URINARY TRACT INFECTION

Fendra Wician, MD
 INTRODUCTION
Disease burden
150 million people worldwide per year
Common in women (50-80% acquire at least
1x in lifetime)
40% from all nosocomial infection
40% of all gram negative septicemia
 CLASSIFICATION & DEFINITION
Based on Anatomical level of infection :
symptomatic infection of :
Urethra : Urethritis
Urinary bladder : Cystitis
Kidney : Pyelonephritis

Prostat : Prostatitis
 CLASSIFICATION & DEFINITION
Based on Clinical consideration :
Uncomplicated UTI
Acute cystitis or pyelonephritis in non pregnant
women
w/o urological structural problem and urinary tract
system abnormalities
w/o underlying comorbid condition

Complicated UTI
All other types of UTI
 CLASSIFICATION & DEFINITION
Asymptomatic Bacteriuria (ASB or ABU)
Presence of bacteria in urinary tract in
asymptomatic individual
Ussualy accompanied with pyuria
 ETIOLOGY
E.coli 70-90%
Staph saprophyticus (5-10%)
Klebsiella
Proteus
Enterococci
Citrobacter
PATOGENESIS
 EVIRONMENT FACTORS
Vaginal Ecology:
Colonization of the vaginal introitus & periurethral
area with organisms from the intestinal flora (usually E.
coli)
critical initial step in UTI pathogenesis

Postmenopausal predominant vaginal lactobacilli

are replaced with gr (-) bacterIa
Sexual intercourse risk E.coli colonization
Spematicide toxic to normal vaginal microflora
 EVIRONMENT FACTORS
Protective effects of lactobacilli
Prevent attachment of E.coli to uroepithelial
cells
Lower pH by production of lactic acids
Production of bacteriocins, surfactans and
hydrogen peroxyde
 EVIRONMENT FACTORS
Anatomic & Functional abnormalities
Any condition that permits urinary stasis or obstruction
predisposes to UTI

Foreign body : stones & urinary catheter provide an inert surface

for bacterial colonization

Prostatic hypertrophy, neurogenic bladder, urinary diversion

surgery Vesicoureteral reflux & ureteral obstruction create
an environment favorable to UTI

Inhibition of ureteral peristalsis & ureteral tone

vesicoureteral reflux (important in pyelonephritis in pregnant
women)
 HOST FACTORS
GENETIC background
Women w/ recurrent UTI are more likely have Hx:
first UTI before 15 y.o
maternal history of UTI

Mutations in host response genes (TLR and IL 8 receptor) linked

to recurrent UTI and pyelonephritis.

Polymorphisms in IL 8receptor gene CXCR1 susceptibility to

pyelonephritis

expression of CXCR1 on neutrophils impairs neutrophil-

dependent host defense against bacterial invasion of the renal
parenchyma
 PATHOGEN FACTORS
E.coli intestinal & extraintestinal
Extraintestinal E.coli uropathogenic E.coli

Virulence factors :
Surface adhesins mediate binding to
specific receptors on the surface of
uroepithelial cells
 PATHOGEN FACTORS
Surface adhesins :
P fimbriae important in the pathogenesis of
pyelonephritis & bloodstream invasion from the
kidney
Type 1 pili (fimbria) play a key role in initiating
E. coli bladder infection

E. Coli sequence type 131 type I fimbriae &

produce extended spectrum beta lactamase
ORENUC UTI Host Risk Factor Category
 UTI RISK FACTOR
Modifiable risk factors
Behavioural factors:
Frequent intercourse
Use of spermicides
New sexual partner
Exposure to antibiotic
Reduced estrogen
 PATHOGENESIS
Mode of introduction of organism into urinary tract :
Ascending Infection
Hematogenous dissemination
 PATHOGENESIS
Hematogenous dissemination:
Primary source of infection is elsewhere
Involve less than 2% of all UTI
More frequent in immunocompromised patient
Involve highly virulence organism, ex:
Staph aureus
Salmonella
Candida sp
Mycobacterium tuberculosis
 SIGN & SYMPTOMS
PATIENT APPROACH
The most important issue to be addressed
when a UTI is suspected is the
characterization of the clinical syndrome
Asymptomatic bacteriuria
Cystitis
Pyelonephritis
Prostatitis
Complicated UTI
 SIGN & SYMPTOM
Cystitis
Dysuria
Urinary frequency
Urinary urgency
Nocturia
Suprapubic discomfort
hematuria
 SIGN & SYMPTOM
Pyelonephritis
Fever with chills
Nausea vomiting
Flank or loin pain
Renal angle tenderness
 DIAGNOSTIC TEST
Urine dipstick
Leukocyte esterase
High accuracy among urology patients
(sens 48-86%, spe 17-93%)

Nitrite test
High accuracy in pregnant & elderly women
(sens 45-60%, spe 85%-98%)

Neg test on both help to rule out UTI

Pos test needs further evaluation
 DIAGNOSTIC TEST
URINALYSIS
>10 WBC/hpf
RBC
bacteria
 DIAGNOSTIC TEST
Urine culture
Gold standard

In symtomatic woman with uncomplicated cystitis

1.000 cfu/ml of clean catch mid stream voided urine
(MSU) can be considered significant

In symtomatic woman with uncomplicated

pyelonephritis
10.000 cfu/ml of MSU can be considered
significant
 DIAGNOSTIC TEST
Clinically relevant bacterial count
 DIAGNOSTIC TEST
Diagnosis of ABU
100.000 cfu/ml of MSU in 2 consecutive
samples obtained at least 24 h apart
 DIAGNOSTIC TEST
Radiologic
Not needed in uncomplicated UTI

Consider in:
Unresponsive or delayed response to treatment
Genitourinary tract malformation
Persistent hematuria
Renal insufficiency
THERAPY UNCOMPLICATED CYSTITIS
Treatment strategy based on the type of UTI

CYSTITIS
1st line Antibiotic :
Nitrofurantoin
TMP-SMX
Phosphomycin
Pivmecillinam
THERAPY UNCOMPLICATED CYSTITIS
2nd line Antibiotic :
Fluroquinolones (cipro, oflo, levo, but not
Moxi)
Beta lactam antibiotic
THERAPY UNCOMPLICATED CYSTITIS
 THERAPY - PYELONEPHRITIS
GET URINE CULTURE SUSCEPTIBILITY !

1st line antibiotic:

Consider 7 day course Cipro or 5 day Levo
With or without parenteral ceftriaxone or
aminoglycoside
 THERAPY - PYELONEPHRITIS
If sensitive to TMP-SMX 14 days TMP-SMX
If no TMP SMX sensitivity data
Give initial parenteral ceftriaxone or
aminoglycosides

B lactam less effective

 THERAPY - PYELONEPHRITIS
In PYELONEPHRITIS require hospitalization
Therapy Based on urine culture

Empiric:
IV fluoroquinolone
Aminoglycoside +/- ampicillin
Cephalosporin +/- aminoglycoside
Carbapenem
Beta lactam + beta lactamase inhibitor
 THERAPY
UTI in male
Uncomplicated UTI in male
TMP-SMX 7-14 days

Prostatitis
Therapy based on urine culture
Duration of treatment :
Acute protatitis 2-4 weeks
Chronic prostatitis 4-6 weeks
 Risk factor for
Fluoroquinolone resistant E.coli
Urinary catheter
Urinary tract disorder
Recurrent UTI
Hospitalization
Use of fluoroquinolones
 Asymptomatic Bacteriuria (ABU)
Significant bacteria in urine specimen but no
clinical feature
May not require treatment

Need treatment in:

1. pregnant women
2. patient undergoing urological surgery or
procedure
 Asymptomatic Bacteriuria (ABU)
Diagnosis of ABU
100.000 cfu/ml of MSU in 2 consecutive
samples obtained at least 24 h apart
 Asymptomatic Bacteriuria (ABU)
1-5% of healthy premenopausal women
4-19% in healthy elderly women and men
0.7-27% in diabetes patients
2-10% in pregnant women
15-50% in institutionalised elderly
23-89% in spinal cord injury patients

The spectrum of bacteria in ABU is similar to species

found in uncomplicated or complicated UTIs,
depending on the presence or not of a risk factor
 Asymptomatic Bacteriuria (ABU)
Bacteremia & sepsis are common in patients with
ABU undergoing genitourinary procedures
associated with mucosal bleeding

Ex: ABU in transuretheral resection of prostate

antibiotic has to be initiated shortly prior to
procedure
should not continued beyond the procedure,
unless an indwelling catheter is in place
 Asymptomatic Bacteriuria (ABU)
ABU in pregnancy Increase risk:
Pyelonephritis
Premature labour
Low birth weight infants
 Asymptomatic Bacteriuria (ABU)
Treatment ABU in pregnancy
Cephalosporin for 3-7 days
Repeat culture periodically

Treatment of pyelonephritis in pregnancy

Beta lactam agents +/- aminoglycosides
 CAUTI
Most common nosocomial infection
40% of all nosocomial infection
 CAUTI
Clinical features
Fever
Lethargy & malaise
Hematuria
Renal angle tenderness
Altered mental state
Pelvic discomfort
 CAUTI
Management
Prevention CAUTI
Avoid unnecessary use of urinary catheter
Removal of catheter when no longer necessary

Use of bladder acidifying agents, antimicrobial

washes, topical disinfectans, antimicrobial
drainage bag solution NOT
RECOMMENDED
THANK YOU
CLASSIFICATION & DEFINITION
UTI RISK FACTORS
UTI RISK FACTORS
 DIFFERENTIAL DIAGNOSIS
Vaginitis
Cervicitis
Urethritis
Non infectious vaginal & vulvar irritation
Ca urinary bladder
UTI in PREGNANCY
 Nitrofurantoin
monohydrate/macrocrystals
Nitrofurantoin monohydrate/macrocrystals
(100 mg twice
daily for 5 days) is an appropriate choice for
therapy due to
minimal resistance and propensity for
collateral damage
(defined above) and efficacy comparable to 3
days of
trimethoprim-sulfamethoxazole (A-I).
 Trimethoprim-sulfamethoxazole
Trimethoprim-sulfamethoxazole (160/800 mg [1
doublestrength
tablet] twice-daily for 3 days) is an appropriate choice
for therapy, given its efficacy as assessed in numerous
clinical
trials, if local resistance rates of uropathogens causing
acute
uncomplicated cystitis do not exceed 20% or if the
infecting
strain is known to be susceptible (A-I).
 Fosfomycin trometamol (3 g in a single dose) is an
appropriate choice for therapy where it is available due
to
minimal resistance and propensity for collateral
damage, but it
appears to have inferior efficacy compared with
standard shortcourse
regimens according to data submitted to the US Food
and Drug Administration (FDA) and summarized in the
Medical Letter
 Pivmecillinam (400 mg bid for 37 days) is an
appropriate choice for therapy in regions where it is
available
(availability limited to some European countries; not
licensed
and/or available for use in North America), because of
minimal resistance and propensity for collateral
damage, but
it may have inferior efficacy compared with other
available
therapies (A-I).
 The fluoroquinolones, ofloxacin, ciprofloxacin, and
levofloxacin, are highly efficacious in 3-day regimens
(A-I)
but have a propensity for collateral damage and should
be
reserved for important uses other than acute cystitis
and thus
should be considered alternative antimicrobials for
acute
cystitis
 b-Lactam agents, including amoxicillin-clavulanate,
cefdinir, cefaclor, and cefpodoxime-proxetil, in 37-day
regimens are appropriate choices for therapy when other
recommended agents cannot be used (B-I). Other b-lactams,
such as cephalexin, are less well studied but may also be
appropriate in certain settings (B-III). The b-lactams generally
have inferior efficacy and more adverse effects, compared with
other UTI antimicrobials (B-I). For these reasons, b-lactams
other than pivmecillinam should be used with caution for
uncomplicated cystitis.
 Amoxicillin or ampicillin should not be used
for
empirical treatment given the relatively poor
efficacy, as
discussed in the 1999 guidelines [1] and the
very high
prevalence of antimicrobial resistance to these
agents
worldwide [811] (A-III).
 Oral ciprofloxacin (500 mg twice daily) for 7 days, with or
without an initial 400-mg dose of intravenous ciprofloxacin, is
an appropriate choice for therapy in patients not requiring
hospitalization where the prevalence of resistance of community
uropathogens to fluoroquinolones is not known to exceed 10%
(A-I). If an initial one-time intravenous agent is used, a longacting
antimicrobial, such as 1 g of ceftriaxone or a consolidated
24-h dose of an aminoglycoside, could be used in lieu of an
intravenous fluoroquinolone (B-III). If the prevalence of
fluoroquinolone resistance is thought to exceed 10%, an
initial 1-time intravenous dose of a long-acting parenteral
antimicrobial, such as 1 g of ceftriaxone (B-III) or
a consolidated 24-h dose of an aminoglycoside, is
recommended (
 A once-daily oral fluoroquinolone, including
ciprofloxacin (1000 mg extended release for 7 days)or
levofloxacin (750 mg for 5 days), is an appropriate choice
for therapy in patients not requiring hospitalization where
the prevalence of resistance of community uropathogens is
not known to exceed 10% (B-II). If the prevalence of
fluoroquinolone resistance is thought to exceed 10%, an initial
intravenous dose of a long-acting parenteral antimicrobial, such
as 1 g of ceftriaxone (B-III) or a consolidated 24-h dose of an
aminoglycoside, is recommended (B-III).
 Oral trimethoprim-sulfamethoxazole (160/800 mg [1
double-strength tablet] twice-daily for 14 days) is an
appropriate choice for therapy if the uropathogen is known
to be susceptible (A-I). If trimethoprim-sulfamethoxazole is
used when the susceptibility is not known, an initial
intravenous dose of a long-acting parenteral antimicrobial,
such as 1 g of ceftriaxone (B-II) or a consolidated 24-h dose
of
an aminoglycoside, is recommended (B-III).
 Oral b-lactam agents are less effective than other
available agents for treatment of pyelonephritis
(B-III). If an
oral b-lactam agent is used, an initial intravenous
dose of a
long-acting parenteral antimicrobial, such as 1 g
of ceftriaxone
(B-II) or a consolidated 24-h dose of an
aminoglycoside, is
recommended (B-III).
 Women with pyelonephritis requiring hospitalization
should be initially treated with an intravenous antimicrobial
regimen, such as a fluoroquinolone; an aminoglycoside,
with
or without ampicillin; an extended-spectrum cephalosporin
or extended-spectrum penicillin, with or without an
aminoglycoside; or a carbapenem. The choice between
these
agents should be based on local resistance data, and the
regimen should be tailored on the basis of susceptibility
results
(B-III).
 UTI in special group
UTI in pediatric age group
UTI in pregnancy
UTI in catheterized patient
 In Male
1.000 cfu/ml significant for diagnosis