Urinary Tract Infection 

&
Pyelonephritis
Boudhayan Das Munshi
MBBS, DNB General Medicine, Fellowship in Diabetology(JIPMER), MNAMS
Assistant Professor General Medicine
AIIMS Kalyani
 Specific Learning Objectives

At the end of the session the learner should be able to

1. Describe the clinical syndromes  of urinary tract
infection(UTI)
2. Outline the treatment of UTI
3. Apply the  principles in diagnosis and treatment of UTI
 Outline

• Terminologies
• Epidemiology
• Causative Organisms
• Risk factors
• Etiopathogenesis
• Diagnosis
• Investigations
• Treatment
 Terminologies

• Asymptomatic v/s Symptomatic

• Cystitis v/s Pyelonephritis
• Uncomplicated UTI vs Complicated UTI
• Recurrent UTI
• CAUTI
• ASB
 Epidemiology

• Age wise gender distribution

• 50 – 80% of women acquire UTI during lifetime
Etiopathogenesis
 Organisms

• Escherichia coli
• Staphylococcus saprophyticus
• Klebsiella Acute Uncomplicated Cystitis
• Proteus
• Enterococcus 
• Citrobacter
• Pseudomonas aeruginosa
• Acinetobacter
Pyelonephritis
• Morganella
• Staphylococcus aureus
 Risk Factors

• Frequent sexual intercourse

• Diaphragm with spermicide
• History of UTI ( Younger age/Recent )
• Anatomical factors – cystoceles, urinary incontinence,
residual urine
• Males – Congenital urinary tract abnormalities, lack of
circumcision
• Foreign body in the urinary tract eg Urinary catheter or stone
– inert surface for bacterial colonization
• Delayed response to therapy
 Qs
Question
Why lack of circumcision is associated with increased risk of
UTI in Men ?

Answer
E. coli colonize glans and prepuce  and migrate into the
urinary tract of uncircumcised men
 ASYMPTOMATIC
Clinical Presentation BACTERIURIA

PYELONEPHRITIS
• Fever, rigors
• Low back pain/
flank/loin pain CYSTITIS
• Costovertebral Click to add text • Dysuria
angle pain • Urinary frequency,
• Nausea, Vomiting urgency, hesitancy
• Nocturia
• Suprapubic
Discomfort
• Gross hematuria
Name the type of fever found in Pyelonephritis

PICKET FENCE FEVER

Xanthogranulomatous Pyelonephritis- Staghorn Calculus
Emphysematous Pyelonephritis
 CLINICAL PATIENT CHARACTERISTICS DIAGNOSTIC & MANAGEMENT
PRESENTATION CONSIDERATIONS
Acute onset of Otherwise healthy women who is non Consider uncomplicated cystitis
Urinary pregnant, low risk for multidrug  No urine culture needed
symptoms resistance  Consider telephone management
• Dysuria Women with a history of or risk factors for Consider uncomplicated cystitis or STD
• Frequency STD
• Urgency  Urinalysis, Culture
 STD evaluation, Pelvic exam
Male with perineal, pelvic or prostatic Consider Acute Prostatitis
pain  Urinalysis and culture
 Consider Urology consultation

Patient with indwelling urinary catheter Consider CAUTI

 Exchange or remove catheter
 Urinalysis and culture
 Blood cultures if fever
All other patients Consider Complicated UTI
 Urinalysis and culture
 Address any modifiable anatomic or
functional abnormalities
 CLINICAL PATIENT DIAGNOSTIC &
 PRESENTATION CHARACTERISTICS MANAGEMENT
CONSIDERATIONS
Acute onset of back pain, Otherwise faculty woman Consider uncomplicated
nausea/vomiting, or fever who is not pregnant pyelonephritis
with or without cystitis  Urine culture
symptoms  Consider outpatient
management
All other patients Consider Pyelonephritis or
Acute Prostatitis( Male)
 Urine culture
 Blood culture
 CLINICAL  PATIENT DIAGNOSTIC &
PRESENTATION CHARACTERISTICS MANAGEMENT
CONSIDERATIONS
Systemic symptoms Elderly patients, Consider Complicated
• Fever patients with spinal UTI
• Altered mental cord injury, Consider other
status immunocompromise, etiologies
• Leucocytosis no alternate diagnosis Urine culture
Blood culture
 CLINICAL  PATIENT CHARACTERISTICS DIAGNOSTIC &
PRESENTATION MANAGEMENT
CONSIDERATIONS
No urinary Positive urine culture in patient who is Consider ASB
symptoms pregnant, renal transplant recipient or  Screening and treatment
patient undergoing urological procedure warranted
Positive urine culture in all other patients Consider ASB
 No additional work up or
treatment required
Positive urine culture in patient with Consider CA-ASB
indwelling catheter  No additional workup or
treatment needed
 Consider prophylaxis or
patient initiated
management
 CLINICAL PATIENT  DIAGNOSTIC & MANAGEMENT
 PRESENTATION CHARACTERISTICS CONSIDERATIONS

Recurrent acute Otherwise healthy women who is not Consider recurrent cystitis
urinary symptoms pregnant  Urine culture to establish
diagnosis
 Consider prophylaxis or
patient initiated
management( see text)

Male patient Consider chronic bacterial

prostatitis
 Consider Urology consult
 Urine  Dipstick

Nitrite Leucocyte esterase

 Urine C/S- Microbiologic Criteria

Urinary Tract Infection

(Cystitis) Asymptomatic Bacteriuria
Males- >= 103 CFU/ml

Females->= 102 CFU/ml >= 10 5 CFU/ml

 Urine Culture Sensitivity

REQUIRED NOT REQUIRED

• Women • Women
1. Recurrent UTI 1. Uncomplicated cystitis
2. Suspected bacterial
resistance
3. Pregnancy
• Men
Urine Culture and Sensitivity– Mixed Bacterial Culture

Contamination 1.Long term catheterization

2.Chronic urinary retention
Microbial flora 3.Fistula between urinary
• Distal tract and genital
urethra tract/gastrointestinal tract
• Vagina
• Skin
 Treatment

Antimicrobial Agent
• Dose • Site of infection
• Duration • Complicating Conditions

 Local resistance
 Drug availability
 Patient factors
 Empirical Management- Antimicrobial agent

Minimal effect on fecal flora Maximal effect on fecal flora

• Pivmecillinam • Trimethoprim
• Fosfomycin • TMP-SMX
• Nitrofurantoin • Quinolones
• Ampicillin
 Qs & Ans

Question
Rates of pathogen eradication are lower and relapse rates
are higher with beta lactam antibiotics . Why ?

Answer
β-lactams fail to
eradicate uropathogens from the vaginal reservoir
 Asymptomatic Bacteriuria

• Indications
Pregnant women
Urologic surgery
Neutropenic / Renal Transplant
Why should  ASB  during pregnancy be treated?

ASB

Pyelonephritis

Pre Term
Delivery

Low Birth
Weight
 UTI in pregnant women

• Antibiotics – Nitrofurantoin, Ampicillin, Cephalosporins

• Avoid Sulphonamides, Fluoroquinolones
 CAUTI( Catheter associated UTI)

• >=103 CFU/ml
• Catheter change – Remove biofilm associated organisms that
could serve as a nidus for reinfection
• 7 to 14 days of antibiotics
• Intermittent catheterization vs long term indwelling urethral
catheterization
 Candiduria

• Indwelling catheter
ICU 
Diabetes Mellitus
Broad spectrum antimicrobial drugs
• Rx – Fluconazole (200- 400 mg/day for 7-14 days)
Symptomatic cystitis
Pyelonephritis
High risk of disseminated disease(Neutropenia/ Urologic
manipulation/Clinically unstable/LBW)
 Qs

1. When can you clinically  suspect development of

Intraparenchymal abscess formation in a patient on
treatment for Pyelonephritis ?
2. What are the causes of Acute Papillary necrosis ?
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