Urinary Tract

Infections
Introduction
UTI: presence of organisms in the urinary
tract together with symptoms and signs of
inflammation.
UTI accounts for about one-third of
hospital-acquired infections.
E.coli major pathogen.
Symptoms - variable: Many are
asymptomatic, some present atypically
(children, elderly)
Definitions
Significant bacteriuria: presence of at
least 1,00,000 bacteria/mL of urine.
Asymptomatic bacteriuria: significant in
the absence of symptoms in the patient.
Cystitis: syndrome of frequency, dysuria
and urgency, which usually suggests
infection restricted to LUT (bladder,
urethra).
Urethral syndrome: syndrome of
frequency & dysuria in the absence of
significant bacteriuria with a conventional
pathogen.
 Acute pyelonephritis: acute infection of one
or both kidneys. LUT is usually involved.
 Chronic pyelonephritis: either continuous
excretion of bacteria from kidney; or frequent
recurring infection of the renal tissue; or to a
particular type of pathology of the kidney
seen microscopically or by radiographic
imaging, which may or may not be due to
infection.
 Relapse: recurrence caused by the same
organism that caused the original infection.
 Reinfection: recurrence caused by a different
organism, hence a new infection.
Epidemiology
Babies & Infants
Infants up to age 6 months

Symptomatic UTI – prevalence 2/1000

Asymptomatic UTI – 2%
Common in Boys than Girls.
Children
In preschool children: sex ratio reverses –
prevalence of bacteriuria in girls: 4.5%;
boys: 0.5%.
In older children: girls – 1.2%; boys –
0.03%.
3-5% of girls and 1-2% of boys will
experience a symptomatic UTI during
childhood.
In girls 2/3rd of UTIs are asymptomatic.
Occurrence of bacteriuria during childhood
appears to lead to a higher incidence of
bacteriuria in adulthood.
Adults
In women – prevalence of bacteriuria: 3-
5%
About one in eight adult women has
symptomatic UTI each year.
20% recurrent, with peak age incidence in
the early 20s.
Uncommon in healthy young men, with
0.5% of adult men having bacteriuria.
The rate of symptomatic UTI in men rises
progressively with age, from 1% annually
at age 18 to 4% at age 60.
Elderly
20% among women and 10% among
men.
In hospital: urinary catheterization.
Etiology and Risk factors
Acute uncomplicated: E.coli; 80% of infections
Other 20%:
Gram negative: Klebsiella, Proteus species
Gram positive: cocci- enterococci,
staphylococcus
saprophyticus (in young, sexually active
women)
Associated with structural abnormality:
congenital anomalies, neurogenic bladder and
obstructive uropathy: Pseudomonas
aeruginosa, enterobacter, serratia species.
Hospital-acquired infections, including
catheterization
Rare: anaerobic bacteria and fungi, UT
tuberculosis.
Pathogenesis

 3 possible routes:
 the ascending: most common
 blood-borne: spread to kidney in bacteraemic illness
(Staphylococcus aureus septicaemia)
 lymphatic : rare.

 In women: UTI is preceded by

colonization of the vagina, perineum,
periurethral area by the pathogen,
ascends into bladder via urethra.
 Uropathogens colonize the urethral
opening of men and women.
Preponderance of UTI in female: urethra is
shorter and urethral meatus is closer to
the anus.
Sexual intercourse is important in forcing
bacteria into female bladder.
Riskincreased by use of diaphragms and
spermicides.
Circumcision reduces the risk in male
child.
The organism
E.coli- few serotypes are responsible for
UTI.
Some strains possess certain virulence
factors that enhance their ability to cause
infection, specially upper UT.
The Host
High urea concentration, extremes of
osmolality and pH inhibit the growth.
Defence mechanisms: flushing mechanism
of bladder emptying, glucosaminoglycan
present on bladder mucosal surface is
intrinsically resistant to bacterial adherence.
When bladder is infected, WBCs are
mobilized to the bladder surface to ingest
and destroy the bacteria.
Abnormalities of the UT
Structural abnormality leading to
obstruction of urinary flow increases the
infection.
Congenital anomalies of ureter/urethra,
renal stones and enlargement of prostate.
Renal stones: Proteus and Klebsiella
species.
Vesicoureteric reflux (VUR): caused by
failure of physiological valves at the
junction of ureters and the bladder, which
allows urine to reflux towards to kidneys
when the bladder contracts.
Diminished ability to empty the bladder
may be due to spinal cord injury.
Clinical manifestations

Most of UTIs are asymptomatic.

Symptoms mainly as a result of irritation
of bladder and urethral mucosa.
Clinical features are variable and depend
on age.
Babies & infants
Often overlooked or misdiagnosed.

Common: non-specific symptoms – failure

to thrive, vomiting, fever, diarrhea and
apathy.
Major risk factor for the development of
renal scarring, which causes future
complications like chronic pyelonephritis,
hypertension, renal failure in adulthood.
Children:
Above age of 2: classic symptoms –
frequency, dysuria, haematuria.
Acute abdominal pain, vomiting also
present.
Adults
Typical symptoms of lower UTI: frequency,
dysuria, urgency and haematuria.
Acute pyelonephritis: fever, rigors, loin
pain in addition to lower tract symptoms.
Chlamydia trachomatis, Neisseria
gonorrheae, mycoplasmas or other
organisms.
Urinary Tuberculosis
Non-infectious origin – menopausal
estrogen deficiency or allergy.
Respond to standard antibiotic therapy.
Elderly
Mostly asymptomatic, or symptoms are
not diagnostic because common in elderly
people.
Non-specific symptoms like falls and
confusion or infection may be the cause of
deterioration in pre-existing conditions
(DM, CCF)
UTI is one of the most frequent causes of
hospital admission among elderly.
Investigation
Identification and quantification
Most reliable method of diagnosing UTI is
by quantitative urine culture.
Midstream urine sample (MSU) is used.
Pour-plate technique: Most accurate. But,
unsuitable for a high-volume laboratory
because it is expensive and time-
consuming.
The streak-plate method: Using a
calibrated-loop technique to streak a fixed
amount of urine on an agar plate. Simple
to perform and less costly.
Susceptibility of the organism
Knowledge of bacterial susceptibility and
achievable urine concentration of the
antibiotics puts the clinician in a better
position to select an appropriate agent for
treatment
Management
The goals of UTI treatments:
(i) To prevent or to treat systemic
consequences of infection,
(ii) To eradicate the invading organism(s),
(iii) To prevent the recurrence of infection.
Management UTI includes: initial
evaluation, selection of an antibacterial
agent and duration of therapy and follow
up evaluation.
The selection of antimicrobial agent is
based on the severity of the presenting
signs and symptoms, the site of infection
and whether the infection is determined to
be uncomplicated/complicated.
Others: antibiotic susceptibility, side-
effect potential, cost and the comparative
inconvenience of different therapies.
Pharmacologic factors: to achieve conc in
the urine, rate and extent of excretion
through the kidney, GFR (depends on the
molecular size and degree of protein
binding of the agent.)
Sulfonamides, tetracyclines,
aminoglycosides enter the urine via
filtration.
β-lactam agents, quinolones are filtered
and are secreted into the urine and
achieve high urinary concentrations
despite unfavorable protein-binding
characteristics or the presence of renal
dysfunction.
Non-specific therapy
Fluid hydration – to produce rapid dilution
of bacteria and removal of infected urine
by increased voiding.
Low pH - antibacterial activity of the urine
due to high concentrations of various
organic acids.
Large volumes of cranberry juice increase
the antibacterial activity of the urine and
prevent the development of UTIs.
Lactobacillus probiotics: prevent female
UTIs by decreasing the vaginal pH and
decreasing E. coli colonization.
Estrogenreplacement (In postmenopausal
women) prevention of recurrent UTIs.
Pharmacological Therapy
Based on the categorization of acute
uncomplicated cystitis, symptomatic
bacteriuria, asymptomatic bacteriuria,
complicated UTIs, recurrent infections or
prostatitis.
Commonly Used Antimicrobial Agents in the
Treatment of Urinary Tract Infections
Therapy for Lower Tract Infections in
Adults
Management of UTIs in Female.
Management of UTIs in Male
Antimicrobial Chemotherapy
Drug selected on the basis of efficacy,
safety and cost, select agent with the
narrowest possible spectrum, for the
shortest possible time.
Oral: trimethoprim, β-lactams
(amoxicillin, co-amoxiclav),
cephalosporins, fluoroquinolones
(ciprofloxacin, norflaxacin, ofloxacin) and
nitrofurantoin.
I.V: β-lactams (amoxicillin), cefuroxime,
quinolones (ciprofloxacin),
aminoglycosides (gentamicin).
Uncomplicated lower UTI
Adult
Based on accurate, up-to-date
antimicrobial susceptibility patterns.
Trimethoprim, cefalexin, co-amoxiclav or
nitrofurantoin.
Duration of therapy
7-10 days.
3-day regimen
Children
Risk of renal scarring should be diagnosed
and treated promptly.
β-lactams, trimethoprim, nitrofurantoin.
7-10days.
 Oral antibiotics for LUTIs
Antibiotics Dose Side effects Contraindica Comments
(adult) tions
Amoxicilli 250- Nausea, Penicillin High levels
n 500mg diarrhoea, hypersensiti of
TID allergy vity resisatance
in E.coli
Co- 375- ” ” Amoxicillin
amoxiclav 625mg +
TID clavulanic
acid
Cefalexin 250- ” Cephalexin
500mg hypersensiti
QID vity,
porphyria
Trimethop 200mg BD Nausea, Pregnancy,
rim pruritus, neonates,
allergy folate
deficiency,
porphyria
Nitrofuran 50mg QID Nausea, Renal Modified
toin allergy, rarely failure, -release
Acute pyelonephritis
Severely ill, hospitalization, parenteral
antibiotic.
Drugs: cefuroxime, ceftazidime, co-
amoxiclav, quinolones, gentamicin,
meropenem.
1st choice: parenteral cefuroxime,
gentamicin/ ciprofloxacin.
10-14 days.
 Parenteral antibiotics for
pyelonephritis
Antibiotics Dose Side effects Contraindicat Comments
(adult) ions
Cefuroxim 750mg Nausea, Cephalospori
e TID diarrhoea, n
allergy hypersensiti
vity,
porphyria
Ceftazidim 1gm TID ” ”
e
Co- 1.2gm TID ” Penicillin
amoxiclav hypersensiti
vity
Gentamici 80-120mg nephrotoxicit Pregnancy, Monitor
n TID or y., ototoxicity myasthenia levels
5mg/kg
OD
Ciprofloxa 200- Rash, Pregnancy,
cin 400mg BD pruritus, children
tendinitis
Relapsing UTI
Causes: Renal infection, structural
abnormalities of UT, in men- chronic
prostatitis.
7-10 days – 2week course – 6week course
Structural abnormalities - surgical
correction.
Prostatitis: select drugs with good tissue
penetration – trimethoprim,
fluoroquinolones.
Catheter-associated infections
Principles:
◦ Do not treat asymptomatic infection
◦ If possible, remove the catheter before treating
symptomatic infection
Catheters are often changed on aesthetic
grounds.
Antimicrobial catheters are available, lead
to decreased incidence of bacteriuria and
symptomatic infection.
Rifampicin, minocycline are incorporated.
Bacteriuria in pregnancy
Prevalence of asymptomatic bacteriuria:
5%.
One third proceed to develop acute
pyelonephritis.
Amoxicillin, cefalexin, nitrofurantoin
depends on the sensitivity profile of the
organism.
7 days therapy.
Prevention and prophylaxis
Folklore and naturopathic
recommendations.
Cranberry juice: inhibit adhesion of
bacteria to UT cells on the surface of the
bladder.
Antibiotic prophylaxis: long term, low-
dose
Trimethoprim 100mg, nitrofurantoin 50mg