Part III

Microbiology as Applied to Infectious

Diseases

CHAPTER 27
URINARY TRACT
INFECTIONS

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 Dr Sonal Saxena, MD

Director Professor and Head of the Department of Microbiology

Maulana Azad Medical College,

New Delhi

and

Dr Amala A Andrews, MD

Maulana Azad Medical College,

New Delhi

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INTRODUCTION
Urinary tract infections (UTIs) affects all age groups
Most common UTIs are those of the bladder (cystitis) and the renal pelvis or
the kidneys (pyelonephritis)

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 Anatomically classified as
Upper UTI: Involves the kidney or ureter
Acute pyelitis—infection of the pelvis of the kidney
Acute pyelonephritis—infection of the parenchyma of the
kidney
TYPES OF Lower UTI: Involves infection from the urinary bladder

UTI downwards
Urethritis—infection of the urethra
Acute urethral syndrome (in women, it is often caused by
Chlamydia)
Cystitis—infection of the urinary bladder
Prostatitis—infection of the prostate

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 Based on how it is acquired, UTI may be classified as
Community-acquired

TYPES OF
Hospital-acquired (Chapter 11)

UTI UTI can present as :

Acute UTI
Chronic UTI

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PREDISPOSING FACTORS FOR UTIs
Age: The incidence of UTI increases with age
Gender: Young and sexually active females are specifically prone to the infection
Pregnancy: Increases the risk of UTIs
Structural and functional abnormalities of the urinary tract: Increased risk of UTI
Metabolic factors: Diabetes mellitus increases the risk of UTIs
Interventions: Instrumentation including catheterization and any surgical procedure may
result in a UTI

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 Bacteria ascend from the anterior urethra through the column of
urine

If there is stasis of the urine either in the bladder or ureters due to

neurogenic or mechanical causes, the microorganisms colonise
and establish infection

PATHOGENE Hematogenous spread to the urinary tract occurs in less than 2%

SIS of cases

Factors influencing establishment of infection

• Host factors (gender, age and familial predisposition)

• Microorganism (presence of type 1 pili [fimbriae]) or adhesins, e.g.,
uropathogenic E. coli
• Environmental factors (vaginal colonisers, pH, anatomic and functional
abnormalities...)

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ETIOLOGY
Table 27.1 Etiological agents of urinary
tract infections

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CLINICAL FEATURES
Asymptomatic bacteriuria
Symptomatic UTI: The common symptoms include urgency and frequency of micturition
associated with discomfort or pain
Cystitis(lower UTI): Dysuria, fever with chills and frequency
Pyelonephritis or pyelitis (upper UTI): Flank or loin pain, tenderness, high fever and rigor
Infants and children with UTI: Fever, vomiting, diarrhea and poor feeding

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LABORATORY Fig. 27.1 Flowchart of the approach to the diagnosis of

DIAGNOSIS urinary tract infections

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 SPECIMEN Fig. 27.2 Types of urine samples to be collected
(MSU—midstream urine; CSU—catheter sample of
COLLECTION urine; EMU—early morning urine)

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TRANSPORT
At room temperature within half an hour or refrigerated at
4°C for up to four hours
Beyond this time, such a sample should not be processed
for bacterial culture
If delay expected, a special container with 1.8% boric acid
is provided, in which urine, which can be kept at room
temperature for up to 24 hours

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Microscopy
An uncentrifuged sample is examined by direct microscopy for pus cells and bacteria.
presence of pus cells and bacteria in large numbers  bacterial infection of the urinary tact
Screening
For the presumptive diagnosis of significant bacteriuria
Dipstick tests
i) Griess nitrite test: Presence of nitrite indicates the presence of nitrite-reducing bacteria in
urine.
ii) Leukocyte esterase test: Positive dipstick test helps in diagnosing cystitis

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iii) Catalase test: positive in bacteriuria and hematuria
iv) Triphenyl tetrazolium chloride (TTC) test: positive indicates presence of bacteria
v) Gram stain
vi) Glucose test paper tests
vii) Dip slide culture

None of the screening methods is as sensitive or reliable as culture

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CULTURE
Quantitative culture provides an estimate of the total number of bacteria in 1 mL of urine
Pour plate method
Semi-quantitative culturing is done on blood agar or MacConkey agar with a standard
calibrated loop
A colony count of 105/mL is considered significant.
Counts between 104/mL and 105/mL are of uncertain significance.

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CULTURE
Counts less than this are considered significant if:
The patient is already on antibiotics
There is an obstruction in the urinary tract
A fungal infection is present
Pyelonephritis is present
The specimen has been collected by suprapubic aspiration

Fig. 27.3 Semi-quantitative culture of

urine using a calibrated inoculation loop

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 If ≥3 types of organisms are grown, these are considered as
contaminants, which may have been introduced into the urine
sample from the perineal region or skin or external urethral
meatus due to improper collection
Detection of antibody-coated bacteria differentiates upper UTI
CULTURE (involvement of the kidney) from lower UTI
Upper UTI results in antibody response, which allows the
antibody to coat the microorganism
Can be detected in the urine by immunofluorescence using
antihuman immunoglobulin tagged to a fluorescent dye
Antibiotic sensitivity testing is done

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TREATMENT
Community-onset UTI can be treated with ciprofloxacin
and nitrofurantoin (for out-patients)
For complicated UTI and those with renal involvement, a
higher antibiotic like third-generation cephalosporin or
ceftriaxone may be given
In case of hospital-acquired UTI and/or catheter-associated
UTI, carbapenems or piperacillin/tazobactam may be given
Prescribe appropriate antibiotics only after a sensitivity
report becomes available.

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