UROGENITAL TRACT INFECTIONS

Anatomy of the region & host defenses Lactobacilli Asymptomatic Bacteriuria moreota definition
q uantitative
• Anterior urethra, vagina à only areas colonized • In addition to GU tract: mouth, intestines, stomach • Relatively common finding
• Other structure (including uterus) à sterile unless there is a • Gram positive rods, non-spore forming • Present in ~5% of unselected medical outpatients, 10%
disease or an anatomic abnormality • Facultative or strict anaerobes, produce lactic acidKantolerate pregnant patients at term, also in hypertensive and diabetic
• High volume urinary flow “flushing” (low residual volume), • Rarely cause UTIs à do not grow in urine well patients
oxygen
lining of bladder, exfoliation of uroepithelial cells, structures • Anatomic obstruction increases incidence
prevent backflow • Nearly all patients with indwelling catheter with open
• Protective components drainage for more than 48 hrs
o Antimicrobial properties of urine (high urea Recurrent UTIs
concentration, immunoglobulins, etc.) • 3 or more UTIs within a 12 month period
o Presence of normal microbiota • Relapse
Differentiating Upper and Lower UT disease: UTI Risk Factors • Re-infection
• Gender (female) • New infection
• Recent sexual intercourse (abrasions, etc) • Predisposing factors
• Recent use of a diaphragm with spermicide • 20-25% women with acute/uncomplicated cystitis have 2 or
systemic more infections/year
• History of recurrent infection
• Urinary catheter • Often re-infection occurs with different E.coli strain
• Diabetics Uncomplicated vs. complicated UTI
• History of long-term antibiotic use Uncomplicated UTI
• Lifestyle & behavioral practices • No specific pre-dispoing factors
caankpain Ascending vs Descending UTIs • No structural abnormalities, etc.
Epidemiology of UTIs • Descending is far less common • ~95% monomicrobial
• Serious health problem affecting millions of people each year • Asending à microorganisms may travel from urethra à Complicated UTI
• 2nd most common type of infection in the body bladder à kidney • Predisposing anatomic, functional, or metabolic abnormalities
rectum urethra
• 10 million doctor visits in the US alone/year, 2-3million ED UTI Clinical Presentation • Requires more aggressive evaluation and follow up
visits/year (US 2007) • Often polymicrobial
• Symptomless in some
• Antimicrobials for UTIs: 15% of all outpatient rx’s Etiology varies between complicated & uncomplicated UTIs
• Frequent urge to urinate
• Annual health care cost & missed work is ~3.5 billion

Aff
• Painful, burning sensation during urination riskeadorsaruncomplica
• Women: 20-40% develop during lifetime shorter urethra • General malaise and pain otherwise areditarent
complicated
• Men: less common; can be very serious when occurs canada
• Pressure, fullness, pain in lower abdomen
• USA: women that develop a UTI: 20% will have recurrence
• Cloudy, blood-tinged urine; strong odor
• Women with > UTIs: increased risk of recurrence
• Fever would indicate pyelonephritis! e.com e.co
• UTIs in children: more common in those under age of 2
• Pregnant women with UTIs: untreated – increased risk of
delivering low birth weight/premature infants
o Smooth muscle relaxation
o Urethral dilation Role of Catheterization
o Greater chance to progress to pyelonephritis • UT: most common site of healthcare-associated infection,
accounting for more than 40% of the total #
Normal microflora
• Most (66%-86%) follow instrumentation of the urinary tract,
• Urethra
mainly urinary catheterization
o Lactobacilli
• UTI: not only complication of long-term urinary
o Streptococci
catheterization
o Coagulase-negative Staphylococci
o Obstruction à bacterial glycocalyx (biofilm) easierargro
• Vagina:
o Encourages formation of encrustations and infection
o More diverse, influenced by hormones
stones consisting of urea, other complex substances
o Newborn girls à colonized with lactobacilli, vaginal flora
o Local infections (urethritis, periurethral abscess,
becomes more diverse over time
epididymitis, and prostatitis)
o Lactobacilli à become more prominent at puberty
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cpostmenopausal moremixedflora

Differentiating between the clinical syndromes
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Pathogens associated with Cystitis and
pyelonephritis
UROGENITAL TRACT INFECTIONS
UTI Responsible Microbes: Pathogenesis Host defense
• Serotypes E. coli ~85% of community-acquired, ~50% of • Urine flow and cell exfoliation
hospital acquired UTIs • Innate and adaptive immune responses
• Virulence factors contributing to UTIs: • Within the lumen of the bladder
o Adhesins (pili, fimbriae, etc.) attachmentadhesion o Antimicrobial peptides
o IgA proteaseslysis immunoglobulins
a
o Hemolysins (get cytokine release, inflammation) vialysis
o Competition with iron-sequestering proteins
o Tamm-Horsfall proteinindirectlypreventattachmentote
o Ureases (i.e. P. mirabilis) otros § Binds specifically to type 1 fimbriated E. coli
o Siderophore expression ironacauisition § Key urinary anti-adherence factor serving to
o Factors promoting colonization and movement prevent type 1 fimbriated E. coli from binging to
• Primary cause of UTIs: the urothelial receptors
o UPEC (Uropathogenic E. coli) (p234)
• Gram negative rods, normal habitat is GI tract of humans
and animals O
• Specific virulence targeted therapies
• Pathogens: distinguished by acquired genes (iron
acquisition, siderophores) à virulence -distinct UPEC
associated biosynthetic pathways
00
Uropathogenic E. coli (UPEC)
• Key virulence features:
o Type I pili (cystitis)
o P pilli (pyelonephritis)
• Additionally:
o a-hemolysincytotoxic
o siderophorecinnacquisition UTI: Other Etiologies
o pathogenicity islands Organisms predominantly responsible for remaining UTIs
O-serogroups~75% of isolates reside within only 6 of the 200 (~15% community-acquired, ~50% of hospital-acquired)
• Staphylococcus saprophyticus (p,180,185-6)
• Proteus mirabilis (p270)
• Klebsiella species (p269)
• Mycoplasma and Ureaplasma (p364-7)
• Candida (p675-83)
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 UROGENITAL TRACT INFECTIONS
Staphylococcus saprophyticus Summary of key characteristics of bacteria most
• Cause of UTIs (usually young, sexually active women) – associated with UTIs:
“honeymoon cystitis”
• Infrequent asymptomatic colonizer of UT
honeymoons
• Infections have been on the increase
weddings
• Shows seasonality (tends to occur in summer)
• Whole genome sequencing, comparative analysis –
uropathogenicity due to:
o Novel cell-wall anchored adhesin
o Redundant uro-adaptive transport systems
o Urease

Proteus mirabilis
• Virulence factors: Interpretation of Urinalysis data
o Proteases
o Hemolysins
o Biofilm formation
o Urease production
• Urine à smells like ammonia, toxic to kidneys
(alkaline à urine struvite crystals)
E coli urease
Diagnosis of UTIs
• Clean catch urine specimen (unspun, midstream)
• White and red blood cells, bacteria
• Culture and sensitivity tests
• ~20% of patients with UTIs do not have pyuria
• No simple test to distinguish between upper from
lower UTIs Other clinical outcomes:
• Abbreviated work-ups common (no culture, follow-up)
o Leukocyte-esterase test
• Prostatitis: spectrum of disorders, some
o Nitrates à nitrites infections (E. coli most common)
o UTI symptoms in the presence of leukocytes are o Acute bacterial prostatitis is most serious
considered adequate to make a diagnosis of UTI but least common (chronic more common)
• Urine cultures with 105 CFUs have defined infection o Reflux of urine from urethra into prostate
• 102 CFUs in symptomatic women yields accurate
ducts
diagnosis
• Epididymitis: microorganisms can enter from
dipstick
prostate via ejaculatory duct:
o Pathogens vary in younger men vs. older
o Predisposing factors include prostatitis,
calometric
indwelling urinary catheters, urologic surg.
*Can be side effects as a result of STIs
Image on the R à WBCs seen under microscope of urine Stella Yun
 UROGENITAL TRACT INFECTIONS
Vaginitis BV Diagnosis using Amsel Criteria

ex
• Bacterial vaginosis (BV), Vulvovaginal Candidiasis
(VVC), Trichomoniasis
• Usually characterized by
o Vaginal discharge
o Vulvar itching
o Irritation
o Odor
• Common types
o Bacterial vaginosis (40-45%)
o Vulvovaginal candidiasis (20-25%)
o Trichomoniasis (15-20%) STI Wet Prep: Bacterial Vaginosis
Bacterial Vaginosis / Vaginitis Clue cells (epithelial cells covered with small
• Normal balance of bacteria in vagina is disrupted – Gram negative/Gram variable rods)
replaced by certain overgrowth
o Sometimes accompanied by discharge Summary Table – Vaginitis Differentiation
(unpleasant odor, may be thin, white or gray)
o Pain, itching, or burning outside vagina
• Most women report no signs/symptoms
• BV: most common vaginal infection in childbearing
aged women (sexual activity?)
• Having BV can increase HIV transmission
• Examining the vaginal discharge under the Other diagnostic tools:
microscope can help distinguish BV from
Candidiasis and Trichomonas • Vaginal gram stain (Nugent criteria)
• A sign of BV: unusual vaginal cell called a “clue cell” o Should normally show lactobacilli
• Women with BV (polymicrobial) have fewer than o Mixed flora with absent/low lactobacilli
normal vaginal lactobacilli indicates BV
• Vaginal pH > 4.5 à can be suggestive of BV • DNA probe
Clinical presentation
• Newer diagnostic modalities include:
o Proline aminopeptidase (PIP) activity test
card
o Sialidase tests

“Clue cells” à diagnosis

of
adherence

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Stella Yun
 UROGENITAL TRACT INFECTIONS
Defining Sex: What is it?
Candida albicans: Characteristics vaginitis Urogenital Tract Infections: UTIs vs
• Have to be EXPLICIT in taking history and make sure you know what patients
• Oval, yeasts
• Primary site of colonization is GI tract STIs are discussing
• Normal microflora • Have to be EXPLICIT with your patients as far as prevention, behaviors that
• Commensals: lead to increased risk of STIs, explanation of outcomes and treatment
o Vagina Note: importance of taking a thorough sexual history
o Urethra
o Skin, under the nails
Source of infection à patient
• ~75% of adult women à at least one episode
• ~50% having two or more episodes (weakened immune
system, more frequent & severe)
• Most cases caused by C. albicans (85%-90%)
• Second most common cause of vaginitis, estimated costs of 1
billion annually in the US
• Occurrence rare in men
• Other conditions that may put a woman at risk for genital
candidiasis: Overall Importance of STIs extends beyond immediate infection:
o Pregnancy • Some (HSV2 and syphilis) can increase risk of HIV acquisition
o Diabetes mellitus • Some can have serious reproductive health consequences
o Use of broad-spectrum antibiotics o Infertility following PID
o Corticosteroid medications o Gonococcal ophthalmia (mother-to-child transmission)
Diagnosis of Vulvo vaginal Candidiasis • Drug resistance, especially for gonorrhea, is a major threat to reducing the
• 10% KOH or saline wet prep: pseudohyphae and/or budding impact of STIs worldwide
yeast (conidia) STIs:
• pH: normal range 4.0-4.5 • Affect both sexes, all socio-economic groups
• if pH >4.5: concurrent BV or trichomoniasis • Disproportionately affect:
• cultures are not useful for routine diagnosis: can’t distinguish o Women, infants of infected mothers
normal colonization from significant infection o Adolescents and young adults
• consider patient history, signs, and symptoms o Certain ethnic/racial groups
o 115-24 year olds represent ¼ of the sexually active population à nearly
½ of all new STDs

Clinical manifestations of Candidiasis

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Stella Yun