URINARY TRACT INFECTION

URINARY TRACT ANATOMY

 KIDNEY

 URETER

 VESICA URINARIA/URINARY BLADDER

 URETRA
Organ ekskresi :

 membuang sisa hasil metabolisme

 mengeluarkan kelebihan cairan

Organ sekresi

 hormon produksi darah merah

(eritropoetin)

 hormon pengatur tekanan darah : sistem

renin angiotensin aldosteron

 hormon mengatur metabolisme tulang :

calcitriol

Organ pengatur

 keseimbangan cairan dan elektrolit darah

(terutama :natrium, kalium)
Urinary Tract Infection

Prevalence
 Community-dwelling elders – 25%
Swart, Soler & Holman, 2004

}
 Long-term care elders 25-50% of women
(chronically bacteriuric) 15-40% of men
Juthani-Mehta et al., 2005

 Marked increases in women & men after age 65

Wagenlehner, Naber & Weidner, 2005
INCIDENCE

FEMALES:
- 15% of all women at some time in life
- INFANTS - < 1 percent
- CHILD HOOD - 1 - 3 percent
- CHILD BEARING AGE - 2 to 5 %
- PREGNANCY - 2 - 10 %
- OLDER WOMEN - 5 to 15%
MALES:
- INFANTS - 1 percent
- UPTO 45 years - < 1 percent
- AFTER 45 years - 5%
- Generally infections are rare before 45 years when
present in young adults - prostatis is likely
 Urinary Tract Infection Defined
Definition
Women: Presence of at least 100,000 colony-
forming units (cfu)/mL in a pure
culture of voided clean-catch urine
Men: Presence of just 1,000 cfu/mL
indicates urinary tract infection
*Some labs do not routinely identify & determine the
sensitivity of organisms for specimens with <10,000
cfu/mL. May have to special request.
Swart, Soler & Holman, 2004
Urinary Tract Infection

 Urinary tract infection—most common source of

bacteremia, a dangerous systemic infection in
long-term care facilities

 Bacteremia—40 times more likely to occur in

catheterized than non-catheterized residents

 Bacteremia leads to significant morbidity and

mortality in the vulnerable elderly
Nicolle, 2005
URINARY TRACT INFECTION

UPPER URINARY TRACT:

Kidney and Ureters
LOWER URINARY TRACT:
Bladder, prostate, urethra.
PYELONEPHRITIS
Bacterial invasion of renal interstitium (Upper U Tract)
(A) ACUTE:
SYMPTOMATIC
Fever, Chills, flank pain
POSITIVE URINE CULTURE
URINARY TRACT INFECTION (contd.)
(B) CHRONIC:
- Presumptively of Bacterial infection
- Acute symptoms are usually absent
- Urine culture is often negative
- Diagnosis:
Radiological - DIAGNOSTIC
Histological findings - NON-SPECIFIC

CYSTITIS, URETHRITIS, PROSTATITIS

Bacterial invasion of Lower Urinary tract
SYMPTOMATIC:
Dysuria, frequency, urgency
URINE CULTURE:
Positive
URINARY TRACT INFECTION (contd.)

URETHRAL SYNDROME (1/3 of women with symptoms)

SYMPTOMATIC:
URINE CULTURE -
ROUTINE NEGATIVE for CULTURE
3/4 - Have pyuria
- Low Bacterial counts
- STD

ASSYMPTOMATIC BACTERIURIA
- POSITIVE URINE CULTURE
- NO ASSOCIATED SYMPTOMS
URINARY TRACT INFECTION (contd.)

RECURRENT INFECTIONS
(a) RELAPSING:
- Repeat infection with the SAME organism
despite treatment and cure
- Occurs after 1-2 weeks of stopping antibiotic
therapy
- More commonly after Bacterial
Pyelonephritis
OR Prostatitis

(b) RE-INFECTION:
- Repeat infection with a NEW organism
- More common in cystitis and urethritis
CLINICAL PRESENTATION
- LOWER URINARY SYMPTOMS:
(L.U.T) DYSURIA
FREQUENCY
URGENCY
- UPPER URINARY:
(U.U.T) PAIN
FEVER WITH CHILLS
- ASSYMPTOMATIC
- WITH L.U.T. SYMPTOMS AND BACTERIURIA
- 1/2 HAVE PYELONEPHRITIS
- 1/2 HAVE CYSTITIS
- WITH ACUTE LOWER URINARY SYMPTOMS
- 60-70% HAVE BACTERIURIA
- MAJORITY OF REST ALSO HAVE
UNDERLYING INFECTION
- SEXUALLY TRANSMITTED
- LOW COLONY COUNT - BACTERIAL
PREDISPOSING FACTORS TO UTI

1: SEX:
FEMALES : Short urethra, proximity to anus
MALES : Prostatis, prostatic obstruction
2: PREGNANCY:
Urine is more nutrient
Stasis, obstruction, ureteral dilatation
3: OBSTRUCTIVE UROPATHY:
Infection accelarates renal damage
stasis predisposes to infection
4: NEUROGENIC BLADDER:
Residual bladder urine
Frequent catheterization
PREDISPOSING FACTORS TO UTI (contd)
5: VESCICO URETERIC REFLUX:

6: RENAL DISEASES:
Gout, nephrocalcinosis
Sickle cell disease
Hypokalemia, hypercalcemia

7: DIABETES:

8: IMMUNODEPRESSION:
Post renal transplant

9: INSTRUMENTATION OF URINARY TRACT

Catheter, cystoscopy etc:
CATHETER ASSOCIATED INFECTIONS

- SINGLE (STAB) CATHETERIZATION: < 2%

- INDWELLING CATHETER : 5% per DAY
- ORGANISMS DIFFER:
Proteus, Pseudomonas, Klebsiella, Serratia
ROUTE OF INFECTION:
- INTRA LUMINAL
- PERI URETHRAL
SIGNIFICANCE
- MOST ARE ASSYMPTOMATIC & BENIGN
- 1 to 2% DEVELOP BACTEREMIA

IS THE COMMONEST SOURCE OF BACTEREMIA

IN HOSPITAL PATIENTS
 Causative Pathogens
UTI in Women

 Escherichia coli—gram (-) etiologic agent in ~ 80% of all UTI’s


=
Research indicates primary source of microbial invasion is
retrograde colonization by intestinal pathogens

 Other factors influencing colonization: vaginal pH, urethral length,

capacity of bacteria to adhere to urothelium
Osborne, 2004
Causative Pathogens, cont’d

Polymicromial bacteriuria

 Contamination most frequent cause of multiple microorganisms

 25-33% in LTCF’s may be polymicrobic due to fistulas, urinary

retention, infected stones, or catheters

Midthun, 2004
Causative Pathogens, cont’d
Age/Type Specific Pathogens

 Younger patients, rare in elderly—Staphylcoccus, saprophyticus

(gram pos.) – 10-15%
 Elderly diabetics
 Klebsiella species (gram neg.) most common

 LTCF elderly
 E. coli ~ 30%
 Proteus species (part of host flori in GI tract) ~ 30%
 Staphylcoccus aureus, Klebsiella, Pseudomonas (gram neg.) and Enterococcus
(gram pos.) ~ 40%

Swart, Soler & Holman, 2004

 Symptoms versus Asymptomatic
Bacteriuria
Asymptomatic Bacteriuria (ASB)
 Defined as the presence of bacteria in urine of patients who do not
have dysuria, urinary frequency, urgency, fever, flank pain, or other
symptoms related to irritation of the urethra, bladder, or kidney
Swart, Soler & Holman, 2004

 Strictly defined—exists when 2 urine cultures done with clean-

catch specimens are positive in a patient who has no urinary tract
symptoms
Foxman, 2003
Symptomatic vs Asymptomatic
Bacteriuria, cont’d

ASB

 Frequent in elderly, even > prevalent in residents of LTCF:

elderly >70 yrs old

women: 16-18%

men: 6%
Symptomatic vs. Asymptomatic Bacteriuria,
cont’d
Asymptomatic Bacteriuria (ASB)

 Most ASB in the elderly is associated with complicating factors

such as:
 Hormonal: post-menopausal women
 Anatomical: prostatic obstruction in men, cystocele in women
 Functional: CNS, i.e., P.D. & dementia
 Metabolic: diabetics (ASB females with Type 2 diabetes—
29%)
 Immunological: ↑’s in inflammatory mediators (cytokines, acute
phase proteins)
 Instrumental: indwelling catheter→always bacteriuric symptoms

Wagenlehner, Naber & Weidner, 2005

 Screening/Diagnosis

Asymptomatic Bacteriuria

 No universally accepted criteria for the diagnosis,

treatment, or surveillance of UTI, specifically in LTCF
residents

 Treatment of ASB is associated with ↑ adverse

antimicrobial effects, re-infection with organisms or
increasing resistance
Nicolle, et al., 2005
 Screening & Diagnosis
Guideline Criteria for Treatment
The following are a recommended minimum set of criteria adapted from the McGeer (1991) and
Loeb et al. (2001) studies necessary to initiate diagnostics and AB Rx.
Indwelling catheter present:
present:
two of the following must be met
 Fever (>38°C/100.4°F)
(>38°C/100.4°F) or increase of 1.5°C
(2.4°F) above baseline temperature.
 Chills
 New costovertebral angle tenderness
 New suprapubic pain, flank pain or
tenderness
 Decreased mental or functional status
(delirium)
 New-onset hematuria, foul-smelling urine,
or amount of sediment
Catheter is not present:
present:
three of the following must be met
 Acute dysuria alone (key indicator) or fever
(>38°C/100.4°F)
(>38°C/100.4°F) or increase of 1.5°C (2.4°F)
above baseline temperature
 Chills
 Frequency
 Urgency
 New costovertebral angle tenderness
 Decreased mental or functional status (may be
new or increased incontinence related) *
 New-onset hematuria, foul-smelling urine or
(+) sediment
 New suprapubic pain, flank pain or tenderness
PEMERIKSAAN SPESIMEN: URIN

 urin bersih
 urin tengah
 urin tampung
 URIN BERSIH
(clean voided urine specimen)

 pemeriksaan urinalisa rutin

 Urin bersih, biasanya urin pertama pagi hari alasan:
 konsentrasinya lebih tinggi
 jumlah lebih banyak
 memiliki pH lebih rendah.
 Jumlah minimal 10mL
 Tidak ada cara pengambilan khusus: klien dapat
melakukannya sendiri .
 Spesimen harus bebas dari feses
 Diperlukan urin segar (pengambilan kurang dari 1
jam), bila tidak segera: urin harus dimasukan
dalam lemari pendingin
Alasan:
 Bila urin berada dalam suhu ruangan untuk
periode waktu lama maka kristal urin dan sel
darah merah akan lisis/hancur serta berubah
menjadi alkalin.
 URIN TENGAH
(clean-catch or midstream urin specimen)

 untuk pemeriksaan kultur urin: untuk mengetahui mikroorganisme

yang menyebabkan infeksi saluran kemih

 Cara lain bila tidak menggunakan kateter lebih berisiko

menyebabkan infeksi.

 Perlu mekanisme khusus agar spesimen yang didapat tidak

terkontaminasi.
Cara Pengambilan :

 bersihkan area meatus urinarius dengan sabun dan air

atau dengan tisue khusus lalu keringkan
 buang urin yang keluar pertama dimaksudkan untuk
mendorong dan mengeluarkan bakteri yang ada
didistal
 tampung urin yang ditengah. Hati-hati memegang
wadah penampung agar wadah tersebut tidak
menyentuh permukaan perineum.
 Jumlah yang diperlukan 30-60mL
 URIN TAMPUNG
(timed urin specimen)
 Ada pemeriksaan urin yang memerlukan seluruh produksi urin
yang dikeluarkan dalam jangka waktu tertentu, rentangnya
berkisar 1-2 jam – 24 jam.
 Urin tampung
 disimpan di lemari pendingin
 diberi preservatif (zat aktif tertentu)
Tujuan:
mencegah pertumbuhan bakteri atau mencegah
perubahan/kerusakan struktur urin.
 Biasanya urin ditampung di tempat kecil lalu dipindahkan
segera ke penampungan yang lebih besar.
SPESIMEN KATETER INDWELLING

 Mendapatkan urin steril

 diambil dengan jarum suntik melalui area kateter yang
khusus disiapkan untuk pengambilan urin.
 Klem kateter selama kurang lebih 30 menit jika tidak
diperoleh urin waktu pengambilan.
 kultur urin diperlukan 3 mL, Untuk kultur urin, hati-hati
dalam pengambilan agar tidak terkontaminasi
 30 mL untuk urinalisa rutin..
 Laboratory Analysis
Dipstick Testing
Used in primary care & LTC settings. But for institutionalized adults, urinalysis is
preferable.

 Chemically impregnated reagent strips (UA Chemstrip Screen) provide

preliminary/quick determinations of:

pH bilirubin
protein blood
glucose *nitrite
ketones *leukocyte esterase
urobilinogen specific gravity
Fischback, 2004

 Fairly reliable, although U.S. Preventive Services Task Force (USPSTF)

report from research studies these have “poor positive & negative

predictive value” for detecting bacteriuria in asymptomatic patients.

www.ahrq.gov/clinic (2005)
Laboratory Analysis, continued
Routine Urinalysis—Key Indicators of Infection
Urine collection 1st morning specimen is best
Straight catherization for those incontinent, functionally or cognitively
impaired
Specific gravity Measure of kidney’s abiltiy to concentrte urine
Range of SG depends on state of hydration
Appearance Cloudy, may not indicate WBC’s
Could indicate a change in urine pH → causes precipitation
Alkaline urine → phosphates → cloudy
Acid urine → urates → cloudy

Color Pale yellow to amber

Variations can be caused by medications, disease processes (*nl urine
darkens on standing 30 min. after voiding—oxidation of urobilinogen to
urobilin)

Odor nl → faint odor when freshly voided

Foul-smelling—often presence of bacteria which splits urea to form
ammonia
Fischbach, 2004
 Laboratory Analysis, continued
Routine Urinalysis, continued
pH Acid or base—measures free H+ ion concentration in urine
7.0—neutral. Indicates kidney function
Determines if systemic acid-base disorders of
metabolic/resp. origin
 control of pH → manages bacteriuria, renal calculi & drug
Rx
 bacteria from a UTI → produce alkaline urine

Blood or Always an indicator of kidney/UT damage

Hemoglobin
Protein Single most important indication of renal disease
(Albumin)
Microalbuminu Below dipstick range of detection
ria Detects deteriorating renal function in diabetic patients
(standard screener)

Fischbach, 2004
Laboratory Analysis, continued
Routine Urinalysis, continued

*Nitrite Dipstick - rapid, indirect method to detect bacteria

(Bacteria)  common gram-negative organisms contain
enzymes → reduce nitrate
in urine to nitrite
 some UTI’s are caused by organisms that do not
convert nitrate to nitrite
(e.g., staphylococcus, streptococci)
*Leukocyte Esterase is released by leukocytes (WBC’s) in urine
Esterase Microscopic exam & chemical test

__________
*U/A testing positive for nitrite & leukocyte esterase should be
cultured for bacterial pathogen
 Urine Culture and Sensitivity
 Traditional gold standard for significant bacteriuria
>100,000 cfu/mL of urine. Some argue criteria for
bacteriuria is only 100 cfu/mL of a uropathogen in
symptomatic females or 1,000 in symptomatic males.

 Bacterial identification from urine C&S, key in

males and females with complicated UTI’s.
 Other Laboratory Tests
Complete Blood Count with Differential
 Indicated to R/O bacterial infection supports treatment plan
 Careful evaluation of WBC & differential (left shift)

Electrolytes
 R/O dehydration & if IV fluids replacement needed

BUN, Creatinine
 Determine ↓ renal function for nephrotoxic medications

Blood Culture
 Identify bacteremic organism in suspected urosepsis
 Treatment Plan
 Early detection/Rx → goal is to prevent systemic infection, bacteremia
 Initiation of antibiotic treatment is recommended for a clinically-
diagnosed UTI. Adjust medication when urine C&S is final
 Selection of antibiotic must be individualized and consider:
 Side effect profile
 Cost
 Bacterial resistance
 Likelihood of compliance (convenience, fewer pills/day ↑’s compliance)
 Effect of impaired renal function on dosing
 Possible adverse drug reactions ↑ in elderly (multiple drugs, co-morbidities.
Osborne, 2004
Swart et al. 2004
Treatment Plan

AB Rx for at least 10 days for institutionalized

elderly, as short-term therapy may not be as

effective.

Ten-14 days, if indicated, for complicated UTI.

(recommended for males) Evercare, 2004

Conventional regimen of 7-10 days duration is

usually recommended.Wagenlehner et al. 2005
Treatment Plan
Complicated UTI
 Can be common in LTC patients
 Associated with azotemia, obstruction, or indwelling foley
 Can lead to bacteremia, life-threatening systemic infection

Recommended Treatment for Acute Complicated UTI

IV antibiotic therapy--*consider renal & hepatic elimination,

creatinine clearance for dosage adjustment
 3rd generation cephalosporin (Ceftriaxone = Rocephin) Rx 1 gram IV every
24 hours
 Or if fluoroquinolones (Levofloxacin = Levaquin) 250-500 mg IV every 24
hours
 Continue until afebrile, minimum of 48 hrs, then start oral therapy and fluids
x 14 days.
Mahan-Buttaro et al., 2006