 Urinary tract infections are common,

especially among women

 20-30% of women have recurrent urinary

tract infections (UTI) at some time in their
life.
 UTIs in men are less common and primarily

occur after 50 years of age.

 Although the majority of infections are
 acute
 short-lived
 they contribute to a significant amount of

morbidity in the population.

 Severe infections result in a loss of renal
function and serious long-term sequelae.

 In females, a distinction is made between

cystitis, urethritis and vaginitis, but the
genitourinary tract is a continuum and the
symptoms often overlap.
 Coagulase negative staphylococci
 Viridans nonhemolytic streptococci
 Lactobacilli ♀
 Diphtheroids
 Non pathogenic Neisseria species
 Commensal Mycobacterium species
 Yeasts
 Bacterial infection :

 usually acquired by the ascending route from

the urethra to the bladder

 The infection may then proceed to the kidney.

 Occasionally, bacteria infecting the urinary tract

invade the bloodstream to cause septicemia.
 Bacterial infection :

 Less commonly, infection may result from

hematogenous spread of an organism to the
kidney

 with the renal tissue being the first part of

the tract to be infected.
 From an epidemiological viewpoint,
 UTIs occur in two general settings:

1-community-acquired and
2-hospital (nosocomially) acquired, most often
being associated with catheterization.

Hospital-acquired UTIs, while less common

than community acquired, contribute
significantly to overall nosocomial infection
rates.
 The Gram-negative rods:

 Escherichia coli (the commonest cause of

ascending UTI )
 Other members of the Enterobacteriaceae:

-Proteus mirabilis
-Klebsiella, Enterobacter, Serratia spp. and
Pseudomonas aeruginosa
 The Gram-negative rods:
 Enterobacteriaceae:

-Proteus mirabilis:
associated with urinary stones (calculi),
probably because this organism produces a
potent urease,
which acts on urea to produce ammonia,
rendering the urine alkaline.
 The Gram-negative rods:
 Enterobacteriaceae:

-Klebsiella, Enterobacter, Serratia spp. and

Pseudomonas aeruginosa :
are more frequently found in hospital-
acquired UTI
because their resistance to antibiotics favors
their selection in hospital patients
 Gram-positive species
 Staphylococcus saprophyticus :

◦ especially in young sexually active women.

 Staphylococcus epidermidis and
 Enterococcus species are more often

associated with UTI in hospitalized patients

(especially those with AIDS), where multiple
antibiotic resistance can cause treatment
difficulties.
 Gram-positive species
 corynebacteria and lactobacilli
 Obligate anaerobes: very rarely
 Hematogenous spread to the urinary tract:

 other species may be found:

 Salmonella typhi,
 Staphylococcus aureus
 Mycobacterium tuberculosis (renal

tuberculosis).
Downloaded from: StudentConsult (on 28 February 2011 02:58 PM)
© 2005 Elsevier
 rare
 hemorrhagic cystitis and other renal

syndromes
 may be recovered from the urine in the
absence of urinary tract
 The human polyomaviruses, JC and BK
 cytomegalovirus (CMV) and
 rubella
 Adenovirus:hemorrhagic cystitis
 The rodent-borne hantavirus
 mumps and HIV
 Candida spp. and
 Histoplasma capsulatum
 The protozoan: Trichomonas vaginalis
 Schistosoma haematobium : hematuria.
 A variety of mechanical factors predispose to UTI
 Pregnancy, prostatic hypertrophy, renal calculi,
tumors and strictures are the main causes of
obstruction to complete bladder emptying
 Catheterization is a major predisposing factor for
UTI
 A variety of virulence factors are present in the
causative organisms
 The healthy urinary tract is resistant to bacterial
colonization
 A key feature is the detection of significant
bacteriuria.
 Infection can be distinguished from

contamination by quantitative culture

methods
 the urinary tract is sterile,
 the distal region of the urethra is colonized with
commensal organisms,
 which may include periurethral and fecal
organisms.
 As urine specimens are usually collected by
voiding a specimen into a sterile container, they
become contaminated with the periurethral flora
during collection.
 Infection can be distinguished from
contamination by quantitative culture methods.
 the urinary tract is sterile,
 the distal region of the urethra is colonized with
commensal organisms,
 which may include periurethral and fecal
organisms.
 As urine specimens are usually collected by
voiding a specimen into a sterile container, they
become contaminated with the periurethral flora
during collection. Midstream urine (MSU)
 Infection can be distinguished from
contamination by quantitative culture methods.
 is defined as 'significant' when a properly
collected midstream urine (MSU) specimen is
shown to contain over 105 organisms/ml.
 Infected urine usually contains only a single
bacterial species.
 Contaminated urine usually has <104
organisms/ml and often contains more than
one bacterial species
 Distinguishing infection from contamination
when counts are 104-105 organisms/ml can
be difficult.
 urine specimens collected from:
 Catheters
 nephrostomy tubes
 suprapubic aspiration directly from the

bladder:
 any number of organisms may be significant

because the specimen is not contaminated by

periurethral flora.
Infection of sites in the urinary tract below
the bladder
 by organisms that are not members of the

normal fecal flora:

 may not lead to the presence of significant
numbers in the urine.
 Difficult
 'Bag urine' may be collected by sticking a

plastic bag to the perineum in girls or to the

penis in boys
 such specimens are frequently heavily

contaminated with fecal organisms.

 with minimum delay
 because urine is a good growth medium
 for many bacteria and multiplication of

organisms in the specimen between

collection and culture will distort the results
 should be collected before antimicrobial
therapy is started.
 If the patient is receiving, or has received,

therapy within the previous 48 h, this should

be stated clearly on the request form.
 a catheter specimen of urine is used
 Patients should not be catheterized simply to

obtain a urine sample.

M. tuberculosis
 Schistosoma haematobium
 M. tuberculosis

 three early morning urine samples on

consecutive days
 S. haematobium

 the last few ml of a late morning urine

sample collected after exercise
 Microscopic examination of urine allows a
rapid preliminary report
 Bacteria may be seen on microscopy when

present in the specimen in large numbers.

 However, they are not necessarily indicative

of infection,
 but may indicate that the specimen has been

poorly collected or left at room temperature

for a prolonged period of time.
 Microscopic examination of urine
 The presence of red and white blood cells,

although abnormal, is not necessarily

indicative of UTI.
 infection of the urinary tract and elsewhere
(e.g. bacterial endocarditis)
 renal trauma
 calculi
 urinary tract carcinomas
 clotting disorders
 thrombocytopenia
 Occasionally, red blood cells may contaminate
urine specimens of menstruating women.
White blood cells are present in the urine in
very small numbers (e.g. <10/ml) in health
 a count of over 10/ml is considered

abnormal, but is not always associated with

bacteriuria.
 Sterile pyuria is an important finding and may
reflect: concurrent antibiotic therapy
 other diseases such as neoplasms or urinary

calculi
 infection with organisms not detected by

routine urine culture methods.

 Renal tubular cells, seen in the urine of

aspirin-misusers, may be confused with

white blood cells. Urinary casts are also
indicative of renal tubular damage.
 A laboratory diagnosis of significant
bacteriuria requires quantification of the
bacteria
 Conventional culture methods produce

results within 18-24 h, but rapid methods

(e.g. based on bioluminescence, turbidimetry,
leukocyte esterase/nitrate reductase test,
etc.) are also available.
 storage - the urine must be cultured within 1
h of collection or held at 4°C for not more
than 18 h before culture
 antibiotic treatment - in a patient receiving

antibiotics, smaller numbers of organisms

may be significant and may represent an
emerging resistant population.
 fluid intake - the patient may be taking more
or less fluid than usual, and this will clearly
influence the quantitative result
 the specimen - the quantitative guidelines

are valid for MSU specimens; they do not

apply to catheter specimens, suprapubic
aspirates or nephrostomy samples.
 1. Microscopy
 2. Quantitative culture


3. Susceptibility testing
 Gram staining→ presence of leukocytes
and microorganisms
 microscopic examination:
 Presence of significant number of bacteria in
uncentrifuged urine sample–high magnifaction
power in immersion field; x1000- with Gram stain):
≥ 1 bacterium or bacteria/high power field.
 conventionally accepted to correspond ≥105
CFU/mL)
 Culture:
Presence of significant number of bacteria
inuncentrifuged urine sample (quantitative
culture result): ≥ 103 to ≥105 CFU/mL
 Bacteria/ no.of coloni
 In asemptomatic patients
 105 cfu/ml (male 104): identification and
antibiotic susceptibility test (AST)
 104- 105 cfu/ml : contact with clinician if >2
bacteria is seen
 102 cfu/ml : significant if it is taken from
catheter
 10 cfu/ml: significant if its suprapubic
aspiration
 E. coli (%50-90)
 Other Enterobacteriaceae
 S. saphrophyticus (♀)
 P. aeruginosa
 Enterococcus spp.
 Other CNS
Practicals of
Urinary Tract Infection
Important aspects of Microbiologic
Examination of UTI:

- Urine collection
- Urine analysis
- Interpretation of microbiology
laboratory result
 Type of Specimens
Midstream urine (MSU)
Adhesive bag
Suprapubic aspiration
Catheter sample
The urinary catheter

Urine specimens for laboratory investigations can be collected

from catheterized patients as shown (left). The second port is for
putting fluids into the bladder (right).

Urine from the drainage bag should not be tested because it may have
been standing for several hours.
TRANSPORT MEDIA

dipslides
One side is CLED media, the
Sterile other can be MacConkey
Urine container (MAC) agar or blood agar.
Urine analysis;
1- Dip stick (leukocyte esterase ,nitrate test)
Urine analysis;
1- Dip stick (leukocyte esterase ,nitrate test)
2-microscopic ex; cell-counting chamber
 Laboratory examination of urine

Quantitative (Colony counts)

a urine sample is streaked on surface of

+1 Blood Agar plate and CLED agar / Mc Conkey
+2 agar with a special loop calibrated to deliver
a known volume.
+3
Over night incubation
+4
Isolation of colonies,Biochemical tests,
Drug susceptibility test,

Over night incubation

RESULT
Urinary Tract infection Module’05 …..
GRAM NEGATIVE GRAM POSITIVE
Escherichia coli Enterococcus

Klebsiella Staphylococcus saprophyticus

Proteus Streptococcus agalactiae

(group B)
Other Enterobacteriaceae Staphylococcus aureus
(Enterobacter,Citrobacter….)

Pseudomonas aeruginosa

•Other organisms ;
•Candida
•Schistosoma haematobium
 culture media

blood agar MacConkey agar

CLED agar

an enriched medium a differential medium Selective medium

Blood agar

An enriched medium,
especially for culturing
fastidious
microorganism and
observed the hemolytic
reaction
MacConkey's agar showing
both lactose and non-lactose fermenting colonies.
Lactose fermenting colonies are pink whereas
non-lactose fermenting ones are colourless or
appear same as the medium.|
 CLED agar

Selective culture medium for detection and isolation

Of Escherichia coli and coliform bacteria in urine
gram negative bacilli
E coli

Indole Reactions
Negative Positive
Klebsiella pneumoniae
E coli

Klebsiella
Klebsiella pneumoniae
E coli

Klebsiella
 proteus is Urease positive
CLED  [(Cystine-Lactose- Urease splits urea into
ammonia; and alkalinizes
Electrolyte-Deficient) - the urine with production of
inhibits the proteus swarm crystals
Proteus spp,
Pseudomonas aeruginosa
 E coli Klebsiella pneumoniae

Pseudomonas aeruginosa

Proteus spp,
Three API 20E strips :
a. Immediately after inoculation
b. After 24 hours incubation
c. That in ( b) after addition of reagents to certain wells.

The organisms here is Escherichia coli.

Enterococcus species

 Bile Esculin hydrolysis

Both Group D streptococci

and enterococci produce a
positive (left) bile Esculin
hydrolysis test.
Catalase
2H2O2  O2 + 2H2O
Streptococci vs. Staphylococci
Differential
Characteristics
S. aureus
Staphylococcus
aureus

Coagulase POS

Coagulase NEG
 NOVOBIOCIN TEST

Staphylococcus saprophyticus Staphylococcus epidermidis

(resistant-Novobiocin) (sensitive-Novobiocin )
Antibiotic sensitivity test: Agar diffusion method
 Case 1
The blood agar plate and CLED plate provided were inoculated
with a sample of urine from a patient with a suspected urinary
tract infection. Examine the plates and photographs provided.
•Identify the colonies on the blood agar plates and photographs.
The photographs show the results of the Gram stain of each
colony type.
•Large colonies are Gram……….and small colonies are Gram……….

CLED plate Blood agar Gram stain

 Case 2
These Blood agar and CLED agar plates were
inoculated with MSU from a 45 years old man
suspected of having bladder stone and
complaining of burning micturation.
Urine examination showed :
Moderate number of WBC and a PH of 8

CLED Blood agar

A) What is the likely this pathogen?
B) How would you confirm the identity of this pathogen?
C) What is the role of this organism in forming stones?
 Candida albicans

Growth on Sabouraud's
Dextrose Media Candida albicans on blood
agar;
Chlamydospore Germ tube test
Schistosoma haematobium

Schistosoma
haematobium
(urine; eggs 115-170 x 45-
65 micrometers)
(primates)