
- Staphylococcus saprophyticus 5%-15%
- Klebsiella, Proteus, Enterococcus, and Citrobacter 5%-
10%
COMPLICATED UTI [e.g. CAUTI]
- E. coli is predominant
- Gram-positive bacteria and yeasts are also important
pathogens in complicated UTI.
- Gram negative rods such as Pseudomonas aeruginosa
& Klebsiella, Proteus, Citrobacter, Acinetobacter, and
Morganella are frequently isolated.
There is an increases resistance of E. coli to antibiotics
commonly used to treat UTI.
Resistance Rates:
 trimethoprim-sulfamethoxazole (TMP-SMX) >20%
 ciprofloxacin >10%
PATHOGENESIS
In the majority of UTIs, bacteria establish infection by
ascending from the urethra to the bladder.
Abnormal micturition and significant residual urine volume
promote infection. Anything that increases the likelihood of the
bacteria in entering and staying the bladder increases the risk
of UTI.
Bacteria can gain access to the urinary tract through the blood
stream. Hematogenous infections may produce focal abscesses
or areas of pyelonephritis within kidney and result in positive
urine cultures.
ENVIRONMENTAL FACTORS
Vaginal Ecology. Vaginal colonization with E. coli increases the
risk of UTI. Nonoxynol-9 in spermicide is toxic to the normal
vaginal lactobacilli that makes increases the risk for E. coli
vaginal colonization and bacteriuria.
Anatomic and Functional Abnormalities. Any condition that
allows urinary stasis or obstruction predisposes the individual
to UTI. Stones or urinary catheters provide an inert surface for
colonization and formation of bacteria. Vesicoureteral reflux,
ureteral obstruction secondary to prostatic hypertrophy,
neurogenic bladder, and urinary diversion surgery create an
environment favorable to UTI. Inhibition of ureteral peristalsis
and decreased ureteral tone leading to vesicoureteral reflux.
the distance of the urethra from the anus—are considered to
be the primary reason why UTI is predominantly an illness of
young women rather than of young men.
MICROBIAL FACTORS
Anatomically normal urinary tract presents a stronger barrier to
infection than a compromised urinary tract. E. coli that causes
invasive symptomatic infection of the urinary tract. P fimbriae,
hair-like protein structures that interact with specific receptor
on renal epithelial cells. It is an important in the pathogenesis
of pyelonephritis and subsequent bloodstream invasion from
the kidney. Type 1 pilus (fimbria), which all E. coli strains
possess but not all E. coli strains express. These are thought to
play a key role in initiating E. coli bladder infection.
CLINICAL SYNDROMES
ASYMPTOMATIC BACTERIURIA
- The patient does not manifest any local or systemic
symptoms. Usually bacteriuria detected incidentally
when patient undergoes screening urine culture.
Systemic s/s such as fever, altered mental status,
leukocytosis of positive urine culture doesn’t merit the
diagnosis of symptomatic UTI unless potential
etiologies have been considered.
CYSTITIS
- Typical symptoms are dysuria, urinary frequency, and
urgency, nocturia, hesitancy, suprapubic discomfort,
gross hematuria, unilateral back or flank pain and
fever.
- Fever is an indication of invasive infection of kidney or
prostate.
PYELONEPHRITIS
- Mild pyelonephritis: low-grade fever with/without
lower-back or costovertebral-angle pain
- Severe Pyelonephritis: high fever, rigors, nausea,
vomiting, flank pain, loin pain.
- Fever is the main feature distinguishing cystitis from
pyelonephritis. The fever of pyelonephritis typically
exhibits a high spiking pattern and resolves over 72h of
therapy.
- Papillary necrosis may also be evident in some cases of
pyelonephritis complicated by obstruction, sickle cell
disease, analgesic nephropathy, or combinations of
these conditions. Rapid rise in creatinine may be the
first indication of condition in some rare cases.
- Emphysematous Pyelonephritis: severe for associated
with production of gas in renal and perinephric tissues.
Occurs almost exclusively in diabetic pt.
COMPLICATED UTI
DIAGNOSTIC TOOLS
- Xanthogranulomatous Pyelonephritis occurs when
chronic urinary obstruction together with chronic
infection leads to destruction of renal tissue.
PROSTITIS
- Infectious and noninfectious abnormalities of the
prostate gland.
- Acute bacterial prostatitis presents as dysuria,
frequency, and pain in the prostatic pelvic or perineal
area. Fever and chills are usually present, and
symptoms of bladder outlet obstruction are common.
- Chronic bacterial prostatitis presents recurrent
episodes of cystitis and sometime associated with
pelvic and perineal pain.
- Symptomatic episode of cystitis or pyelonephritis in pt
with an anatomic predisposition to infection, with
foreign body in the urinary tract, or predisposing
factors that is delayed response to therapy.
(I) History
- One symptom of UTI (dysuria, frequency, hematuria,
or back pain) and without complicating factors, the
probability of acute cystitis or pyelonephritis is 50%.
- A combination of dysuria and urinary frequency in the
absence of vaginal discharge increases the probability
of UTI to 96%
- Significant concerns: STD [caused by Chlamydia
trachomatis], may be inappropriately treated as UTI.
Differential dx to be considered when women present
with dysuria includes cervicitis, vaginitis, herpetic
urethritis, interstitial cystitis, and noninfectious vaginal
or vulvar irritation.
- Pt with more than one sexual partner and inconsistent
use of condom are at high risk for both UTI & STD.
(II) URINE DIPSTICK, URINALYSIS, AND URINE
CULTURE
- If a woman with acute cystitis is forcing fluids and
voiding frequently, the dipstick test for nitrite is less
likely to be positive, even when E. coli is present.
- Urine dipstick test can confirm the diagnosis of
uncomplicated cystitis in a patient with a reasonably
high pretest prob ability of this disease. Blood in the
urine may suggest dx of UTI.
- Negative dipstick test is not sufficiently sensitive to
rule out bacteriuria in pregnant women, in whom it is
important to detect all episodes of bacteriuria.
- Urine microscopy reveals pyuria in nearly all cases of
cystitis and hematuria. Counts of bacteria are less
accurate than are counts of RBC & WBC.
 - Detection of bacteria in urine culture is diagnostic gold
standard of UTI, culture results don’t become available
until 24h after the patient’s presentation.
DIAGNOSTIC APPROACH
UNCOMPLICATED CYSTITIS IN WOMEN
 If reliable history can’t be obtained, then perform
urine dipstick test is a must.
 Negative dipstick result: urine culture, close clinical
follow up, and pelvic exam is recommended.
COMPLICATED UTI
 Urine culture is warranted
CYSTITIS IN MEN
 Urinalysis
 Ultrasound when pt is febrile with elevated serum
level of prostate-specific antigen and enlarged
prostate & seminal vesicles on ultrasound.
 Surgical: febrile UTI, urinary retention, early
recurrence of UTI, hematuria, voiding difficulties.
 First febrile UTI perform CT or ultrasound
ASYMPTOMATIC BACTERIURIA
 Absence of signs and symptoms referable to UTI.
URINARY TRACT INFECTIONS TREATMENT
Antimicrobial therapy is warranted for any UTI that is truly
symptomatic.
UNCOMPLICATED CYSTITIS (WOMEN)
 TMP-SMX is the first-line agent for treatment.
 Note for collateral damage
 Minimal effect on fecal flora: pivmecillinam,
Fosfomycin, and nitrofurantoin.
 Second line agent: B-lactam but it fails to eradicate
uropathogens from vaginal reservoir.
 Urinary analgesics [phenazopyridine] speed resolution
of bladder discomfort but can cause significant nausea.
 The downside is that women who really do have
cystitis endure discomfort for a longer period and may
meanwhile progress to pyelonephritis.
PYELONEPHRITIS
 Acute uncomplicated pyelonephritis: fluoroquinolones
orally or parenterally
 Combinations of B-lactam and B-lactamase inhibitors
or carbapenem are used in pt with more complicated
hx, previous episodes of pyelonephritis, antimicrobial
resistance, recent UT manipulations.
UTI IN PREGNANT WOMEN
 Nitrofurantoin, ampicillin, and cephalosporins
 Sulfonamides: avoided due to teratogenic effect and
possible role in the development of kernicterus.
 Fluoroquinolones are avoided d/t adverse effect on
fetal cartilage development.
 Pregnant ASB: 4-7 days single dose therapy
 Overt pyelonephritis: parenteral B-lactam therapy with
or without aminoglycosides.
UTI IN MEN
 7 to 14 days of TMX-SMP / fluoroquinolone is
recommended.
 Chronic bacterial prostatitis: 4- to 6- week course of
antibiotics.
 Recurrences: 12-week course of treatment
COMPLICATED UTI
 Xanthogranulomatous pyelonephritis: nephrectomy
 Emphysematous pyelonephritis: percutaneous
drainage and can be followed by elective nephrectomy
prn.
 Papillary necrosis with obstruction required
intervention that relieves obstruction & preserve renal
function.
ASYMPTOMATIC BACTERIURIA
 Do not warrant antimicrobial therapy.
CATHETER-ASSOCIATED UTI
 Remove biofilm-associated organisms that could serve
as nidus for reinfection. Long term catheters have
occult pyelonephritis.
 7-14 days of antibiotics
 Best strategy: intermittent catheterization or avoid
insertion of unnecessary catheters & to remove
catheters once they are no longer necessary.
CANDIDURIA
 Fluconazole 200-400mg for 7-14 days is the first line
regimen for Candida infection.
 For Candida isolates with high levels of resistance to
fluconazole, oral flucytosine and/ or parenteral
amphotericin B are options.
PREVENTION OF RECCURENT UTI (WOMEN)
A preventive strategy is indicated if recurrent UTIs are
interfering with patient’s lifestyle.

Three prophylactic strategies: continuous, postcoital, and

patient-initiated therapy.

Nonmicrobial prevention: lactobacillus probiotics and cranberry

products

PROGNOSIS

Cystitis is risk factor for recurrent cystitis and pyelonephritis,

ASB is common among elderly & catheterized pt but doesn’t
increase risk of death. The absence of anatomic abnormalities
such as reflux, recurrent infection in children & adults doesn’t
lead to chronic pyelonephritis or renal failure.

Infection doesn’t play a primary role in chronic interstitial

nephritis; primary etiologies are analgesic abuse, obstruction,
reflux, and toxin exposure. In renal abnormalities, infection as
secondary factor can accelerate parenchymal damage. In spinal
cord-injuries, indwelling bladder catheter is risk for bladder
cancer. Chronic bacteriuria = chronic inflammation.