Urinary Tract Infection

in Adult
By HSC/FC
Table of content
Anatomy, pathopysiology Investigation
01 By Dr Aimie 04 By Dr Rosalind

Sign and symptoms Management

02 By Dr Radzie 05 By Dr Ming

Classification
03 By Dr Rubini
Ready!
Jomms…
Case No. 1
History
A 27-year-old woman is admitted to the emergency department complaining of pain across
her back. She became unwell 2 days previously when she started to develop a fever and an
ache in her back. The pain has become progressively more severe. She has vomited twice in
the past 6 h. She has had no previous significant medical history, apart from an
uncomplicated episode of cystitis 3 months ago
Case No. 1
Examination

She looks unwell and is flushed. Her temperature is 39.5°C. Her pulse is 120
beats/min and blood pressure 104/68 mmHg. Examination of the cardiovascular and
respiratory systems is unremarkable. Her abdomen is generally tender, but most
markedly in both loins. Bowel sounds are normal.
 Investigation
Bloods Normal Value
Haemoglobin 15.3 g/dL 11.7–15.7 g/dL
White cell count 25.2 % 109/L 3.5–11.0 % 109/L
Platelets 406 % 109/L 150–440 % 109/L
Sodium 134 mmol/L 135–145 mmol/L
Potassium 4.1 mmol/L 3.5–5.0 mmol/L
Urea 14.2 mmol/L 2.5–6.7 mmol/L
Creatinine 106 &mol/L 70–120 &mol/L
Albumin 44 g/L 35–50 g/L
CRP 316 mg/L <5 mg/L
Urinalysis: ++ protein; +++ blood; ++ nitrites
Urine microscopy: >50 red cells; >50 white cells
Abdominal X-ray: Normal
Questions
What is the likely diagnosis?
How would you investigate and manage this patient?
 “Education is not the learning of
facts, but the training of the mind to
think.”
—Albert Einstien
Learning Objective
Master the urinary Diagnosed UTI base
tract anatomy and on clinical findings
UTI and correct
pathophysiology investigation

Able to detect sign

and symptoms of Manage UTI
UTI according to cases like a
it’s classification boss!
 0
1
Anatomy &
Pathophysiology
-By Dr Aimie-
Male
Female
Etiology
Escherichia coli remains the predominant
pathogens (80%).

Other causative organisms of UTI:

● Klebsiella and enterobacter species
● Proteus mirabilis/vulgaris
● Staphylococcus aureus/sapropyhticus
● Enterococcus faecalis
● Pseudomonas aeruginosa
Route of transmission

Ascending Route

Descending Route

Lymphatic Route
Factors predispose to infection:

Host Bacterial

• Female anatomy • Bacterial adhesins

• Incomplete voiding • Type 1 and P-fimbriae
• Obstruction • Hemolysin production
• Paralysis
• Poor hygiene
• Bladder catheterization
• Underlying disease
Pathogenesis

Colonization Ascension

Urethra Bladder Ureters Kidneys

Uroepithelium Pyelonephritis
penetration Acute kidney Injury
 02
Sign & Symptoms
-By Dr Radzie-
Lower
eg. Urethritis , Cystitis, Prostatitis

Dysuria Frequency
Urgency Hematuria
Burning

Suprapubic Cloudy urine with

discomfort/p offensive smell
ain
Upper
eg. Pyelonephritis, Pyelonephrosis, Renal anscess

Fever Vomiting Malaise

Rigors

Loin/back Sign of
pain sepsis/septic shock
(occasional)
Elderly

Paeds
 03
Classification
-By Dr Rubini-
Uncomplicated
Without underlying renal or neurologic disease

Is usually considered to be cystitis or

pyelonephritis that occurs in premenopausal adult
women with:

● No structural/functional abnormality of urinary

tract
● Not pregnant
● Have no significant comorbidity
Complicated UTI with underlying structural, medical or
neurologic disease
Can involve either sex at any age

i) The patient is a child or pregnant

ii) Patient has any of the following

● A structural/functional urinary abnormality and

obstruction of urine flow
● A comorbidity that increases the risk of
acquiring infection, eg. poorly controlled DM,
CKD or immunocompromised
● Recent instrumentation or surgery of urinary
tract
Hang on
there!
 04
Investigation
-By Dr Rosalind-
Laboratory
● Can be diagnosed by UFEME (dipstick)

● To identify microorganism infected Urine C&S is required

● Renal profile blood is useful to monitor kidney function as a

complication of UTI can lead to deranged RP.
When to do UFEME
If symptom presents

Positive Negative Negative

Nitrite Nitrite Nitrate
alone

OR AND AND

Positive Nitrate Positive Negative

& Leukocyte Leukocyte Leukocyte
esterase esterase esterase

Probable UTI Probable UTI Consider

alternative
diagnosis
Send Urine
C+S before
antibiotics
Differential diagnoses
● Acute appendicitis

● BPH/prostatitis

● STIs, gonorrhea/chlamydia

● Vaginitis

● Painful bladder syndrome

● Pelvic inflammatory disease

UFEME Bottle
 Special Notes on Nitrites/Leukocytes
● Some bacteria (proteus, e.coli etc) can convert dietary nitrates into nitrites.
Normally, no nitrites are present in urine.
● Reasons for false negatives are insufficient time for conversion of nitrates in the
bladder (need 4H to metabolise), low nitrate diets, non-nitrite producing bacteria,
and low urinary pH (cranberry juice).

● Nit -ve Leu -ve, good for ruling out UTI (specificity 94%, sensitivity 40%
especially in nursing home populations)

● Nit +ve and Nit -ve

OR Sensitivity 75% Specificity 66%
● Nit -ve and Leu +ve

● Hence, the UFEME/dipstick is useful for ruling in UTI, but not good for ruling out
UTI
Special Notes on Nitrites/Leukocytes

Nitrite producing bacteria

 When to do Urine C&S

Pregnant Symptomatic women that

Suspected All men with
women for did not resolved/ recur
recurrent symptoms of
antenatal within 2-4 weeks of
UTI UTI
screening treatment

From age-care
Suspected UTI Women with suspected
facility with UTI Previous
with complicated
symptoms OR non antibiotics
hospitalization UTI/upper UTI or
specific symptoms resistant UTI
for > 1/52 in last sepsis/chills + rigor
suggestive of
infection 6 months
Technique of urine collections
Midstream Urine
Contamination rate
In/Out Cathether MSU In/Out
10%
25%
Suprapubic aspiration
1%
Bag urine SPA
Bag urine 50%
not recommended
Radiology
● In ED setting – usually bedside scan can be done as an adjunct to
identify the cause or the complications in UTI

● Formal ultrasound usually not an urgent in ED

● In bedside scan – bladder stone, renal stones can be seen which

could be possible causes of UTI or any renal abscess /cyst which
could be the complication of UTI .
 When to do USG
Severe Suspected
Clinically ill pyelonephritis renal anscess

Recurrent symptoms
Presistent clinical within a few weeks of
symptoms despite treatment
Suspected
48-72 hs of Suspected
urinary tract
appropriate renal cysts
obstruction
antimicrobial
therapy
 05
Management
-By Dr Ming-
 Treatment
Preferred Alternative In Patient

Uncomplicated
Cystitis T. Cephalexin 500mg BD T. Cefuroxime 250mg BD
(include during x1/52 x1/52
pregnancy)

Uncomplicated T. Augmentin 625mg TDS IV Ceftriaxone 1g OD

IV Augmentin 1.2g TDS
Pyelonephritis x2/52 (In Patient)

Complicated IV Ceftriaxone 1g OD +/-

T. Augmentin 625mg TDS IV Augmentin 1.2g TDS
(includes cathter- Aminoglycoside
x1/52 +/- Aminoglycoside
associated) (In Patient)
Take home message
● Female urinary tract is shorter than men so more prone to infections

● If asymptomatic treat only pregnant patients or prior to urological procedure.

● Urine cultures - ONLY if recurrent or complicated UTI, or suspected

pyelonephritis. Not for simple cystitis.

● Imaging - for pyelonephritis, to exclude obstructive cause. Refer for outpatient

scan in MEN with recurrent UTI.

● Treat as UTI only if BOTH history, examination and investigations agree. NOT on
investigations alone.

● If significant UTI pain can give analgesia

● Discharge advice – keep hygiene, post-coital voiding and drinking large volumes
of water
 No question?

Thanks!
Please answer the post CME question sent to
your e-mail

All the best!

 References
Anatomy
• Kucheria R, Dasgupta P, Sacks SH, et al
Urinary tract infections: new insights
into a common problem Postgraduate
Medical Journal 2005;81:83-86.
• Alan JW, Louis R Alan W, Craig A,
CAMPBELL-WALSH
UROLOGY(11TH ed), Elsev
• https://visualsonline.cancer.gov/details.c
fm?imageid=9754ier (2016)
Sign & Symptoms
Shirley Ooi 2nd edition
Classification
• Tintinalli’s Emergency Medicine Manual 8TH
Edition, Chapter 53
Investigation
• http://farmasi.ummc.edu.my/pharmguideref/antibioticguideline
• http://www.myhealth.gov.my/en/urine-test-strip/
Management
• https://www.betterhealth.vic.gov.au/health/conditionsan
dtreatments/urinary-tract-infections-uti
• https://www.uptodate.com/contents/acute-simple-
cystitis-in-women
• https://www.uptodate.com/contents/acute-simple-
cystitis-in-men
• HSgB Antibiotic Guidelines 2019
Post CME Questions
What is the most common cause of urinary
tract infection?
A. Escherichia coli (E. Coli)
B. Staphylococcus aureus (S. Aureus)
C. Chlamydia
D. Mycoplasma
Ans: A

Which is a common UTI risk factor in

adults?
A. Enlarged prostate
B. Catheter usage
C. Diabetes
D. All of the above
Ans: D
What is the main investigation for UTI The following patients with UTI are considered as
A. Renal profile complicated UTI except
B. ultrasound KUB A. 30 weeks pregnant female
C. UFEME B. Has underlying HIV
answer.C C. Recently had a cystoscopy
D. First presentation of symptomatic UTI
without any functional abnormality of urinary tract
Which of the following is the best technique Ans: D
urine collection for UTI ?
A . initial stream of urine A pregnant woman who is infected with UTI
B . midstream of urine needs prompt medical attention to prevent
C. urine collection from urine bag A. Premature delivery
Answer :B B. High blood pressure
C. Both A and B
D. None of these
Ans: C
What are signs and symptoms of UTI in adults A urinary tract infection might involve the
A.Frequency A. Kidneys
B.Dysuria B. Ureter
C.Milky/ cloudy urine C. Bladder
D.All the above D.All of the above
answer D answer: D

Urinary Tract infection are mainly Each of the following organisms

caused due to is an important cause of UTI except
A. Bacteria spread from bowel to urinary tract A. Klebsiella pneumoniae
B. Old age B. Bacteroides fragilis
C. All of the above C. Proteus mirabilis
D. Non of these D. Escheria coli
Ans: A ANS: B