Urinary tract infection

UTI
• inflammatory response of urothelium to
bacterial invasion.
• Bacteriuria : bacteria in urine
• Asymptomatic or symptomatic
• Bacteriuria + pyuria= infection
• Bacteriuria NO pyuria = colonization
• Pyuria :
• WBCs in urine.
• Infection
• T.B
• Bladder stone.
Complicated VS uncomplicated
• Un complicated UTI: • Complicated UTI:
• UTI structurally & • Anatomical or
functionally normal funtional abnormality.
urinary tract. • Male.
• Female. • Longer time to
• Respond to short respond to ttt
course of antibiotic
• Isolated UTI:
• 6 months between infections.
• Recurrent UTI:>2 infections in 6 months
• 3 UTI in 12 months.
• Reinfection by different bacteria.
• Persistence : same organism from focus within
the urinary tract.
• Struvate stone.
• Bacterial prostatitis.
• Fistula
• Urethral diverticulum.
• atrophic infected kidney.
• Unresolved infection:
• in adequate therapy , bacterial resistance
to ttt.
 Risk factors to bacteriuria
• Female • Stone
• Age • GU malignancy.
• Low estrogen • Obstruction.
( menopause) • Voiding dysfunction.
• Pregnancy. • Institutionalized
• D.M elderly
• Previous UTI.
• FC
 Microbiology
Faecal-drived bacteria • Complicated UTI
Uncomplicated UTI • E.coli 505
E.Coli, G-ve baccillus, • Enterococ faecalis.
(85%- 50%) • Staph aureus
Staph saprophyticus • Staph epidermidis
Enterococ faecalis • Pseudomonas
Proteus aeruginosa
Klebsiella.
 Route of infection
• Ascending
• Short urethra
• Reflux
• Impair urteric
peristalisis.
• Pregnancy
• Obstruction
• G-ve , Edotoxins
• Organism P pili
 Route of infection
• Haematogenous: • Lymphatics:
• Uncommon. • Rarely in
• Staph aureus. inflammatory bowel
• disease,
Candida fungemia.
reteroperitoneal
• T.B abscess
• Increase UTI risk • Protect against UTI

• Increase bacterial • Host defences

virulence
 Factors increasing bacterial
virulence
• Adhesion factors
• Toxins
• Enzyme production.
• Avoidance of host defense mechanisms
 Factors increasing bacterial
virulence
• Adhesion factors • Mannose –sensitive
• G-ve bacteria, Pili • (type 1)
• Attachment to host • Produced by all strains
urothelial cells. E.coli
• Single type or different
types e.x E.coli • Certain pathogenic types
• Defined functionally be of E.coli mannose
mediating resistant pili
hemagglutination (HA) of ( pyelonephritis)
specific erythrocytes
 Factors increasing bacterial
virulence
• Avoidance of host • Toxins:
defense mechanisms • E.coli cytokines,
• E.coli pathogenic effect on
• Extracellular capsule host tissues

• Immunogenisity phagocytosis

• M.Tuberculosis reisit • Enzyme production:

phagocytosis by • Proteus ureases
preventing
phagolysosome fusion • Ammonia struvite
stone formation
 Host defences
• Protective
• Mechanical (flushing of urine) antegrade flow of
urine
• Tamm-Horsfall protein (mucopolysaccharide
coating bladder prevent bacterial attachment)
• chemical : Low Urine PH & high osmolality
• Urinary Immunoglobulin I gA inhibit adherence
 Lower UTI
• Cystitis: infection& inflammation of the
bladder
• Frequency, samll volumes, dysuria,
urgency, offensive urine SP pain,
haematuria, fever & incontinence.
 Investigation
• Dipstick of MSU • Nitrite testing:
• WBC ( pyuria ) • Bacteriuria.
• 75 -95% sensitivity • Specificity >90%
infection • Sensitivity 35- 85%
• False –ve • + test ------- infection
• False +ve • - --------infection
• Other causes of
pyuria
 Investigation
• Microscopy :
• Bacteria :
• False –ve low bacterial count
• False +ve contamination (lactobacilli &
corynebacteria ) epithelial cells
• RBCs & pyuria
 Investigation
Indications for further
investigations in LUTI.
• Symptoms of Upper • KUB
UTI.
• Ultrasound
• Recurrent UTI.
• IVU
• Pregnancy
• cystoscopy
• Unusal infecting
organism ( proteus
suggest infection
stone)
 DD
• Non-infective cystitis:
• radiation cystitis
• Drud cystitis ( cyclophosphamide )
• Haemorrhagic cystitis
• Urethritis
 Treatment
• Aim : • Resistance :
• Eliminate bacterial • Intrinsic (proteus)
growth from urine. • Genetically
• Empirical ttt before transferred between
culture & sensitivity bacteria by R
for the most likely plasmids.
organism.
• Adgusted according
to the culture &
sensitivity.
 Recurrent UTI
• >2 in 6 months or 3 within 12 months

Reinfection Bacterial persistence

 Recurrent UTI
• Reinfection ( different • Bacterial persistance
bacteria) ( same organism
• After prolonged from a focus within
interval with tract) within short
adifferent organism interval
• Reinfection in females • Functional or
• No anatomical nor anatomical problem.
functional pathology • The underlying
• In males BOO, problem should be
urethral stricture treated
 Management Reinfection UTI
• Females
• KUB, Ultrasound, cystoscopy
• Simple Reinfection
TTT
Avoid spermicides
Estrogen replacement therapy
Low dose antibiotic prophylaxis
 Female recurrent reinfection
• Prophylactic antibiotic:
• Reduce infection 90% at bed time 6-12
months
• Symptomatic reinfection
• Trimethoprim
• Nitrofurantoin
• Cephalexin
• Fluoroquinolones
 Female recurrent reinfection
• Natural youghart
• Post-intercourse antibiotic prophylactic
• Self-started therapy
 Management of bacteria
persistance
• Investigations:
• Kub, renal ultrasound.
• C.T, IVU
• Cystoscopy

• Treatment :
• For the functional or anatomical anomaly
 Antibiotics
• Empirical therapy.
• Definitive therapy.
• Bacterial resistance to drug therapy.
 Acute pyelonephritis
• Clinical Dx:
• Flank pain
• Fever.
• Elevated WBCs

• DD:
• acute cholecystitis.
• Pancreatitis.
 Acute pyelonephritis
• Risk factors:
• VUR
• UTO
• Spinal cord injury
• D.M
• Malformation
• pregnancy
• FC
 Acute pyelonephritis
• Pathogenisis :
• Initially patchy
• Inflammatory bands from renal papilla to
cortex.
• 80% E.coli, others klebsiella, proteus&
pseudomonas.
 Acute pyelonephritis
• Urine analysis & culture.
• CBC , U&E
• KUB & ultrasoundif no response with I.V
antibiotic for 3 days go for CTU
 Perinephric abscess
• Pathogenesis.
• Suspected??
• C.T, ultrasound
• PC drainage .
• Open surgical
 Pyonephrosis
• Infected hydronephrosis.
• Pus accumulation
• Causes
• Ultrasound. C.T
• Management: PCN, I.V antibiotic, I.V
fluids.
Emphysematous pyelonephritis
• Severe form of acute pyelonephritis
• Gas forming organism
• Fever, abdominal pain with radiographic
evidence of gas within the kidney.
• D.M
• Urinary obstruction.
• High glucose level-------fermentation,CO2
production
Emphysematous pyelonephritis
• Presentation: sever acute pyelonephritis
• High fever & systemic upset
• E.coli, commonly,
• Klebsiella & proteus less frequent
 Management
• KUB
• Ultrasound, C.T
• Patients are unwell
• Mortality is high
 Management
• Conservative ?
• I.V antibiotic , IVF
• PC drainage
• Control D.M

• Sepsis is poorly controlled

• Nephrectomy
 Xanthogranulomatous
pyelonephritis
• Severe renal infection
• Renal calculi & obstruction.
• Result in non-functioning kidney
• E.coli & proteus common.
• Macrophage full of fat deposit around the
abscess
• Kidney, perinephric fat
 Xanthogranulomatous
pyelonephritis
• Acute flank pain
• Fever & tender flank mass

• C.T , Ultrasound
• Stone , mass ?? RCC
 Xanthogranulomatous
pyelonephritis
• IV antibiotic ,
• Nephrectomy