URINARY TRACT

INFECTION
A CASE REPORT
DR. Anastasia M Runtunuwu
Senior : DR. Christine Belinda
 • Urinary track infection
CASE
presenting with
REPORT nonspecific complaints
and normal urinalysis in
84 year-old woman
Case profile
An 84-year old woman was transferred to our hospital be- cause of suspected stroke.
She had been well until she sud- denly felt uncomfortable and developed chest
discomfort whilst shopping with her partner. She immediately present- ed to a local
hospital.

• On admission, her blood pressure was 175/100 mmHg and she complained of chest
discomfort and fatigue.
• About 1 hour after admission, she appeared le- thargic, confused and disoriented and
developed difficulties with speaking and word finding.
Case profile
• On admission to our emergency department, she was con- fused and disoriented in
time and place and she was un- able to recall the events of that day.
• Her blood pressure was 177/96 mmHg and her pulse was 92/min.
• Physical and neurologic examinations were otherwise normal; no speech disturbance
was recorded.
• Results of the laboratory tests, including a complete blood count, tests for renal and
hepatic function, electrolytes, glucose, C-reactive protein, creatine kinase and
troponin-T and urinalysis were normal.
• Electrocardiogram and chest radiographs were also normal.
Case profile
• Over the following hours, the patient reported various non-spe- cific complaints, such
as tiredness, chest discomfort and generalized weakness.

• Six hours after admission, she developed fever of 38.5°C

• Leucocyte count in the second urinalysis was slightly higher than the initial finding
(13/high-power field (HPF)), but not significant for a diag- nosis of urinary tract
infection (UTI).

• All results of lumbar puncture were normal.

Case profile
• 12 hours after the admission, she developed urine incontinence and therefore, a third
urine test was taken – and indeed, this urinalysis revealed a clear finding of UTI
(Table 1).

• Klebsiella pneumoniae (106 cfu/ml) was grown in a subsequent urine culture. All
blood cultures remained sterile.
 Past History

• No history of Dementia

• Hypertension and taking antihypertensive daily

• Taking aspirin 100mg daily

• Family history: Not significant.
• Social history : No history of addiction.
• Non-smoker & rarely consumed alcohol
 Results of serial urinalysis and blood tests
for leucocytes and C-reactive protein.
  Local Hospital On admission After 6 hours After 12 hours
 
Nitrite Negative Negative Negative Negative

Leucocytes (+) + Negative +++

Blood + + ++ +++++

Leucocytes /HPF* 0–5 4 13 >>40

Erythrocytes /HPF* 0–5 3 3 30

Leucocytes (×109/l) 7.8 - - 10.5

C-reactive protein (mg/l) <5 - - 1.2

Diagnostic
• After treatment with ceftriaxone, the patient recovered quickly; mental status as well
as blood pressure normalized within 24 hours.

• She was discharged after 3 days of hospital treatment for urosepsis.

• Two months after the hospitalization, she was in her best condition
Urinary Tract
Infection (UTI)
Definition
• A urinary tract infection (UTI) is an infection in any part of your urinary system —
your kidneys, ureters, bladder and urethra. Most infections involve the lower urinary
tract — the bladder and the urethra.

• Women are at greater risk of developing a UTI than are men. Infection limited to your
bladder can be painful and annoying. However, serious consequences can occur if a
UTI spreads to your kidneys.

• Doctors typically treat urinary tract infections with antibiotics. But you can take steps
to reduce your chances of getting a UTI in the first place.
Definition
• A urinary tract infection (UTI) is an infection in any part of your urinary system —
your kidneys, ureters, bladder and urethra. Most infections involve the lower
urinary tract — the bladder and the urethra.

• Women are at greater risk of developing a UTI than are men. Among adults aged
20 to 50 years, UTIs are about 50- fold more common in women.
Risk Factor
1. Sex

2. Anatomy and Physiology of woman’s organ.

3. Urinary Catheters.

4. In Children’s; Due to Vesicoureteral reflux.

5. Hyperplasia: causes obstruction of the uretra.

6. Diabetes.
Pathophysiology of UTI
Etiology
The bacteria that most often cause cystitis and pyelonephritis are the following:
Enteric, usually gram-negative aerobic bacteria (most often)
Escherichia coli : 75 to 95% of cases.
Klebsiella
Proteus mirabilis
Pseudomonas aeruginosa.
Gram-positive bacteria (less often)
Staphylococcus saprophyticus is isolated in 5 to 10% of bacterial UTIs.
Enterococcus faecalis (group D streptococci)
Streptococcus agalactiae (group B streptococci)
In hospitalized patients, E. coli accounts for about 50% of cases. The gram-negative species Klebsiella, Proteus, Enterobacter,
Pseudomonas, and Serratia account for about 40%, and the gram-positive bacterial cocci, E. faecalis, S. saprophyticus, and
Staphylococcus aureus account for the remainder.
Part of urinary tract affected
Kidneys (acute pyelonephritis)
Bladder (cystitis)
Urethra (urethritis)
Signs and symptoms
•Upper back and side (flank) pain
•High fever
•Shaking and chills
•Nausea
•Vomiting
•Pelvic pressure
•Lower abdomen discomfort
•Frequent, painful urination
•Blood in urine
•Burning with urination
•Discharge
Diagnosis
• History. Diagnosis is made primarily by history. In women with dysuria and frequency,
in the absence of vaginitis, the diagnosis is UTI 80% of the time [IC*].
• Urinalysis. Urinalysis for detection of pyuria by dipstick or microscope has a
sensitivity of 80- 90% and a specificity of 50% for predicting UTI [IB*].
• No urine culture. Urine culture is NOT indicated in the vast majority of UTI’s [IIIC*].
UC has a sensitivity of 50% (if threshold for positive is >10 organisms), sensitivity can
5

be increased to >90% if threshold is >10 organisms. Consider urine culture only in

2

recurrent UTI or in the presence of complicating factors

Treatment
• Acute uncomplicated cystitis in women historically has been treated with longer
(7-10 day) courses of antibiotics. However, studies have found shorter courses (3-5
days) of oral antibiotics to be as effective as traditional courses. A review of 28
treatment trials of adult women with uncomplicated cystitis concluded that no
benefit was achieved by increasing the length of therapy beyond 5 days. The
advantages of shorter course therapy include decreased costs of antibiotics,
improved patient compliance and decreased adverse effects of antibiotic treatment
Treatment
• When comparing different treatment strategies, single-dose regimens are less efficient
at eradicating bacteriuria, than 3- 5 day regimens (23-81% versus 77-91% long-term
cure, respectively). No benefit is apparent in increasing theduration of trimethoprim/
sulfamethoxazole (TMP/SMX) or trimethoprim (TMP) beyond 3 days. Cure rates of
82 to 85% have been achieved with 3-day therapy. Adverse effects increase markedly
if treatment is continued past 3 days.
Treatment
• Longer courses of therapy should be used in women who are diabetic, pregnant have
had symptoms longer than 7 days, or have other evidence for complicated UTI (see
Table 2). In general, older women with lifelong history of UTI and no history of
complicating factors are managed as uncomplicated UTI. However, specific
treatment algorithms in this age group have rarely been assessed. Consider 5-days of
nitrofurantoin for those patients whose health status increases risk of urological
defects. However, nitrofurantoin is contraindicated in patients with a CrCl < 50
ml/min.
Complication
• Recurrent infections, especially in women who experience two or more UTIs in a six-
month period or four or more within a year.
• Permanent kidney damage from an acute or chronic kidney infection (pyelonephritis)
due to an untreated UTI.
• Increased risk in pregnant women of delivering low birth weight or premature infants.
• Urethral narrowing (stricture) in men from recurrent urethritis, previously seen with
gonococcal urethritis.
• Sepsis, a potentially life-threatening complication of an infection, especially if the
infection works its way up your urinary tract to your kidneys.
Prevention
•In women who experience ≥ 3 UTIs/yr, behavioral measures are recommended, If
these techniques are unsuccessful, antibiotic prophylaxis should be considered.
Common options are continuous and postcoital prophylaxis.

•Continuous prophylaxis commonly begins with a 6 mo trial. If UTI recurs after 6 mo

of prophylactic therapy, prophylaxis may be reinstituted for 2 or 3 yr.

•TMP/SMX 40/200 mg po once/day or 3 times/wk,

•Nitrofurantoin 50 or 100 mg po once/day, cephalexin 125 to 250 mg po once/day,

Prevention
•Postcoital prophylaxis in women may be more effective if UTIs are temporally related
to sexual intercourse. Usually, a single dose of one of the drugs used for continuous
prophylaxis is effective.

•In postmenopausal women, antibiotic prophylaxis is similar to that described

previously. Additionally, topical estrogen therapy markedly reduces the incidence of
recurrent UTI in women with atrophic vaginitis or atrophic urethritis.