URINARY

TRACT
INFECTION
HISTORY
illness that would last for a year before
either resolving or worsening to involve the
kidneys- Hippocrates

early twentieth century- persistence after 3

weeks of therapy

NITROFURANTOIN- first tolerable and

effective agent
 presence of bacteria in the urinary
tract usually with WBCs and
inflammatory cytokines in the
urine

CYSTITIS PROSTATITIS

ASYMPTOMATIC PYELONEPHRITIS
BACTERIURIA T

A SYM
OM P TOM
IN T IC A
PT C L
Y M B (DIS
S U L E A
A C/Swithout
A S warrants
E) antibiotic
T I IC
treatment therapy
 DEFINITION

ACUTE CYSTITIS OR
UNCOMPLICA PYELONEPHRITIS IN COMPLICAT
ALL OTHER TYPES OF UTI
TED UTI NONPREGNANT OUTPATIENT ED UTI

c
WOMEN W/O ANATOMIC
ABNORMALITIES OR
INSTRUMENTATION OF THE
URINARY TRACT

RECURREN CATHETER
T UTI COMPLICATED/UNCO ASSOCIATE ASYMPTOMATIC
MPLICATED D /SYMPTOMATIC
BACTERIURI
A/INFECTIO
N
 Title text addition
FEMALES>MALES
In pregnant women, ASB has
01 EXCEPT:
1.NEONATAL PERIOD
consequences, screening and
2. AFTER 50 YEARS OLD treatment are indicated

50-80% of women Majority of men w/ UTI have a

acquire at least one functional or anatomic abnormality
02 UTI in their lifetime- of the urinary tract, mostly
uncomplicated secondary to prostatic hypertrophy.
cystitis.

03
05 About 20-30% of
women who have had
Women w/ diabetes
have been found to
one episode of UTI will have a 2to 3-fold
have recurrent UTI higher rate ofASB and
UTI than women
without.
 RISK FACTORS

recent use of a frequent sexual

diaphragm with intercourse
spermicide new sexual partner
frequent sexual UTI in previous 12
intercourse months
history of UTI CYSTITIS
maternal history of UTI
Diabetes
PYELONEPHRITIS Incontinence
 ETIOLOGY

-WORLDWIDE
TERIC GRAM-NEGATIVE RODS THAT HAVE MIGRATED TO THE URINARY TRACTINCREASE OF
RESISTANCE OF
E.COLI TO
ACUTE UNCOMPLICATED CYSTITIS:& PYELONEPHRITIS ANTIBIOTICS
E.COLI(75-90%), S.ASAPROPHYTICUS (5-15%), KLEBSIELLA, PROTEUS,
ENTEROCOCCUS, CITROBACTER (5-10%) >20% RESISTANCE
RATE TO TMP-SMX

COMPLICATED UTI:: -UROPATHOGENS

E.COLI, P.AERUGINOSA, KLEBSIELLA,PROTEUS, CITROBACTER, PRODUCING
ACINETOBACTER, MORGANELLA, GRAM (+) BACT. EXTENDED
(ENTEROCOCCI AND S. AUREUS), YEASTS SPECTRUM B-
Lorem Ipsum dolor sit amet adispicing consectetur LACTAMASES
 PATHOGENESIS

ASCENDING INFECTION FROM THE URETHRA TO THE BLADDER

AND TO THE KIDNEYS

HEMATOGENOUS SPREAD (<2%)- SALMONELLA, S.AUREUS,

CANDIDURIA
 ENVIRONMENTAL
HOST FACTORS
FACTORS
• VAGINAL ECOLOGY
1) COLONIZATION W/ • GENETIC
COLIFORMS BACKGROUND
2) NONOXYNOL-9
3) POSTMENOPAUSAL WOMEN-SHIFT
OF PREDOMINANCE FROM
LACTOBACILLUS TO COLONIZING
FACTORS
GRAM(-)BACTERIA
• ANATOMIC AND FUNCTIONAL
AFFECTING
ABNORMALITIES PROGRESSION
1) URINARY STASIS OR
OBSTRUCTION
-FOREIGN BODIES, MICRONIAL
VESICOURETERAL REFLEX
(PREGNANT), FACTORS
PROSTATIC HYPERTROPHY,
• SURFACE ADHESINS
NEUROGENIC BLADDER,
1) P FIMBRIAE
URINARY
2) TYPE 1 PILUS
DIVEERSION SURGERY
2) DISTANCE OF URETHRA FROM
ANUS
 Title text addition
ASYMPTOMATIC
CYSTITIS PYELONEPHRITIS PROSTATITIS
BACTERIURIA

FEVER INFECTIOUS/NONINFECTIOUS
NO LOCAL/SYSTEMIC DYSURIA “HIGH SPIKING “PICKET FENCE” PATTERN
(CHRONIC PELVIC PAIN
AND RESOLVES OVER 72 HRS OF
SYMPTOMS REFERABLE URINARY FREQUENCY SYNDROME)
THERAPY
TO THE URINARY TRACT URGENCY MILD: LOW GRADE W/ OR W/O LOWER- ACUTE-DYSURIA,
BACK OR COSTOVERTEBRAL ANGLE PAIN FREQUENCY, PAIN IN THE
INCIDENTAL FINDING NOCTURIA, SEVERE: HIGH FEVER, RIGORS, NAUSEA, PROSTATIC/ PERIRENAL
SYSTEMIC S/S + HESITANCY, VOMITTING AND FLANK AND/OR LOIN PAIN AREA, FEVER AND CHILLS,
OBSTRUCTIVE UROPATHY W/ ACUTE
POSITIVE URINE SUPRAPUBIC SYMPTOMS OF BLADDER
PAPILLARY NECROSIS
CULTURE- NOT MERIT OUTLET OBSTRUCTION
DISOMFORT. GROSS EMPHYSEMATOUS PYELONEPHRITIS-
PRODUCTION OF GAS IN RENAL AND CHRONIC-MORE INSIDIOUS,
UTI DX UNLESS W/ HEMATURIA RECURRENT EPISODES OF
PERINEPHRIC TISSUES(DIABETIC)
OTHER POTENTIAL XANTHOGRANULOMATOUS CYSTITIS SOMETIMES W/
PYELONEPHRITIS PELVIC/PERINEAL PAIN
ETIOLOGIES
- CHRONIC URINARY OBSTRUCTION W/
CHRONIC INFECTION LEADS TO
SUPPURATIVE DESTRUCTION OF RENAL
TISSUE.
 COMPLICATED
UTI
SYMPTOMATIC EPISODE OF
CYSTITIS OR PYELONEPHRITIS IN
A MAN OR WOMAN W/ NO
ANATOMIC PREDISPOSITION TO
INFECTION W/ A FOREIGN BODY
IN THE URINARY TRACT, OR WITH
FACTORS PREDISPOSING TO A
DELAYED RESPONSE TO
THERAPY.
 DIAGNOSIS
HISTORY Differential Diagnosis for dysuria:
In women with at least one symptom of UTI and w/o • Cervicits(C.trachomatis,
complicating factors, probability of acute cystitis or N.gonorrheae
pyelonephritis is 50% • Vaginitis(C.albicans, T.vaginalis)
• Herpetic Urethritis
If risk factors for UTI are present without vaginal • Interstitial Cystitis
discharge and complicating factors, probability of • Noninfectious vaginal or vulvar
UTI diganosis is 90%, no laboratory evaluation irritation
needed.

Combination of symptoms like dysuria and urinary

frequency, in the absence of vaginal discharge
increases probability of diagnosis to 96%.Further
laboratory evaluation not necessary before initiation
of definitive therapy.
 URINE DIPSTICK TEST, URINALYSIS
AND URINE CULTURE

DIPSTICK TEST:
• NITRITE URINE CULTURE:
-Enterobecteriaceae • “Gold Standard”
-enough amounts must
accumulate in the • women w/symptoms of cystitis--
urine to test >102 basteria/mL
positive • men- 103 mL
• LEUKOCYTE ESTERASE
-in the host's PMNs in • multiple bacteria- contamination
the urine, lysed or except in long term
intact
• Can confirm diagnosis of uncomplicated cystitis in
catheterization, chronic urinary
patient w/ reasonably high probability of this retention, presence of fistula
disease. between the urinary tract or
• Positivity of either can be interpreted as (+)--- if w/
one symptom of UTI --80%
presence of fistula,
• If (-)for both, consider other explanations, proceed
to Culture.
TREATMENT
UNCOMPLICATED CYSTITIS
IN WOMEN
 UTI IN PREGNANT WOMEN

NITROFURANTOIN, AMPICILLIN AND CEPHALOSPORINS-

relatively safe in pregnancy

• Asymptomatic or Symptomatic UTI- Ampicillin and

Cephalosporins
• Overt Pyelonephritis- parenteral B-lactams therapy w/ or w/o
aminoglycosides
• Avoid Sulfonamides (possibly teratogenic; kernicterus) and
Fluoroquinolones (adverse effects on fetal cartilage)
 UTI IN MEN

• ACUTE BACTERIAL PROSTATITIS

-7-TO 14- day course of Fluoroquinolones or
TMP-SMX
-culture first before initiation of therapy
-tailor to culture results,continue for 2-4
weeks
• CHRONIC BACTERIAL PROSTATITIS
-4- to 6-week course of antibiotics
• RECURRENCES
-12-week course of treatment
 COMPLICATED UTI

-guided by urine culture

-Xanthogranulomatous pyelonephritis- Nephrectomy
-Emphysematous pyelonephritis- Percutaneous drainage--
Elective Nephrectomy
-Papillary Necrosis w/ Obstruction- interventions to relieve
obstruction and preserve renal function
 ASYMPTOMATIC
BACTERIURIA

• pregnant women, persons undergoing urologic

surgery, neutropeniand renal transplant patients
• directed by urine culture results
 CATHETER-ASSOCIATED
UTI

• >/= 103 cfu/mL

• depend on urine culture results
• biofilm-- catheter change
• 7- to 14- day course of antibiotics is recommended
• AVOID INSERTION OF UNNECESSARY
CATHETERS AND TO REMOVE CATHETERS ONCE
THEY ARE NO LONGER NECESSARY
 CANDIDURIA

• FLUCONAZOLE (200-400 mg/d for 14

days (first-line)
• ORAL FLUCYTOSINE AND/OR
PARENTERAL AMPHOTERICIN B
 PREVENTION OF
RECURRENT UTI

• CONTINUOUS
• POST-COITAL
• PATIENT-INITIATED
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