URINARY TRACT INFECTION

AKHYAR ALBAAR
HAERANI RASYID
 Prevalence of UTI

Ratio
Age group % (male:female)

Neonatal 1 3:2
Preschool 2-3 1:10
School age 1-2 1:30
Reproductive age 2-5 1:50
Elderly 20-30 1:10
 Terminology of Urinary Tract Infections (1)

Microbiologic Terminology

Urinary tract infection (UTI) is the presence of microorganisms in the urinary

tract, including the bladder, prostate, collecting system, or kidneys.

Bacterial infection is most common, but fungi, chlamydia, viruses and parasites may
be responsible in some patients

Bacteriuria : Presence of bacteria in the urine.

Asymptomatic bacteriuria : significant bacteriuria in a patients without

symptoms attributable to the urinary tract.

Ribeiro RM, et al. Int Urogynecol 2002;13:198-

 Criteria for diagnosis of significant bacteriuria

Symptomatic women :
• ≥ 102 coliform organisms/ml urine plus pyuria, or
• ≥ 105 of any pathogenic organism/ml urine, or
• Any growth of a pathogenic organism from urine obtained by
suprapubic aspiration

Symptomatic men :
• ≥ 103 pathogenic organism/ml urine

Asymptomatic patients :
• ≥ 105 pathogenic organism/ml urine in two consecutive
samples

Cattel WR : Textbook of Infection of the Kidney & Urinary Tract, 1996:1-7

 Terminology of Urinary Tract Infections (2)

Clinical Terminology

Acute pyelonephritis: a syndrome that consists of localized flank

or back pain combined with systemic symptoms such as
fever, chills, and prostration, caused by infection of the renal
parenchyma and collecting system, and is often complicated
by bacteremia
Chronic pyelonephritis :
Cannot be defined in terms of a clinical syndrome.

It refers to a spesific pathologic appearance of the

kidney. Occurs as a result of recurrent UTIs. This pathology is not
specific and is commonly found in association with other renal
diseases, such as chronic obstruction, uric acid nephropathy,
analgesec abuse, and hypokalemic nephropathy.

Chronic pyelonephritis is the result of progressive

inflammation of the renal interstitium and tubules.
Grossly, the kidneys show uneven scarring and contraction.

To avoid the the implication that chronic pyelonephritis

indicates infection, many authors suggest that the term
chronic interstitial nephritis be used to describe this
pathologic condition of the kidneys.
Cystitis :

Typical symptom are dysuria, frequency, and urgency.

Onset is abrupt
Lower abdomen heaviness and/or lower back pain may be prenet
Urine may be turbid, sometimes foul smelling.
Occasionally, it shows a bloody tinge or its frankly bloody
Acute prostatitis
Acute bacterial infection of the prostate gland. The syndrome
manifests with abrupt onset of fever and perineal pain associated
with symptoms of irritative and obstructive voiding dysfunction

Chronic prostatitis
Bacterial infection of the prostate gland, which the inflammation is
persistent and low-grade. The syndrome manifests with voiding
dysfunction and abdominal or low back dyscomfort.

Urosepsis
Symptomatic bacteremia of urinary tract origin
 Terminology of Urinary Tract Infections (3)

Treatment Terminology

Reinfection :

Reccurence of bacteriuria with an organism different from that originally isolated.

Tend to occur more than 2 weeks after completion of therapy

Response well to therapy, Most likely represent infections of the bladder, occur
weeks to months after treatment of the previous infection, usually
associated with a normal urinary tract

Relapse :

Reccurence of bacteriuria with the same organism as originnally isolated.

Often recur within 2 weeks after antimicrobials have been discontinued.

Usually represent infection of the kidney or prostate.
Anatomic or functional abnormalities are more common.
A long course of antimicrobials or surgery may be required if the urine is to be
permanently sterilized
 Reinfection indicates acquisition of new pathogen, whereas relapse
indicates persistance of the organism within the urinary tract. Reinfection
may occur with an organism identical to the original strain, cannot be
distinguished from relapse.

Chronic UTI :
Frequent recurrennces of sympromatic UTI.

True chronic infection should mean persistence of the same organism in

the urine after months or years (situation of a patient with multiple
relapses of infection, not the patient with frequent reinfections).
 Classification

• Upper UTI = Pyelonephritis

• Lower UTI = Cystitis

• Complicated UTI
• Uncomplicated UTI
 I. Uncomplicated urinary tract infection

• Occurs in individuals with structurally and functionally normal

genitourinary tracts
• Most common bacterial infection that occurs in women, but is
uncommon in men
• May involve the bladder or the kidneys and may be symptomatic
or asymptomatic

II. Complicated urinary tract infection

• As acute or chronic parenchymal infection associated with
a functional or structural urinary tract abnormality
 Underlying factors associated
with ‘complicated’ urinary tract infection

Systemic Conditions
Diabetes mellitus
Papillary necrosis (e.g. analgesic nephropathy)
Immunodeficient states (including immunosuppressive
drug therapy e.g. transplant recipient)

Abnormal drainage of urine

Renal calculi
Obstruction at any site in the urinary tract (extra/intra)
Vesicoureteric reflux
Foreign body in the urinary tract (stent, catheter)
Pregnancy
UTI in men
 Diagnosis Urinary Tract Infection

1. Symptoms
:• Lower UTI
• Upper UTI

2. Urinalysi
s• The presence of ≥ 5-10 WBC / high-power field sediment
midstream urine

3. Culture

4. Radiological
evaluation
• Ultrasound
• Intravenous urography
• CT scanning
 Clinical features of acute lower and
upper urinary tract infection in adult

Lower UTI Upper UTI

Dysuria Systemically unwell
Frequency Fever – rigors
Suprapubic pain Loin pain and tenderness
Malodorous urine Nausea and vomiting
Haematuria Features of lower urinary tract
Normal temperature infection
• Pyuria is not, by itself, diagnostic of urinary
tract infection or an indication for
antimicrobial therapy.

HOWEVER

The absence of pyuria has a high negative

predictive value to exclude UTI
Schrier’s Atlas of Kidney Disease
Culture interpretation

Schrier’s Atlas of Kidney Disease

 Indication of urine culture in the
evaluation of UTI

•Complicated UTI
•Pyelonephritis
•Recurrent UTI
•Asymptomatic UTI : Pregnancy, before & after
urologic instrumentation, after definitive
removal of chronic indwelling catheter
 IMAGING STUDIES (1)
• USG :
– Detect obstruction & its cause; intrarenal and/or
perinephric abscess; estimate kidney size, contour &
consistency
– Preferred initial method of investigating
– Indication :
1. Severe UTI (sign of sepsis) regardless of age and sex
2. Males of any ages except young; sexually active men with risk factors for
UTI
3. Complicated UTI
4. Atypical cases of pyelonephritis in young women (colicky pain, persistent
hematuria)
5. Slow or no resolution of symptoms in young women (persistent of
symptoms longer than 72 hours) while on appropriate anti microbial
treatment.
6. Recurrent pyelonephritis regardless of age and sex
7. Relaps of cystitis (recurrent of UTI with the same organism within 2 weeks
of completing antimicrobial treatment)
 IMAGING STUDIES (2)

• Computed tomography (CT); indicated when

futher clarification of renal anatomy, as in
some cases of intrarenal and/or perinephric
abcess.
• Intravenous pyelography has been replaced
by U/S and CT for most indications.
• Voiding cystourethrography is indicated in the
evaluation of vesicouretheral reflux mainly in
children
Bacterial etiology of urinary tract infection

• E. coli : 70-95% (uncomplicated UTI), 21-54% (complicated)

• S. Saprophyticus : 5-20% (uncomplicated), 1-4% (complicated)
• Enterococci : 1-2% (uncomplicated), 1-23% (complicated)
• Proteus mirabilis : 1-2% (uncomplicated ), 1-10% (complicated)
• Klebsiella spp : 1-2% (uncomplicated), 2-17% (complicated)
• Pseudomonas aeruginosa : <1% (uncomplicated), 2-19% (complicated)
Clinical Classification of Urinary Tract Infection

1. Acute uncomplicated cystitis in women

2. Acute uncomplicated pyelonephritis in women
3. Complicated UTI in both sexes
4. Recurrent infections in women
5. Asymptomatic bacteriuria
6. Catheter associated UTI

McBryde C, Redington. Primary Care Case Rev 2001 ; 4 : 2

 Acute uncomplicated cystitis in
women
Single dose or 3-day course of treatment

Cured

Failure or relapse
(identical pathogens)
Reinfection
(new pathogen)

Treatment for 2 weeks Ultrasonography urinary tract

KUB radiograph

Catel WR. Clin Drug Invest 1995 ; 9 (suppl 1) : 8-13.

Empiric antibiotics can be prescribed using a
first-line agent for a 3-day course without
further evaluation

• Women younger than 55

• No other comorbidities
• Not postmenopausal
• Not pregnant
• No recent UTI
• No vaginitis or cervicitis symptoms
• Presence of increased urinary frequency
• Presence of dysuria.

Litza, Brill. Prim Care Clin Office Pract 2010, 37: 491–507
 Antimicrobial therapy for
uncomplicated cystitis

Abbreviations: DS, double strength; TMP-SMX, trimethoprim-sulfamethoxazole.

Lane DR, Takhar SJ. Emerg Med Clin N Am 2011,29: 539–552
Clinical Classification of Urinary Tract Infection

1. Acute uncomplicated cystitis in women

2. Acute uncomplicated pyelonephritis in women
3. Complicated UTI in both sexes
4. Recurrent infections in women
5. Asymptomatic bacteriuria
6. Catheter associated UTI

McBryde C, Redington. Primary Care Case Rev 2001 ; 4 :

2
Acute uncomplicated pyelonephritis in women

Severe illness
Moderate severity

Outpatients and oral Hospitalization with initial

therapy possible parenteral therapy Urologic
evaluation

No resolution
Resolution
No resolution in 5 days
in 5 days
in 5 days

Radiologic
Treatment 14 Oral treatment 14 days or evaluation
days longer as required
 Antimicrobial therapy for
uncomplicated pyelonephritis

Abbreviation: IV, intravenous

Lane DR, Takhar SJ. Emerg Med Clin N Am 2011,29:539–552
Clinical Classification of Urinary Tract Infection

1. Acute uncomplicated cystitis in women

2. Acute uncomplicated pyelonephritis in women
3. Complicated UTI in both sexes
4. Recurrent infections in women
5. Asymptomatic bacteriuria
6. Catheter associated UTI

McBryde C, Redington. Primary Care Case Rev 2001 ; 4 :

2
 Complicated UTI in both sexes
Hospitalize, urine culture, blood
culture
Empiric therapy with parenteral
regimen
Significant clinical improvement

Yes No
5
Days
Switch to or continue Review antimicrobial susceptibility pattern
oral regimen Radiologic & urologic evaluation
For total 2 weeks Correct reversible risk factors

Review treatment plan as appropriate,

treat for total 2 weeks or longers if necessary

Follow-up urine culture after treatment

Clinical Classification of Urinary Tract Infection

1. Acute uncomplicated cystitis in women

2. Acute uncomplicated pyelonephritis in women
3. Complicated UTI in both sexes
4. Recurrent infections in women
5. Asymptomatic bacteriuria
6. Catheter associated UTI

McBryde C, Redington. Primary Care Case Rev 2001 ; 4 :

2
 Recurrent infections in women
Reccurent UTI in women

Relapse Diagnosis Reinfection

Conventional antibiotic ≥3× ≤2×

therapy 2-6 weeks year year

Sexually active Conventional antibiotic

Postmenopausal therapy 3-7 days

Estrogen substitution
Antibiotic therapy :
(oral & topical)
On demand or
Postcoital or
Longterm prophylaxis
Antibiotic therapy :
On demand or
Longterm prophylaxis

Madersbacher S, et al. Curr Opin Urol 2000 ; 10 : 32.

Drug regimens for long-term, low-dose prophylaxis of
recurrent urinary tract infection

Drug Dose*
Nitrofurantoin 50 mg

Trimethoprim 100 mg

Co-trimoxazole 0.24 g

Norfloxacin 200 mg

Ciprofloxacin 125 mg

Cephalexin 125 mg
( useful if renal insufficiency)
Hexamine hippurate 1g

* Treatment is effective if taken each night, alternate nights, three times a week,
or just after intercourse
Clinical Classification of Urinary Tract Infection

1. Acute uncomplicated cystitis in women

2. Acute uncomplicated pyelonephritis in women
3. Complicated UTI in both sexes
4. Recurrent infections in women
5. Asymptomatic bacteriuria
6. Catheter associated UTI

McBryde C, Redington. Primary Care Case Rev 2001 ; 4 :

2
• Pyuria accompanying asymptomatic bacteriuria
is not an indication for antimicrobial treatment.
• Pregnant women should be screened for
bacteriuria by urine culture at least once in early
pregnancy, and they should be treated if the
results are positive.
• Screening for and treatment of
asymptomatic bacteriuria is recommended
before urologic procedures for which
mucosal bleeding is anticipated.
• Antimicrobial treatment of asymptomatic
women with catheter-acquired bacteriuria
that persists 48 h after indwelling catheter
removal may be considered
• Screening for or treatment of asymptomatic
bacteriuria is not recommended for the following
persons.
– Premenopausal, nonpregnant women.
– Diabetic women.
– Older persons living in the community.
– Elderly, institutionalized subjects.
– Persons with spinal cord injury.
– Catheterized patients while the catheter remains in
situ
Clinical Classification of Urinary Tract Infection

1. Acute uncomplicated cystitis in women

2. Acute uncomplicated pyelonephritis in women
3. Complicated UTI in both sexes
4. Recurrent infections in women
5. Asymptomatic bacteriuria
6. Catheter associated UTI

McBryde C, Redington. Primary Care Case Rev 2001 ; 4 :

2
 Catheter Associated UTI (CAUTI)
• Catheter-risk of bacteriuria increases
each day of use:
• Per day : 5%
• 1 week : 25%
• 1 month : 100%

41
Catheter-Associated Bacteriuria
(Closed Drainage System)

42
Catheter-Associated Bacteriuria
(Open Drainage System)

43
 Acceptable Indications for
Urinary Catheter Placement
• Acute urinary retention or obstruction
• Perioperative use in selected surgeries
• Assist healing of perineal and sacral wounds in
incontinent patients
• Hospice/comfort/ palliative care
• Required immobilization for trauma or surgery
• Chronic indwelling on admission

44
Unacceptable Reasons for Placement

• Urine output monitoring OUTSIDE

intensive care
• Incontinence
• Immobility
• Confusion or dementia
• Patient request

45
• Prevention of bacteriuria: keep the closed catheter system
closed and remove the catheter as soon as possible.
• Irrigation of the catheter and bladder with antibacterial
solutions has not curtailed bacteriuria.
• Asymptomatic bacteriuria need not be treated as long as
catheter short term or long-term, remains in place.
EXCEPTIONS :

1. For patients who may be at high risk of serious

complications (e.g. granulocytopenic patients, solid
organ transplant patients, and pregnant women)
2. Patients undergoing urologic surgery
• In case of symptomatic catheter associated UTI
it may be reasonable to replace or remove the
catheter before

• Seven days is the recommended duration of

antimicrobial treatment for patients with CA-UTI
who have prompt resolution of symptoms, and
10–14 days of treatment is recommended for
those with a delayed response, regardless of
whether the patient remains catheterized or not.
 SUMMARY
• Clinical Classification of Urinary Tract Infection : Acute
uncomplicated cystitis in women, Acute uncomplicated
pyelonephritis in women, Complicated UTI in both sexes,
Recurrent infections in women, Asymptomatic bacteriuria,
Catheter associated UTI

• Clinical features of UTI include Lower UTI (dysuria, frequency,

suprapubic pain, malodorous urine, Haematuria, normal
temperature), Upper UTI (systemically unwell, fever – rigors, loin
pain and tenderness, nausea and vomiting, hypotension and shock,
features of lower urinary tract infection)

• Treatment of UTI depends on clinical presentation.

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