UTI – Misc.

MI -7.1, 7.3
Dr.C.Meenakshisundaram.,MD
1. Which of the following bacteria is rarely associated with
urinary tract infections?
a) E.coli
b)Enterobacter spp
c)Proteus spp
d)Shigella spp
2. A 2-day old premature baby boy born to a 22-year-old
woman developed pneumonia. The mother showed the
symptoms of urinary tract infection after the delivery. The
blood specimen was taken from the baby, beta-hemolytic
colonies were observed in the culture plate after 24
hours. Which could be the possible pathogen that might
have transferred from the mother to the baby?
a) Streptococcus pyogenes 
b) Streptococcus agalactiae 
c) Enterococcus faecalis
d) Streptococcus bovis 
3. Which of the following bacteria is the most commonly
isolated pathogen from the infection pharyngitis?
a) Streptococcus pneumoniae
b) Staphylococcus aureus
c) Streptococcus pyogenes
d) Mycoplasma pneumoniae

4.Name the cocci which are the part of bacterial flora found in
human intestines? Select the correct answer 
a) Enterococcus faecalis
b) Micrococcus luteus
c) Staphylococcus epidermidis
d) Streptococcus mutans
5. Which of the following pathogen is the main cause of
endocarditis in individuals having heart diseases?
a) Streptococcus intermedius
b) Enterococcus faecalis
c) Streptococcus suis
d) Micrococcus luteus
Enterococcal Infections

▫ Enterococci - most common gram-positive cocci to cause UTI.

▫ Initially grouped under group D Streptococcus, but later - reclassified as a
separate genus Enterococcus.
▫ Based on the molecular structure, they are now placed under a new family;
Enterococcaceae.

5
Virulence Factors

▫ Aggregation substances or pheromones - Clumping of adjacent cells to

facilitate plasmid exchange (transfers drug resistance)
▫ Extracellular surface protein (ESP) – Adhesion to bladder mucosa
▫ Common group D lipoteichoic acid antigen - Cytokine release such as
tumor necrosis factor α (TNFα)

6
Clinical Manifestations

▫ Urinary tract infections

▫ Chronic prostatitis
▫ Bacteremia and left-sided endocarditis
▫ Intra-abdominal, pelvic and soft tissue infections, surgical site infections
▫ Neonatal infections: Sepsis (mostly late-onset), bacteremia, meningitis,
and pneumonia.

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Laboratory Diagnosis

▫ Gram-positive oval cocci arranged in pairs, arranged at an angle to each

other (spectacle-shaped appearance)
▫ Blood agar: Non-hemolytic, translucent colonies (rarely produces α or β-
hemolysis)
▫ MacConkey agar: Minute magenta pink colonies

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Laboratory Diagnosis (Cont..)

A B C
A. Gram-positive oval cocci in pairs; B. translucent non-hemolytic colonies
on blood agar; C. Bile esculin hydrolysis test (left—negative, right—positive
result, black color due to esculin hydrolysis).

9
Laboratory Diagnosis (Cont..)

▫ Bile esculin hydrolysis test is positive

▫ Grow in presence of extreme conditions such as—6.5% NaCl, 40% bile,
pH 9.6, 45oC and 10oC
▫ E. faecalis and E. faecium - differentiated by arabinose fermentation test

10
Treatment of Enterococcal infections

For less serious infections :

▫ UTI: Oral therapy with ampicillin, nitrofurantoin or fosfomycin
▫ Intra-abdominal and soft tissue infections: Ampicillin, vancomycin or
linezolid can be given.

12
Treatment of Enterococcal infections
(Cont..)

For invasive infections:

▫ Endocarditis, bacteremia, and meningitis: Combination therapy with a
cell wall–active agent (e.g. penicillin or ampicillin) and an aminoglycoside
(e.g. gentamicin) is recommended
▫ Synergistic effect is due to cell wall alterations produced by cell wall–
active agents - facilitate penetration of aminoglycoside into the bacterial
cell

13
Treatment of Enterococcal infections
(Cont..)

For invasive infections (Cont..):

▫ This combination therapy fails if the isolate is found resistant to either
penicillin or high level aminoglycoside in vitro.
▫ In such case, alternative drugs - vancomycin, linezolid or daptomycin can
be considered.

14
Treatment of Enterococcal infections
(Cont..)

▫ If resistant to vancomycin - linezolid, streptogramins (only active against

E. faecium) and daptomycin

15
Vancomycin Resistant Enterococci
(VRE)
▫ In India, the VRE rate - 9.7% (overall); 2.5% for E. faecalis and 17.4% for
E. faecium (ICMR, 2019)
▫ Mechanism: Mediated by van gene - alters the target site for vancomycin
present in the cell wall - D-alanyl-D-alanine side chain of peptidoglycan
layer - altered to D-alanyl-D-serine or D-alanyl-D-lactate - less affinity for
binding to vancomycin

16
VRE Carriers

▫ Screening for VRE: High risk patients - ICUs and transplantation units
▫ Detection: Rectal swab collected and subjected to (i) Sodium azide agar
with vancomycin or (ii) PCR for detection of van gene.
▫ Management: Infection control measures - hand hygiene and isolation
precautions. Treatment (i.e. decolonization) - recommended for VRE
carriers.

17
Other Gram-positive cocci Causing UTI

▫ Staphylococcus aureus
▫ Staphylococcus saprophyticus
▫ Streptococcus agalactiae

18
Other Bacterial Infections of Urinary
Tract
▫ Renal Tuberculosis
▫ Post-streptococcal Glomerulonephritis (PSGN)
▫ Perinephric and Renal Abscesses

19
Differences between acute rheumatic fever and
poststreptococcal glomerulonephritis

Features Acute rheumatic fever (ARF) Post-streptococcal

glomerulonephritis
(PSGN)
Prior history of Pharyngitis strains Mainly pyoderma, or rarely
infection with pharyngitis strains
Serotypes responsible Most of the strains of group A Only nephritogenic strains
Streptococcus
Immune response Marked Moderate
Complement level Unaltered Low (due to deposition in
glomeruli)
Genetic susceptibility Present Absent
Repeated attack Common Uncommon

20
Differences between acute rheumatic fever and
poststreptococcal glomerulonephritis (Cont..)

Features Acute rheumatic fever (ARF) Post-streptococcal

glomerulonephritis
(PSGN)
Penicillin prophylaxis Indicated Not indicated
Course Progressive Spontaneous resolution
Prognosis Variable Good
Hypersensitivity Type II Type III
reaction

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VIRAL INFECTIONS
OF URINARY SYSTEM
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BK Virus Infection

▫ BK virus causes nephropathy in kidney transplant recipients.

▫ Also cause hemorrhagic cystitis in hematopoietic stem cell transplant
recipients.
▫ Naming: Named after the initials of the patient in whom it was described
first. Polyomavirus, dsDNA

23
BK Virus Infection (Cont..)

Diagnosis: The diagnostic modalities include:

▫ Renal biopsy
▫ PCR
▫ Asymptomatic BK viruria (detection of BK virus DNA in urine)

24
BK Virus Infection (Cont..)

▫ Treatment: There is no specific treatment available.

▫ Cidofovir - treatment of refractory cases.

25
Adenovirus Cystitis

▫ Adenovirus serotypes 11 and 21 - acute hemorrhagic cystitis in children,

especially in boys.

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PARASITIC
INFECTIONS
OF URINARY SYSTEM
27
Urinary Schistosomiasis (S.
haematobium)
▫ Schistosoma haematobium - causative agent of urinary schistosomiasis or
Bilharziasis
▫ Blood trematode (or fluke), resides in venous plexus of urinary bladder and
ureter
▫ Other two blood flukes Schistosoma mansoni and S. japonicum reside in
venous plexus of intestine and mesentery, produce intestinal disease

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Life Cycle

29
Pathogenesis and Clinical Features

Acute Schistosomiasis
▫ The invasion of cercariae in the skin causes dermatitis at penetration site
followed by allergic pruritic papular lesion.

30
Pathogenesis and Clinical Features
(Cont..)

Chronic Schistosomiasis
▫ Urogenital disease - cystitis glandularis
▫ Obstructive uropathies
▫ Bladder carcinoma - Squamous cell carcinoma

31
Laboratory Diagnosis

Urine Microscopy
▫ Diagnosis of S. haematobium
infection - detection of non-
operculated terminal spined eggs
in the urine or rarely in feces

A B

32
Laboratory Diagnosis (Cont..)

Histopathology:
▫ S. haematobium eggs - bladder mucosal biopsy or wet cervical biopsy
specimens (in females).
▫ Number of eggs present in crushed tissue correlates significantly with the
size of the genital lesions.

33
Laboratory Diagnosis (Cont..)

Antibody Detection:
▫ Useful for sero-epidemiology. Detect serum antibodies against S.
haematobium adult worm microsomal antigen (HAMA).
 HAMA-FAST-ELISA (Falcon assay screening test ELISA)
 HAMA-EITB (Enzyme-linked immunotransfer blot)
 IgE and IgG4 are elevated

34
Laboratory Diagnosis (Cont..)

Antigen Detection:
▫ Detection of circulating antigen - recent infection
▫ Circulating cathodic antigen (CCA) and circulating anodic antigen (CAA) -
detected in serum and urine by ELISA or dip stick assays
▫ CCA levels are much higher in urine than CAA.

35
Treatment of Urinary schistosomiasis

▫ Praziquantel - drug of choice; given 20 mg/kg/dose, two doses in single

day.
▫ Metrifonate – alternatively - inhibits acetylcholine receptors on tegument
surface of adult male worm.
▫ Administered in multiple oral doses over weeks - not preferred in control
programs.

36
Prevention

▫ Proper disposal of human excreta and urine

▫ Eradication of snails by using molluscicides - metal salts (iron or
aluminum sulfate), metaldehyde, methiocarb and acetylcholine esterase
inhibitors
▫ Treatment of infected persons.

37
Dioctophyme renale Infection

▫ Dioctophyme renale - “giant kidney worm” - nematode of lower animals

▫ Life cycle: Human infection - ingestion of fish infected with larva of D.
renale.
▫ Larva penetrates - intestine - kidney - transform into adult worms. Adult
worms - larger in size - block the kidney and ureter.
▫ Adult worms lay eggs, that are passed in urine

38
Dioctophyme renale Infection (Cont..)

▫ Clinical features: Hematuria and renal

colic, extensive destruction of kidney
parenchyma.
▫ Laboratory diagnosis: Eggs in urine -
oval-shaped, 60–80 μm size, contain an
embryo surrounded by characteristic thick
sculptured or pitted egg shell
A B

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Trichomonas vaginalis Urethritis

▫ T. vaginalis is a sexually-transmitted parasite that primarily cause

urethritis.
▫ The trophozoites may be detected in urine sediment.

40
FUNGAL INFECTIONS
OF URINARY SYSTEM
41
Candiduria

▫ Isolation of Candida species in urine - common finding - result from

contamination during collection, bladder colonization, or upper UTI (due
to hematogenous or ascending infection from bladder).

42
Candiduria (Cont..)

▫ Treatment of candiduria - considered in the following situations:

 Symptomatic cystitis or pyelonephritis, high-risk for disseminated
disease
 Neutropenic or immunosuppressed patients
 Patients undergoing urologic manipulation
 If upper-pole or bladder-wall invasion or obstruction is associated
 Critically-ill patients (have higher risk for invasive candidiasis)
 Low birth weight infants

43
Candiduria (Cont..)

▫ Fluconazole (for 14 days) - drug of choice, as it reaches high levels in

urine.
▫ Fluconazole resistance - oral flucytosine and/or parenteral amphotericin B
can be considered.

44
1. Which of the following bacteria is rarely associated with
urinary tract infections?
a) E.coli
b)Enterobacter spp
c)Proteus spp
d)Shigella spp

2. A 2-day old premature baby boy born to a 22-year-old

woman developed pneumonia. The mother showed the
symptoms of urinary tract infection after the delivery. The
blood specimen was taken from the baby, beta-hemolytic
colonies were observed in the culture plate after 24
hours. Which could be the possible pathogen that might
have transferred from the mother to the baby?
a) Streptococcus pyogenes 
b) Streptococcus agalactiae 
c) Enterococcus faecalis
d) Streptococcus bovis 
3. Which of the following bacteria is the most commonly
isolated pathogen from the infection pharyngitis?
a) Streptococcus pneumoniae
b) Staphylococcus aureus
c) Streptococcus pyogenes
d) Mycoplasma pneumoniae

4.Name the cocci which are the part of bacterial flora found in
human intestines? Select the correct answer 
a) Enterococcus faecalis
b) Micrococcus luteus
c) Staphylococcus epidermidis
d) Streptococcus mutans
5. Which of the following pathogen is the main cause of
endocarditis in individuals having heart diseases?
a) Streptococcus intermedius
b) Enterococcus faecalis
c) Streptococcus suis
d) Micrococcus luteus
1. Which of the following bacteria is rarely associated with
urinary tract infections?
a) E.coli
b)Enterobacter spp
c)Proteus spp
d)Shigella spp

2. A 2-day old premature baby boy born to a 22-year-old

woman developed pneumonia. The mother showed the
symptoms of urinary tract infection after the delivery. The
blood specimen was taken from the baby, beta-hemolytic
colonies were observed in the culture plate after 24
hours. Which could be the possible pathogen that might
have transferred from the mother to the baby?
a) Streptococcus pyogenes 
b) Streptococcus agalactiae 
c) Enterococcus faecalis
d) Streptococcus bovis 
3. Which of the following bacteria is the most commonly
isolated pathogen from the infection pharyngitis?
a) Streptococcus pneumoniae
b) Staphylococcus aureus
c) Streptococcus pyogenes
d) Mycoplasma pneumoniae

4.Name the cocci which are the part of bacterial flora found in
human intestines? Select the correct answer 
a) Enterococcus faecalis
b) Micrococcus luteus
c) Staphylococcus epidermidis
d) Streptococcus mutans
5. Which of the following pathogen is the main cause of
endocarditis in individuals having heart diseases?
a) Streptococcus intermedius
b) Enterococcus faecalis
c) Streptococcus suis
d) Micrococcus luteus
Thank you