URINARY TRACT

INFECTION
H A Z E L M A R I E O . E C H AV E Z
VETERANS MEMORIAL MEDICAL CENTER
Introduction • Among top 5 reasons for
consultation in health facilities
nationwide.
• 7 million outpatient physician
consults.
• 1 million emergency room
visits
• More than 100,000 hospital
admissions yearly
• 40-60% of all nosocomial
infections
Gross Anatomy
Route of Infection
Pathogenesis
of UTI
Symptomatology of UTI
• UPPER TRACT
Fever, chills, flank
pains, CVA tenderness,
nausea, and vomiting

• LOWER TRACT
Dysuria, frequency,
urgency, gross
hematuria or
hypogastric pain
Symptomatology of UTI
(in different age groups)
AGE PRESENTATION
Neonate and infant Hypothermia, hyperthermia, failure to
thrive, vomiting, diarrhea, sepsis,
irritability, lethargy, jaundice,
maladorous urine
Toddler Abdominal pain, vomiting, diarrhea,
constipation, abnormal voiding pattern,
maladorous urine, fever, poor growth
Symptomatology of UTI
(in different age groups)
AGE PRESENTATION
School age Dysuria, frequency, urgency, abdominal
pain, abnormal pattern (including
secondary constipation, fever), voiding
incontinence or enuresis), malodorous
urine
Adolescent Dysuria, frequency, urgency, abdominal
discomfort, malodorous urine, fever
Diagnostic Tools

• History & PE

• Urine dipstick test

• Urinalysis

• Urine culture – gold standard

Specificity and Sensitivity of
Diagnostic Tests
TEST SENSITIVITY SPECIFICIT COMMENTS
Y
Chemical 30-90 90-95 False-negative
Nitrate tests with dilute urine,
inadequate dietary nitrates,
infection with enzyme-
deficient bacteria
Leukocyte 50-75 80 Pyuria has poor correlation
esterase with bacteriuria
Specificity and Sensitivity of
Diagnostic Tests
TEST SENSITIVITY SPECIFICIT COMMENTS
Y
Microscopic 30-80 30-80 Pyuria has poor correlation
Urinalysis with bacteriuria
(pyuria)
Gram stain 90 ---- Correlates with colony
counts of > 100,000
bacteria/ml in clean-catch
sample using high power oil
immersion
Specificity and Sensitivity of
Diagnostic Tests
TEST SENSITIVITY SPECIFICITY COMMENTS
Clean catch 90-95 80-90 Reliable in continent children;
sensitivity increase with multiple
samples;
>100,000 organisms/ml

Catheterization 90-95 80-90 Contamination is common,

so false-positives may occur
>1000 organisms/ml

Suprapubic >95 >95 Contamination unlikely;

aspiration Any organism present may be
significant
UTI Bacteriology
• Escherichia coli covers 90% of UTIs

in outpatient setting and

approximately
50% in hospitalized patients

• Consider Staphylococcus
saprophyticus in sexually-active,
reproductive-age women
UTI Bacteriology
• > 95% of UTIs are caused by single
bacterial species

• Polymicrobial:
 Catheter-associated infections
(biofilm)
 “foreign body” (stone) or
instrumentation
UTI Bacteriology
Pathogens in
UNCOMPLICATED UTIs
Escherichia coli
Staphylococcus saprophyticus
Klebsiella
Enterococcus fecalis
Pathogens in
COMPLICATED UTIs
Escherichia coli
Klebsiella
Enterobacter cloacae
Serratia marcescens
Proteus mirabilis
Pseudomonas aeruginosa
Enterococcus fecalis
Group B streptococci
Common Bacterial Contaminants

• Staphylococcus epidermidis
• Corynebacteria (diphtheroids)
• Lactobacillus
• Gardnerella vaginalis
• Anaerobic bacteria
Clinical Presentations
of URINARY TRACT INFECTIONS
• Asymptomatic Bacteriuria
• Acute Uncomplicated Cystitis
• Acute Uncomplicated
Pyelonephritis
• Recurrent UTI
• Complicated UTI
Asymptomatic Bacteriuria
(In the absence of symptoms…)
METHOD MEN
Clean-Catch Single (1) voided urine
specimen with isolation of the
one bacterial species in
quantitative counts ≥100,000
cfu/mL.
WOMEN
Two (2) consecutive voided urine
specimens with isolation of the
same bacterial strain in
quantitative counts ≥100,000
cfu/mL.

Catheterization Single (1) catheterized urine specimen with one bacterial species
isolated in a quantitative count ≥100 cfu/mL

ALL DIAGNOSIS of Asymptomatic Bacteriuria should be based on results of

URINE CULTURE SPECIMENS that are COLLECTED ASEPTICALLY and
with no evidence of contamination.
Asymptomatic Bacteriuria
SHOULD BE
Screened & Treated:
✔ ALL Pregnant Women
✔ Patients who will undergo
Genitourinary Manipulation
or Instrumentation
SHOULD NOT BE
Screened & Treated:
✘ Healthy Adults
✘ Elderly
✘ Patients with:
◉ Diabetes Mellitus
◉ Indwelling catheters
◉ Post Solid organ transplant procedure
◉ HIV
◉ Spinal Cord Injury
✘ Urologic Abnormality
Asymptomatic Bacteriuria
SCREENING TESTS:
✔ Screening by urine culture is recommended.
✔ In the absence of facilities for urine culture these can be used:
 Significant pyuria (>10 wbc/hpf)
 Positive gram stain of unspun urine (>2 microorganisms/oif)
Note: Two (2) consecutive midstream urine samples
✔ Urine culture and sensitivity testing are not necessary when urinalysis is negative for pyuria
or
urine gram stain is negative for organisms.
✔ Pyuria accompanying asymptomatic bacteriuria is not an indication for antimicrobial
treatment among patients for whom screening and treatment is not recommended.
Asymptomatic Bacteriuria
ANTIBIOTICS RECOMMENDED DOSE AND
DURATION
PRIMARY *Nitrofurantoin 100 mg BID for 5 days per orem (PO)
(monohydrate)
Nitrofurantoin macrocrystals 100 mg QID for 5 days PO

Fosfomycin trometamol 3 grams single dose PO

ALTERNATIVE *Pivmecillinam 400 mg BID for 3-7 days PO

Ofloxacin 200 mg BID for 3 days PO
Ciprofloxacin 250 mg BID for 3 days PO
Ciprofloxacin XR 500 mg OD for 3 days PO
Levofloxacin 250 mg OD for 3 days PO
Norfloxacin 400 mg BID for 3 days PO
Asymptomatic Bacteriuria
ANTIBIOTICS RECOMMENDED DOSE A N D
DURATION
ALTERNATIVE Amoxicillin-clavulanate 625 mg BID for 7 days PO
Cefuroxime axetil 250 mg BID for 7 days PO
Cefaclor 500 mg TID for 7 days PO
Cefixime 200 mg BID for 7 days PO
Cefpodoxime proxetil 100 mg BID for 7 days PO
Ceftibuten 200 mg BID for 7 days PO
ONLY if with TMP - SMX 160/800 mg BID for 3 days PO
proven
susceptability
Asymptomatic Bacteriuria
ANTIBIOTIC FOR RECOMMENDED DOSE A N D FDA CATEGORY
PREGNANCY DURATION
Cephalexin 500 mg BID for 7 days B
Cefuroxime axetil 500 mg BID for 7 days B
Fosfomycin trometamol 3 g single dose B
Amoxicillin- clavulanate 625 mg BID for 7 days B
100 mg QID for 7 days;
100 mg BID for 7 days for
Nitrofurantoin
monohydrate macrocrystal B
macrocrystal
formulation
(not available locally)
C
TMP - SMX 160/800 mg BID for 7 days
(Avoid in 1st and 3rd trimester)
Clinical Presentations
of URINARY TRACT INFECTIONS
• Asymptomatic Bacteriuria
• Acute Uncomplicated Cystitis
• Acute Uncomplicated
Pyelonephritis
• Recurrent UTI
• Complicated UTI
Acute Uncomplicated Cystitis
• Premenopausal, non-pregnant
women
• Presenting with:
– Acute onset dysuria
– Frequency
– Urgency
– Gross hematuria
– Without vaginal discharge
DIAGNOSTIC TESTS:
 Urinalysis
 Urine Culture
 UTZ of the KUB
 No diagnostic tests needed
(if patient presents with one
or more symptoms)
Acute Uncomplicated Cystitis
ANTIBIOTICS RECOMMENDED DOSE AND
DURATION
PRIMARY *Nitrofurantoin 100 mg BID for 5 days per orem (PO)
(monohydrate)
Nitrofurantoin macrocrystals 100 mg QID for 5 days PO

Fosfomycin trometamol 3 grams single dose PO

ALTERNATIVE *Pivmecillinam 400 mg BID for 3-7 days PO

Ofloxacin 200 mg BID for 3 days PO
Ciprofloxacin 250 mg BID for 3 days PO
Ciprofloxacin XR 500 mg OD for 3 days PO
Levofloxacin 250 mg OD for 3 days PO
Norfloxacin 400 mg BID for 3 days PO
Acute Uncomplicated Cystitis
ANTIBIOTICS RECOMMENDED DOSE A N D
DURATION
ALTERNATIVE Amoxicillin-clavulanate 625 mg BID for 7 days PO
Cefuroxime axetil 250 mg BID for 7 days PO
Cefaclor 500 mg TID for 7 days PO
Cefixime 200 mg BID for 7 days PO
Cefpodoxime proxetil 100 mg BID for 7 days PO
Ceftibuten 200 mg BID for 7 days PO
ONLY if with TMP - SMX 160/800 mg BID for 3 days PO
proven
susceptability
Clinical Presentations
of URINARY TRACT INFECTIONS
• Asymptomatic Bacteriuria
• Acute Uncomplicated Cystitis
• Acute Uncomplicated Pyelonephritis
• Recurrent UTI
• Complicated UTI
Acute Uncomplicated Pyelonephritis
Pathogens INDICATIONS FOR ADMISSION:
E. coli, P. mirabilis,  Inability to maintain oral hydration or
K. pneumonia,
S. saprophyticus take medications
 Concern about compliance
Disposition  Presence of possible complicating
• Mild to moderate conditions
- OPD treatment
 Severe illness with high fever, severe
• Severe (Urosepsis)
– Hospitalization pain, marked debility and signs of
sepsis
Acute Uncomplicated Pyelonephritis

Symptoms : DIAGNOSTIC TESTS:

• Fever, chills, flank pains, CVA  Pyuria ≥ 5 pus cells/hpf of
tenderness,
centrifuged urine
• nausea and vomiting
 Bacteruria ≥ 10,000 cfu/ml
• ± signs and symptoms of lower
UTI  G/S of uncentrifuged urine
• (-) clinical or historical evidence  Blood cultures in patients
of structural
with signs of sepsis
• or functional urologic
abnormality
Acute Uncomplicated Pyelonephritis
ANTIBIOTIC DOSE, FREQUENCY AND
DURATION
ORAL

Primary Ciprofloxacin 500 mg BID for 7-10 days

Ciprofloxacin XR 1000 mg OD for 7 days
Levofloxacin 250 mg OD fo 7-10 days
750 mg OD for 5 days
Ofloxacin 400 mg BID for 14 days
Alternative Cefixime 400 mg OD for 14 days
Cefibuten 400 mg OD for 14 days
Cefuroxime Axetil 500 mg BID for 14 days
Co-amoxiclav 625 mg TID for 14 days
(when GS shows gram + organisms)
Acute Uncomplicated Pyelonephritis
ANTIBIOTIC DOSE, FREQUENCY AND
DURATION
PARENTERAL (given until patient is afebrile)

Primary Ceftriaxone 1-2 grams q 24 hrs

Ciprofloxacin 400 mg q 12 hrs
Levofloxacin 250-750 mg q 24 hrs
Ofloxacin 200-400mg q12 hrs
Amikacin 15mg/kg BW q 24 hrs
Gentamicin +/- ampicillin 3-5 mg/kg BW q 24 hrs
Alternative Ampicillin – Sulbactam (when GS 1.5 grams q 6 hrs
shows gram + organisms)
Reserved for Ertapenem (if ESBL prevalence 1 gram q 24 hrs
MDROs >10%)
Piperacillin-Tazobactam 2.25-4.5 grams q 6-8 hrs
Clinical Presentations
of URINARY TRACT INFECTIONS
• Acute uncomplicated cystitis
• Acute uncomplicated pyelonephritis
• Asymptomatic Bacteriuria
• Recurrent UTI
• Complicated UTI
Recurrent UTI
(Definition)
◉ Healthy non-pregnant woman
◉ No known urinary tract abnormalities
◉ Episodes of Acute uncomplicated cystitis
documented by urine culture
 3 or more in 12 months
 2 or more in 6 months
Recurrent UTI
DIAGNOSTICS:
DIAGNOSTIC WORK-UPS
• Routine screening for
REQUIRED IN:
urologic abnormality is
✔ Gross hematuria
NOT recommended
✔ Obstructive symptoms • Renal ultrasound or CT
✔ Clinical impression of persistent infection scan/stonogram
✔ History of pyelonephritis • Patients with anatomical
✔ History of or symptoms suggestive of abnormalities should be
Urolithiasis referred to a specialist
✔ History of childhood UTI
✔ Elevated Creatinine
Recurrent UTI

RELAPSE REINFECTION
• Arises within 1-2 • Arises after adequate 2 weeks
weeks from previous from previous infection
infection with SAME • Recurrent UTI resulting from a
organism isolate DIFFERENT organism isolate
despite adequate
treatment • May be from SAME organism
isolate after a negative
intervening culture
Recurrent UTI
(Treatment)
7-day Treatment Co-Amoxiclav, Cephalosphorin (2nd
gen) or Ofloxacin
3-day Treatment Akin to Acute Uncomplicated Cystitis.

Intermittent Self-administered Cotrimoxazole

Therapy (2 double strength tablets as single
dose)
Recurrent UTI
(Prophylactic Strategies)
Clinical Presentations
of URINARY TRACT INFECTIONS
• Acute uncomplicated cystitis
• Acute uncomplicated pyelonephritis
• Asymptomatic Bacteriuria
• Recurrent UTI
• Complicated UTI
Complicated UTI

DEFINITION
 Infection in the urinary tract with functional, metabolic or
structural abnormalities
 Predisposes to decreased susceptibility of pathogens thus
resulting in longer treatment duration
 These abnormalities must be treated along with antibiotics to
sterilize the urine and prevent recurrence of UTI
Complicated UTI
(Associated Conditions)
• Indwelling urinary catheter or intermittent catheterization
• Incomplete bladder emptying (>100ml retained urine-post volume)
• Vesicoureteral reflux and other urologic abnormalities including
surgically created abnormalities
• Azotemia due to intrinsic renal disease
• Renal Transplantation
• Diabetes Mellitus
• Immunocompromised Conditions
• Infections with Unusual Pathogens or Drug-Resistant Pathogens
Complicated UTI
NOTE:
Urine gram stain and culture and sensitivity must always be obtained
before the initiation of any treatment ( Grade B)

UTI IN DIABETICS UTI IN FILIPINO PXs

• E. coli • E coli
• Klebsiella pneumoniae • Klebsiella
• Pseudomonas pneumoniae
• Proteus mirabilis
• Pseudomonas
• Enterobacter
• • Proteus mirabilis
Candida
• Enterococcus • Enterobacter
Complicated UTI
(Criteria for Hospitalization)
 Marked debility and signs of sepsis
 Uncertainty in diagnosis
 Concern about adherence to treatment or who are
unable to maintain oral hydration or take oral
medications

(Grade C)
Complicated UTI
(Empiric Treatment)
URINARY TRACT INFECTIONS
In Some Special Groups

• UTI in Pregnancy

• UTI in Men

• Catheter-Associated
UTI
UTI in Pregnancy
• Nitrofurantoin, Ampicillin and
Cephalosphorins
– safe in early pregnancy
• Sulfonamides
– avoided
1st trimester: teratogenic effect
Near term: possible role in development of kernicterus
• Fluoroquinolones
– avoided
UTI in Men
• Goal:
– eradicate prostatic and bladder infection
• Uncomplicated UTI
– 7 to 14 days course of quinolones or
TMP-SMX
• Bacterial prostatitis
– culture based
– 2 to 4 weeks treatment
Catheter-Associated UTI
• Presence of bacteriuria and UTI symptomatology
in catheterized patients
• Pathogenesis
– biofilm formation in the catheter
• Treatment
– Catheter change
– Intermittent catheterization
– 7 to 14 days course of antibiotics
Summary
 UTI, as a commonly encountered illness,
may manifest with various urinary
symptoms

 Laboratory parameters may be utilized,

but is not always necessary

 Use of guidelines in the management is

simple and effective