Infection of the urinary tract

Campbell-Walsh 11th ED, CH12

Sirawit Choksuchat, MD
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 Outline
๐ Definition ๐ Bladder infection
๐ Incidence and epidemiology ๐ Kidney infection
๐ Pathogenesis ๐ Bacteriuria in Pregnancy
๐ Antimicrobial formulary ๐ Bacteriuria in elderly
๐ Antimicrobial prophylaxis ๐ UTI in spinal cord injury patient

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Definition

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 UTI
• Inflammatory response of urothelium to bacterial invasion
•∝ Bacteriuria
and Pyuria
Presence of bacteria in urine Presence of WBC in urine
Colonization VS Infection Infection and/or Inflammation
Significant bacteriuria ∝ UTI

• Bacteriuria w/o Pyuria : Colonization

• Pyuria w/o Bacteriuria : TB, Stones, Cancer

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 • Defined by
UTI
1. Site of origin : Bladder, Kidney
2. Anatomy of urinary tract or functional status of the host

Uncomplicated Complicated
Host Healthy Compromised
Function & Structure Normal Abnormal
ATB response Susceptible/Short course Resistance
Majority Woman Men
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 UTI
• Defined by
3. Relationship to other UTIs
-First or isolated infection : Never had UTI or one remote previous UTI
-Unresolved
-Recurrent

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 Incidence
and
Epidemiology

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 Incidence and Epidemiology
• Most common bacterial infection
• Woman > Men
• Prevalence∝ Older age
U/D : DM, SCI, HIV
Previous UTI
Pregnancy
• Cause significant morbidity

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Pathogenesis

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 Routes of infection
• Ascending
-Most bacteria : Bowel reservoir(Urethra > Bladder > Upper tract)
-Significant role : Adherence of pathogens to urothelial mucosa
-Increased by “Anti-peristaltic effect”
-GN and endotoxin
-Pregnancy
-Ureteral obstruction

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 Routes of infection
• Haematogenous(Uncommon)
-Organism : Staphylococcus aureus, Candida fungemia

• Lymphatic(Uncommon)
-Direct extension of bacteria from adjacent organs
-Unusual circumstances
1.Severe bowel infection
2.Retroperitoneal abscess 12
 Urinary Pathogen
• Sources

-Bowel flora: UPEC(Uropathogenic E.Coli = Most common)

-Perineal skin/Vagina flora: S.epidermidis, Candida albicans

Community acquired Hospital acquired

Gram - Klebsiella
Proteus Pseudomonas
Enterobactor, Citrobactor
Serratia, Providentia
Gram + E.faecalis
S.saprophyticus
(Young sexually active female)
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 UPEC pathogenesis
UPEC attach to epithelium
(Adhesins used)

Internalized into
Detach
bladder cells

IBCs
Rapidly *Biofilms : Shield bacteria from ATB & Immune
Biofilm
growth
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 Alteration in host defenses mechanism
•  
• Obstruction -> Urine stasis
• VUR
• DM -> severe infection, atypical organism(yeast)
• HIV -> 5X prevalence, severity, recurrence
• Pregnancy -> bacteriuria(suitable pH for E.coli growth)
• Spinal cord injuries -> catheterization, neurogenic bladder

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Antimicrobial
Formulary

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 Common antimicrobial
Nitrofurantoin TMP-SMX Quinolone Fosfomycin Cephalo-sporine Amino-
(oral) glycoside
Effective Common Common Common Gram - 1stst: Gram +, 1stst DOC
Enterobacteriaciae VRE E.coli,Klebsiella Febrile UTI
Pseudo 2nd
nd
: Anaerobe +
S.aureus 3rdrd: CAI/HAI TMP-SMX
S.saprophyticus or Ampi
Except Pseudo Pseudo Streptococcus - Enterococcus Gram +
Except Pseudo
Proteus Pseudo
Enterococcus Streptococcus - Enterococcus Gram +
Anaerobe
Proteus Enterococcus Anaerobe
UUT X ✓ ✓ ✓ ✓ ✓
UUT X ✓ ✓ ✓ ✓ ✓
Preg ✓ X X - ✓ ✓
Preg (< 2nd trimester)
✓ X X - ✓ ✓
G6PD (< 2 trimester)
nd
X X ✓ ✓ ✓ ✓
G6PD
SE X
GI X
GI ✓ tendon
Archilles ✓
Rare ✓
Hypersensitivity ✓
Nephro/
Pul. hypersense Rash disorder Ototoxic
SE GI GI Archilles tendon Rare Hypersensitivity Nephro/
Special Prophylactic
Pul. hypersense Prophylactic
Rash Children (Cartilage)
disorder Single dose - -
Ototoxic
consider regimen regimen Warfarin (uncomplicated)
Special Prophylactic Prophylactic Single dose - -
consider regimen regimen (uncomplicated)

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 Common antimicrobial
Nitrofurantoin TMP-SMX Quinolone Fosfomycin Cephalo-sporine Amino-
(oral) glycoside
Effective Common Common Common Gram - 1stst: Gram +, 1stst DOC
Enterobacteriaciae VRE E.coli,Klebsiella Febrile UTI
Pseudo 2nd
nd
: Anaerobe +
S.aureus 3rdrd: CAI/HAI TMP-SMX
S.saprophyticus or Ampi
Except Pseudo Pseudo Streptococcus - Enterococcus Gram +
Except Pseudo
Proteus Pseudo
Enterococcus Streptococcus - Enterococcus Gram +
Anaerobe
Proteus Enterococcus Anaerobe
UUT X ✓ ✓ ✓ ✓ ✓
UUT X ✓ ✓ ✓ ✓ ✓
Preg ✓ X X - ✓ ✓
Preg (< 2nd trimester)
✓ X X - ✓ ✓
G6PD (< 2 trimester)
nd
X X ✓ ✓ ✓ ✓
G6PD
SE X
GI X
GI ✓ tendon
Archilles ✓
Rare ✓
Hypersensitivity ✓
Nephro/
Pul. hypersense Rash disorder Ototoxic
SE GI GI Archilles tendon Rare Hypersensitivity Nephro/
Special Prophylactic
Pul. hypersense Prophylactic
Rash Children (Cartilage)
disorder Single dose - -
Ototoxic
consider regimen regimen Warfarin (uncomplicated)
Special Prophylactic Prophylactic Single dose - -
consider regimen regimen (uncomplicated)
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Antimicrobial prophylaxis for
common Uro procedure

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 Principles
Surgical ATB prophylaxis
• To prevent post procedural infections
• Before procedure 30-120 min
• Limited time after procedure < 24 hr

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Risk factors

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 Summary
ABO prophylaxis when + risk factors
1. Remove catheter
2. Simple cystoscope/Cystogram/VUDS
3. Open or Laparoscopic without entering urinary tract

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 Summary
Fluoroquinolone or TMP-SMX
1. Remove catheter
2. Cystoscope/Cystogram/VUDS
3. TRUS bx
4. ESWL
5. URS

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 Summary
1st gen. cephalosporin
1. Prostate brachy/cryotherapy
2. Open or Laparoscopic without entering urinary tract

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 Summary
1st/2nd gen. cephalosporin or
Aminoglycoside + Metronidazole or Clindamycin
1. Percutaneous renal surgery
2. Vagina surgery
3. Open or Laparoscopic entry into urinary tract

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 Summary
2nd/3rd gen. cephalosporin or
Aminoglycoside + Metronidazole or Clindamycin
1. Open or Laparoscopic involving intestine

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 Special consideration
1. Risk of endocarditis (after GU tract manipulation)
• Prosthetic cardiac valve, Previous IE, Congenital heart disease
• Active infection or colonization
Management: ATB Rx to sterilize urine
-Amoxicillin/Ampicillin -> 1st line for Enterococcus
-Vancomycin -> if cannot tolerate ampicillin

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 Special consideration
2. Patient indwelling with Orthopaedic hardware

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 Bladder infection
1. Uncomplicated cystitis
2. Complicated cystitis
3. Unresolved UTI
4. Recurrent UTI

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 Uncomplicated cystitis
Etiology
• Women(Common)
-E.coli 75-90%
-S.saprophyticus 10-20%
• Young men(Less common)
-E.coli and other Enterobacteriaceae

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Uncomplicated cystitis

SEAS

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 Uncomplicated cystitis
Clinical presentation
• Dysuria, frequency and/or urgency
• Suprapubic pain, hematuria, foul-smelling urine
• No systemic symptom ex. Fever
Lab
• UA: Microscopic pyuria/haematuria
• UC: Only in patient with risk or complicating factors
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Antimicrobial selection

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 Uncomplicated cystitis
Follow up
• UA + UC are recommended in
1. Older women
2. Patient with potential risk factors
3. Men
• Urologic evaluation
Unnecessary in women & young men who respond to ATB
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 Uncomplicated cystitis
Asymptomatic bacteriuria
• Dx: Based on UC without sign and symptom of UTI
• Specimen
• Voided urine - Women: 2 consecutive specimen with same bacteria
(UC > 105 cfu/ml) - Men: 1 specimen

• Single cath - UC > 102 cfu/ml

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 Uncomplicated cystitis
Asymptomatic bacteriuria screening and treatment
• Screening and ATB is recommended in
1. Pregnant woman
2. Prior urological intervention

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 Complicated cystitis
• Occur in patient with
1.Compromised urinary tract

2. Caused by very resistant pathogens

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 Complicated cystitis
• Clinical spectrum: Mild cystitis - Life threatening Urosepsis
• Treatment: ATB + Correct complicating host factors

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Unresolved UTI

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 Unresolved UTI
Management
• Fluoroquinolone 7 days -> Adjust for UC
• Renal function and radiological intervention
(should be performed if UC show susceptible pathogen)

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 Recurrent UTI
Reinfection Bacterial persistence
UTI New event Relapse
Interval Vary/Long interval Closed intervals
Organism Different Same
Source Outside Inside : Stone/Prostate
ATB Prophylaxis Suppression
Uro abnml No Usually
Treatment Long term ATB Usually be cured by
1. Sx remove
2.Correction of infection
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Recurrent UTI : Bacterial persistence

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 Recurrent UTI : Reinfection
• Urological evaluation is essential in
1. All men with reinfection
2. Women with evidence of upper tract infections

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 Recurrent UTI : Reinfection
•  
• ATB management in women recommended in
• 2 symptomatic UTI over 6 months period
• 3 symptomatic UTI within 12 months period
• Regimens
1. Low dose continuous prophylaxis: After UC no growth
2. Self start intermittent therapy: Full dose Quinolones
3. Post coital prophylaxis: Nitrofurantoin/TMP-SMX/Cephalexin/Quinolones
(Single dose)
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 Recurrent UTI : Reinfection
Low dose continuous prophylaxis : Minimal effect to bowel/vg flora
1. TMP-SMX (40-200 mg)
2. TMP alone (50 mg)
3. Nitrofurantoin (50-100 mg)
4. Cephalexin (250 mg)

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 Recurrent UTI : Reinfection
•  
Other strategies: Cranberry juice
• Contains proanthocyanidin adherence of UPEC to uroepithelium
(in vitro)
• RCT: 200-750 ml/day - risk of symptomatic, recurrent infection ~ 12-20%
(in low risk patient)

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Recurrent UTI

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 Kidney infection
1.Acute pyelonephritis
2.Acute focal/multifocal nephritis
3.Emphysematous pyelonephritis
4.Renal abscess
5.Infected hydronephrosis and Pyonephrosis
6.Perinephric abscess

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 Acute pyelonephritis
Definition: Inflammation of kidney and renal pelvis
Clinical: Upper tract sign
• Abrupt onset of fever with chills
• Unilateral/Bilateral flank pain or CVA tenderness
• Often accompanied by dysuria, frequency and urgency

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 Acute pyelonephritis
Lab
• UA: Numerous wbc(clumps), Granular or Leukocyte cast
• UC and H/C: positive(some)

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 Acute pyelonephritis
Bacteriology
• Most common: E.coli(80%)
• More resistant species: Proteus, Klebsiella, Pseudomonas, Serratia
Enterobacter, Citrobacter
Recurrent UTI
Hospitalization
Catheterization
• Rare: Gram positive (E.faecalis, S.aureus, S.epidermidis)
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 Acute pyelonephritis
Imaging: U/S KUB or CT scan should be evaluated in
1. Patients with risk factors : May require intervention

Urinary tract Abscess/

Obstruction Special complication

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 Acute pyelonephritis
Imaging: U/S KUB or CT scan should be evaluated in
2. Not respond after 72 hours of Rx

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Acute pyelonephritis

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 Acute focal/multifocal nephritis
(Lobar nephronia)
• Uncommon severe form of acute renal infection
• Midpoint spectrum between acute pyelonephritis and abscess
• Heavy leukocyte infiltrate in confined renal lobe
Single lobe = Focal
Multiple lobe = Multifocal
Clinical: ~ Acute pyelonephritis but usually more severe
• 50% are DM
• Sepsis is common 58
 Acute focal/multifocal nephritis
•  
Imaging:
US : Poorly marginated, sonolucent & disrupt corticomedullary junction
CT c contrast : Wedge shaped area of enhancement

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 Acute focal/multifocal nephritis
Management: Typically respond to medical therapy
• Hydration
• IV ATB for at least 7 days then oral ATB 7 days
• If not respond -> Further imaging to rule out
-Obstructive uropathy
-Abscess formation
-Carcinoma
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 Emphysematous pyelonephritis
•  
• Urologic emergency(mortality rate 19-43%)
Character:
• Acute necrotizing parenchyma and perirenal infection
• Caused by gas forming uropathogens
Risk factors:
• DM -> E.coli produce CO2 by fermentation of sugar
• Urinary tract obstruction calculi/papillary necrosis/renal impairment
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 Emphysematous pyelonephritis
Most common organism: E.coli
Clinical:
• Female > Male
• Classic triad = fever, vomiting, flank pain
• Severe acute pyelonephritis
• Pneumaturia (involved collecting system)

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 Emphysematous pyelonephritis
Radiologic finding (Dx based on radiography)
1. Plain film:
• Mottled gas shadows over involved kidney
• Extends to perinephric space and retroperitoneal

DDx : Emphysematous pyelitis

-Non DM
-Less serious
-Respond to ATB

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 Emphysematous pyelonephritis
2. U/S: Strong focal echo(Intraparenchymal gas)
3. CT scan(Imaging of choice): Defined extension of disease
-Absence of fluid   Type I (mortality rate 50-60%)
(Rapid destruction of renal parenchyma)
-Presence of streaky/mottled gas
-Perirenal fluid
Type II (mortality rate <20%)
-Presence of bulbly or loculated gas

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 Type II
Loculated gas

Type I
Streaky gas

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 Emphysematous pyelonephritis
Management
• Initial: Fluid resuscitation + Broad spectrum ATB
Urinary drainage(obstructed kidney)
• Nephrectomy when
-Not improved after a few day of therapy
-Nonfunctioning & non obstructed kidney

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 Renal abscess
•  
• Collection of purulent material confined in renal parenchyma
• Index patient: Renal disease or obstruction
• Organism: Gram negative organism
• Routes:
1. Ascending infection(common) Tubular obstruction
2. Hematogenous(rare) Gram positive septicemia

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 Renal abscess
Clinical:
• Fever, chills, abd/flank pain, malaise, weight loss(occasional)
• History:
• Gram positive infection or septicemia 1-8 weeks Prior onset of
• UTI or pyelonephritis weeks symptoms

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 Renal abscess
Lab:
• Marked leukocytosis
• H/C positive (13-32%)
• Pyuria and bacteriuria (when communicates with collecting system)
Imaging: distinguish abscess from other inflammatory renal diseases
• U/S – quickest and least expensive method
• CT scan(imaging of choice) – severity of abscess

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Renal abscess : Acute

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Renal abscess : Chronic

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 Renal abscess
•  
Management
• 3 cm : ATB alone
Not improved
• 3-5 cm : ATB in clinical stable patient
• >5 cm :
Percutaneous drainage
• All sizes in immunocompromised host

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 Infected HDN/Pyonephrosis
Infected HDN
• Bacterial infection in a hydronephrotic kidney
Pyonephrosis
• Infected HDN with suppurative destruction of renal parenchyma
(Total or nearly total loss of renal function)

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 Infected HDN/Pyonephrosis
•  
Clinical:
• Very ill, high fever, chills, flank pain and tenderness
• Previous history - calculi/infection/surgery of urinary tract
Imaging:
• U/S
• Infected HDN: HDN with fluid debris
• Pyonephrosis: focal area of echogenicity within HDN
• CT scan: Renal pelvis thickening, perirenalfat stranding
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Infected HDN/Pyonephrosis

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 Infected HDN/Pyonephrosis
Management:
• Initial: ATB + Drainage of infected pelvis(Ureteral cath or PCN)
• Identify and treat cause if obstruction

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 Peri/Paranephric abscess
•  
Perinephric abscess
Cause
• Rupture of an acute cortical abscess into perinephric space
• Hematogenous spread Skin infection
Risk factor
• Pyonephrosis
• DM (1/3 of perinephric abscess)
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 Peri/Paranephric abscess
Paranephric abscess
Cause
• Rupture of perirenal abscess into pararenal space
• Infection of bowel, pancreas, pleural cavity, psoas,spines

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 Peri/Paranephric abscess
Most common pathogen: E.coli, Proteus, S.aureus
Clinical:
• Insidious onset(> 5 days)
• Similar to pyelonephritis
• Abdominal/flank mass(50%) + CVA tenderness
• Psoas abscess(flexion and external rotation of hip)

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 Peri/Paranephric abscess
•  
Lab:
• Leukocytosis, Cr rising Pyuria
• UC & H/C
Imaging:
U/S: Anechoic mass – echogenic collection within Gerota fascia
CT scan: Primary abscess, extension of disease

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 Peri/Paranephric abscess
•  
Management:
• <3 cm: ATB alone -> Aminoglycoside + Methicillin or Oxacilline(Antistaph)
• 3 cm or not respond to ATB:
-Percutaneous drainage(U/S or CT guided)
-Sx drainage
-Nephrectomy(non function or severe infected)

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 Infectious
Granulomatous Nephritis
1.Xanthogranulomatous pyelonephritis
2.Malacoplakia

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 Xanthogranulomatous Malacoplakia

Nature Rare, severe chronic renal infection Unusual inflammatory

Unilateral/Nonfunctioning/Enlarged kidney Multiple organs involved
Obstructive uropathy from Stones (GU/GI/Lung/Bone/Skin/LN)
(50% = Staghorn) Originate in Bladder
Pelvis and calyx -> Parenchyma-> Collecting

Gross Massively enlarged kidney Soft, yellow-brown plaques

Nephrolithiasis and Perinephric fibrosis

Micro Xanthoma cell : Lipid-laden macrophages Von Hansemann cells

(foamy histiocyte with dark nuclei & clear cytoplasm) (Large histiocyte)
Michaelis-Gutmann bodies

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 Xanthogranulomatous Malacoplakia
Age Any age, peak in 50-70 yrs > 50 yrs
Sex F>M F>M
Bacteriology Proteus E.Coli
(May only from tissue culture)
Clinical UTI(Flank pain, Fever with chill) Bladder irritability, Hematuria
Flank mass Cystoscope: mucosal plaque/nodule
Persistent bacteriuria
Imaging CT triad (Accuracy= 50-80%) CT scan
1. Unilateral renal enlargement 1. No stone
2. Little or non function kidney 2. No HDN
3. Large calculus in renal pelvis 3. Small foci of malacoplakia
(Hypodense)

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 Xanthogranulomatous Malacoplakia
Mx • ATB for • Control UTI
Mx •1.Eradicate
ATB for infection • 1.Fluoroquinolones
Control UTI
1.Eradicate infection
2.Restore renal function 1.Fluoroquinolones
2.Ascorbic acid and cholinergic agents
2.Restore renal function 2.Ascorbic
• Nephrectomy 3. Rifampin,acid
TMP,and cholinergic agents
Doxycycline
•If can’t
Nephrectomy
If
exclude malignancy • 3. Rifampin, TMP, Doxycycline
Nephrectomy
• can’t exclude
Partial malignancy
nephrectomy •1. Fail
Nephrectomy
medication
•If localized
Partial nephrectomy 1.
disease
If localized disease 2. Fail medication
Symptomatic unilateral renal lesion
2. Symptomatic unilateral renal lesion
Prognosis Lipid-laden macrophage Related to extent of the disease
Prognosis 1. RCC (Survival: Unilateral
Related to extent>of
Bilateral disease)
the disease
2. TCC of pelvis or bladder (Survival: Unilateral > Bilateral disease)
3. SCC of pelvis

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Bacteriuria in Pregnancy

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 Bacteriuria in Pregnancy
•  
• Prevalence of asymptomatic bacteriuria = Non pregnancy ~ 2-7%
• Risk:
1. Lower socioeconomic class
2. Multiparity
3. Sickle cell trait
• Spontaneous resolution is unlikely Less ability to clear bacteriuria
• Pyelonephritis (60-75% during 3rd trimester HDN and stasis)
20-40% of pregnant woman with untreated bacteriuria
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 Bacteriuria in Pregnancy
•  
Anatomical and physiologic change -> Susceptible to pyelonephritis
1. Renal size ~ 1cm : Vascular and interstitial volume
2. Smoot muscle atony of collecting system(Esp. 3rd trimester)
• Progesterone effect and Gravid uterus
3. Bladder change :
• Hyperemic and congest
• Hypertrophy from estrogen effect
• Capacity from progesterone
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 Bacteriuria in Pregnancy
•  
Anatomical and physiologic change -> Susceptible to pyelonephritis
4. Augmented renal function : CO GFR and RBF
• Glomerular filtration 30-50%
• Urinary protein excretion(Upto 300 mg/day)

If Cr > 0.8 or BUN > 13

Need further investigation

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 Bacteriuria in Pregnancy
Complication
1. Prematurity and prenatal mortality
2. Maternal anemia
Lab
• UC in all pregnant women during 1st trimester

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 Bacteriuria in Pregnancy
Management

3-7 days course

then f/u UC

*CEF-T
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Bacteriuria in Elderly

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 Bacteriuria in Elderly
Epidemiology:
• 20% of women
• 10% of men Age > 65 years have bacteriuria

• Mostly asymptomatic
• Prevalence increasing with 1. Age
2. Concurrent disease
• Screening for asymptomatic bacteriuria: Not recommended
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Bacteriuria in Elderly

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 Bacteriuria in Elderly
•  
Pathophysiology of aging
• Cell-mediated immunity
• Neurogenic bladder dysfunction
• Perineal soiling from incontinence
• Incidence of urethral catheter placement
• Change in vaginal environment(woman)

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 Bacteriuria in Elderly
Management:
• Prescribe ATB for only symptomatic patient
LUTS: 7 days
Severe systemic infection: 10-14 days
• Fluoroquinolones = effective in this population

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Catheter-associated
Bacteriuria

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 Catheter-associated Bacteriuria
• Most common HAI (40%)
• Usually asymptomatic
• Bacteriuria rate: CIC(1-3% per cath) < Indwelling catheter(10% per day)
Risk factor
Duration
Female
Catheter care violation

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 Catheter-associated Bacteriuria
Organism: E.coli (most common)
• Pseudomonas, Proteus, Enterococcus -> Biofilm growth
• Polymicrobial (long term cath > 30 days)
Lab
• Significant bacteriuria: > 102 cfu/ml
• Pyuria is not indicator

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 Catheter-associated Bacteriuria
Management
• Aseptic insertion and maintain closed system
• Treat only symptomatic
• Change catheter every several weeks

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 UTI in patient
with spinal cord injury

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 UTI in patient with spinal cord injury
•  
Epidemiology
• UTI = most common cause of fever in SCI patient
• Risk factors
Impaired voiding/overdistension of bladder
 Risk of urinary obstruction/VUR/instrumentation/stones
Poor hygiene/ fluid intake/perineal colonization
 Host immune from chronic illness

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 UTI in patient with spinal cord injury
Pathogenesis
• Indwelling catheter -> most likely lead to UTI
• Infection rate: Urethral = Suprapubic catheter
• Delayed onset of bacteriuria in suprapubic catheter
• CIC = Lowest risk for significant long term UT complication
Ex. UTI, fever, bacteriuria, prostatitis, epididymitis

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 UTI in patient with spinal cord injury
•  
Clinical presentation
• Mostly asymptomatic Loss of sensation
• Symptom ex. flank/back/abdominal discomfort
urine leakage between cath, cloudy urine
Bacteriology
• E.coli(20%)
• Resistant organism ex. Enterococci, Proteus, Pseudomonas
Klebsiella, Serratia, Staph, Candida 110
 UTI in patient with spinal cord injury
Management : Only symptomatic patient require treatment
• Collect UC before start ATB
• Afebrile: Oral fluoroquinolone
• Febrile: IV Aminoglycoside + Penicillin or 3rd gen cephalosporine
• Duration: 4-5 days for mildly symptomatic, 10-14 days for sicker
• If clinical not improved in 24-48 hrs
1. Reculture and adjustment of ABO
2. Imaging for ruling out obstruction/stone/abscess
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THANK YOU Insert Image

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