Urinary-Tract Infections

Dr Robin Smith

‡ Definition
± Significant bacteriuria in the presence of symptoms

‡ Importance
± Common community infection
‡ 25% of women will suffer at least 1 UTI in lifetime ‡ 5.5 million GP prescriptions per year

± Most common hospital-acquired infection
‡ 9% of inpatients have a hospital-acquired infection ‡ 25% of all hospital-acquired infections are UTIs

Epidemiology: changes with age
‡ Neonates
± 1 -2% ± Males > females

‡ 1 yr old
± F:M = 4.5 : 0.5%

‡ School
± F:M = 1.2 : 0.03%

‡ Adults
± F:M = 1-3 : 0.1%

‡ Elderly
± F:M = 20 : 10%

Staphylococcus saprophyticus ± Instrumentation ‡ Catheterisation. coli.Pathogenesis (1) ‡ Ascending infection ± Colonisation of urethra ‡ Women > men ± Bowel carriage of urovirulent strains ‡ Urovirulent E. cystoscopy ± Stagnation of urine .

Pathogenesis (2) ‡ Haematogenous route ± Affect renal parenchyma ‡ Staphylococcus aureus bacteraemia / endocarditis ± (Lymphatic route) .

Host-parasite interaction: host defence ‡ Urinary flow ‡ Urinary tract mucosa ‡ Urine itself ± pH and osmolality ± urinary substances ‡ Systemic immune system ‡ Surrounding area ± Genital tract / perineal environment .

Host-parasite interaction: microbial virulence ‡ Bacterial virulence ± adherence ± evade immune system ± invasion ± nutrition and survival .

frequency. urgency. systemic symptoms ‡ Elderly ± Asymptomatic. suprapubic pain. proteinuria. loin pain. incontinence. poor feeding. vomiting ‡ Older Children and Adults ± Lower Urinary Tract (cystitis) ‡ Dysuria. turbid urine. non-specific: confusion . haematuria ± Upper urinary tract (pyelonephritis) ‡ + fever.Symptoms ‡ Young children ± Non-specific: fever. failure to thrive.

Diagnosis ‡ Method of urine collection ± Mid-stream clean catch ± Catheter urine ± Bag urine ± Suprapubic urine ± Ureteric urine ‡ Method will influence result and management .

leukocyte esterase. nitrites ‡ negative predictive value = 99% .Diagnosis: urinalysis sticks ‡ Dipsticks ± protein.

crystals ± Gram stain ± not routine . sterile pyruria ± RBC.Diagnosis: microscopy ‡ Microscopy ± >50 WBC / mm3 ‡ NB. casts.

Diagnosis: culture ‡ Culture ± mainstay of diagnosis ± impossible to sterilise urethra / periurethral area ‡ degree of contamination is inevitable ‡ quantification aims to differentiate infection from contamination .

Diagnosis: culture ‡ Criteria for laboratory diagnosis of UTI ± 100.000 (105) cfu of a single bacterial species / ml ‡ False negatives: ± ± ± ± ± Patient already on antibiotics Frequent bladder voiding Men Slower growing organisms Suprapubic and ureteric urine ‡ False positives: ± Contamination .

Diagnosis: culture ‡ Technique ± Calibrated loop containing 0.001ml urine ± 100 colonies on plate = 105 colonies / ml .

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Diagnosis: culture ‡ Sources of error ± Errors in collection ‡ poor preparation of patient ‡ previous antibiotics ± Errors in transit ‡ delayed examination ± cells break down ‡ lack of refrigeration ± bacteria multiply ± Errors in laboratory .

coli 13% Klebsiella 11% Proteus 4% Staphylococcus saprophyticus 1% others ± (enterococci. pseudomonas.Organisms ‡ ‡ ‡ ‡ ‡ 71% E. other staphylococci) .

Management ‡ Antibiotic treatment ± Ideally await culture and sensitivity result ‡ 50% will settle ± Empirical choice for severe or complicated infection ‡ cover the most likely pathogens ‡ local resistance rates .

GP urines sent to RFH ± 2005 ‡ Resistance of enterobacteriaceae in urine sent by GPs ± Amoxycillin ± Trimethoprim ± Augmentin ± Cephalexin ± Nitrofurantoin ± Ciprofloxacin 50% 28% 20% (further 11% are intermediate) 13% 11% 7% .

gentamicin ± Duration ‡ Uncomplicated: 3 days ‡ Complicated: 7-14 days ‡ Other management options ± ± ± ± remove catheters hydration voiding education cranberry juice. nitrofurantoin ± ciprofloxacin ± IV ceftriaxone. cephalexin. co-amoxiclav. growing evidence for probiotics .‡ Antibiotic options ± trimethoprim.

Special groups: Infants / young children ‡ Reflux ± 30-50% with symptomatic bacteriuria ± Recurrent infection ‡ Renal scarring ± Renal failure ‡ Prompt treatment and prophylaxis ‡ Thorough investigation ‡ Importance of getting sample collection right .

Special groups: Pregnancy ‡ Asymptomatic bacteriuria ± 30% will get pyelonephritis ‡ Association with prematurity and low birthweight infants ‡ Importance of screening and prompt treatment .

Special groups: Others ‡ Young men ± single UTI requires investigation for structural abnormality ‡ Diabetics ± kidneys are already under threat ± previous treatment possible resistant organisms ‡ Hospitalised patients ± co-morbidity ± catheterisation: >10% get UTI ± possible resistant organisms .

vomiting +/-Bacteraemia ‡ high fever. blood cultures ‡ Antibiotics for •10 days ‡ Image renal tract for abscess formation . sepsis ‡ MSU. nausea. rigors.Pyelonephritis ‡ 1% of UTIs progress to pyelonephritis ‡ Mainly women ‡ Elderly men: prostatism ‡ Symptoms Usual UTI symptoms + Renal parenchyma involvement ‡ loin pain.

Urethritis and urethral syndrome ‡ Symptoms may not be UTI ± No symptoms of bladder irritation ± STIs ‡ Gonococcus. Chlamydia. Non-specific urethritis ± Urethral/perineal lesions ‡ HSV. caruncle ± Chemical irritation .

MSU ± Three glass urine test ‡ MSU ‡ Prostatic massage secretions ‡ Post-massage MSU . Fungi ‡ Symptoms ± Fever.Prostatitis ‡ Inflammation of the prostate ± Bacterial prostatitis ‡ STI ‡ Spread from urinary tract (NB: post-instrumentation) ‡ Haematogenous spread ± Rare: TB. rigors. hesitancy. perineal/rectal/testicular pain. incomplete voiding ‡ Diagnosis ± Sexual screen.

Case study 1 ‡ A 40 year old lady presents with fever. vomiting and loin pain ± What is the likely diagnosis? ± State two diagnostic investigations .

‡ The isolate from her blood cultures is shown ± What aetiology is likely? ± Suggest suitable treatment plan .

105 cfu/ml of E. ‡ Urine microscopy and culture results are as follows: ± Microscopy: >50 WBC/mm3.Case study 2 ‡ A one-year boy old presents with fever and vomiting: ± clinical examination does not reveal an immediate focus of infection. coli ‡ Is this a UTI? ‡ Are any additional investigations necessary? . ± No red blood cells ± Culture 104 . ± several attempts to collect a clean catch sample fail and a supra-pubic aspirate is performed.

so CSU was sent for culture ‡ Urine microscopy and culture results are as follows: ± Microscopy: no white blood cells /mm3 ± Culture: >105 cfu/ml of Klebsiella spp/ml ‡ Would you treat with antibiotics? ‡ Would management change if he develops signs of a fever or increasing pain over the bladder? ‡ What concerns would you have if he had acquired this organism while in hospital? . He was sent home with a supra-pubic catheter attached to a bag. He is well and able to care for himself competently.Case study 3 ‡ A 75 year old man presents to a urology follow-up clinic ± ± ± ± Prostatic surgery for prostatic enlargement two weeks ago. On examination. ± Urine in the bag appears cloudy. he has mild lower abdominal discomfort but no temperature.

Take home messages ‡ Very common infection ± Majority are straightforward ± Many clear without antibiotics ‡ Accurate diagnosis can be difficult ‡ Accurate diagnosis can be important ± Special groups at risk of complications ‡ Use antibiotics wisely ± Potential for massive misuse of antibiotics .

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