DRA.

GLORIA
M. AGUIRRE
INTERNAL MEDICINE/INFECTIOUS
DISEASES
DEFINITION

 Urinary tract infection (UTI) refers to a symptomatic bacterial infection within the urinary
tract.
 Lower urinary tract infection – cystitis (symptomatic infection of the bladder)

 Upper urinary tract infection – acute pyelonephritis (symptomatic infection of the kidney).

 These definitions are based upon a grouping of symptoms.

 However, the bacterial infection may extend beyond the anatomical area suggested by the
terminology.

•Eur J Obstet Gynecol Reprod Biol. 2011 Jun;156(2):131-6.

•Dtsch Arztebl Int. 2010 May;107(21):361-7.
DEFINITION

 Asymptomatic bacteriuria:  in patients without indwelling catheters is ≥10 5 colony-forming units (CFU)/mL
(≥108 CFU/L) in a voided urine specimen without signs or symptoms attributable to UTI.
 This is only treated in certain cases:
 prior to a urological operation
 in pregnant women
 in immunocompromised patients (post-transplant kidney patients)

 In most cases does not require treatment.

 UTIs may be considered complicated if symptoms of pyelonephritis emerge, or if a UTI is found in certain patient
populations, including the immunosuppressed, men, pregnant women, diabetics, those with a history of
pyelonephritis, or those with structural abnormalities of the urinary tract

•Eur J Obstet Gynecol Reprod Biol. 2011 Jun;156(2):131-6.

•Dtsch Arztebl Int. 2010 May;107(21):361-7.
LOWER URINARY TRACK INFECTION

 CYSTITIS
 URETHRITI
S
 EPIDEMIOLOGY

 The prevalence of UTI is higher in women than in men:

 about 81% of UTI occurs in women

 peak between 16 and 35 years.

 Approximately 27% of women with a first episode of UTI record a recurrence within 6 months, and
48% within the first year.
 UTI is responsible for about 15% of all antibiotic prescriptions in the community with more than 1.6
billion dollars spent every year.
 UTI results in nearly 7 million office visits, with additional 1 million visits to emergency rooms which
result in over 100,000 hospitalizations every year in the USA alone

Medina, Martha, and Edgardo Castillo-Pino. “An introduction to the epidemiology and burden of urinary tract infections.” Therapeutic advances in urology vol. 11 1756287219832172. 2 May. 2019, doi:10.1177/1756287219832172
 EPIDEMIOLOGY
Uropathogenic Escherichia
coli (E. coli. UPEC) is the
dominant infectious agent in
both uncomplicated and
complicated UTIs.
Enterococcus spp.
and Candida spp. are
substantially more common
in complicated infections,
while Staphylococcus
saprophyticus is rare.

Medina, Martha, and Edgardo Castillo-Pino. “An introduction to the epidemiology and burden of urinary tract infections.” Therapeutic advances in urology vol. 11 1756287219832172. 2 May. 2019, doi:10.1177/1756287219832172
Flores-Mireles AL, Walker JN, Caparon M, et al. Urinary tract infections: epidemiology, mechanisms of infection and treatment options. Nat Rev Microbiol 2015; 13: 269–284.
 PATHOPHYSIOLOGY
Although the
When that
Bacteria enter the urinary system is
happens,
urinary tract designed to keep
bacteria may take
through the out such
hold and grow
urethra -> begin microscopic
into a full-blown
to multiply in the invaders, these
infection in the
bladder defenses
urinary tract.
sometimes fail.

 Most commonly due to infection with Escherichia coli species (80-90% of cases). Other causes
include Klebsiella, Enterococcus, Proteus mirabilis and Staphylococcus saprophyticus.

https://www.mayoclinic.org/diseases-conditions/urinary-tract-infection/symptoms-causes/syc-20353447Jan-Feb;28(1):255-77; quiz 327-8.

•N
. Engl J Med. 2012 Mar 15;366(11):1028-37.
•Lancet Infect Dis. 2004 Oct;4(10):631-5.
•Radiographics. 2008 Jan-Feb;28(1):255-77; quiz 327-8.
•N Engl J Med. 2012 Mar 15;366(11):1028-37.
•Lancet Infect Dis. 2004 Oct;4(10):631-5.
•Radiographics. 2008 Jan-Feb;28(1):255-77; quiz 327-8.
 SYMPTOMS

Salvatore S, Salvatore S, Cattoni E, Siesto G, Serati M, Sorice P, Torella M. Urinary tract infections in women. Eur J Obstet Gynecol Reprod Biol. 2011 Jun;156(2):131-6. doi: 10.1016/j.ejogrb.2011.01.028. Epub 2011 Feb 23. PMID:
21349630
CYSTITIS
 Usually caused by Escherichia coli (E. coli), a
type of bacteria commonly found in the
gastrointestinal (GI) tract.

 However, sometimes other bacteria are

responsible like Klebsiella, Enterococcus, Proteus
mirabilis and Staphylococcus saprophyticus.

 Sexual intercourse may lead to cystitis

 All women are at risk of cystitis because of their
anatomy — specifically, the short distance from
the urethra to the anus and the urethral opening
to the bladder.

 Periurethral colonization by the invading pathogen

appears to be the initiating step in a cascade of
events leading to a UTI.
URETHRITIS
 This type of UTI can occur when GI bacteria spread from the anus to the
urethra.
 Also, because the female urethra is close to the vagina, sexually transmitted
infections, such as herpes, gonorrhea, chlamydia and mycoplasma, can
cause urethritis.
N Engl J Med. 2012 Mar 15;366(11):1028-37.
Lancet Infect Dis. 2004 Oct;4(10):631-5.
DIAGNOSIS

• While UTIs may be classified in the literature

 Anamnesis (Medical history)
according to location and symptoms, it is clinically
 Urinalysis very difficult to determine the extent of infection
 Growing urinary tract bacteria in a lab based on symptoms.
• Elderly women may present with only urinary
 Images of urinary tract
incontinence and no other symptoms

Only a positive urine culture is considered truly diagnostic of a UTI, however, urine
should only be cultured in the setting of clinical infection or infective symptoms

Asymptomatic bacteriuria is common and does not require treatment

TREATMENT
Resistance of E. coli to
fluoroquinolones in
Mexico is as high as 60%

Kalpana Gupta, Thomas M. Hooton, Kurt G. Naber, Björn Wullt,

Richard Colgan, Loren G. Miller, Gregory J. Moran, Lindsay E.
Nicolle, Raul Raz, Anthony J. Schaeffer, David E. Soper,
International Clinical Practice Guidelines for the Treatment of Acute
Uncomplicated Cystitis and Pyelonephritis in Women: A 2010
Update by the Infectious Diseases Society of America and the
European Society for Microbiology and Infectious Diseases, Clinical
Infectious Diseases, Volume 52, Issue 5, 1 March 2011, Pages
Hooton TM. Clinical practice. Uncomplicated urinary tract infection. N Engl J Med. 2012 Mar 15;366(11):1028-37. doi: 10.1056/NEJMcp1104429. PMID: 22417256.
Hooton TM. Clinical practice. Uncomplicated urinary tract infection. N Engl J Med. 2012 Mar 15;366(11):1028-37. doi: 10.1056/NEJMcp1104429. PMID: 22417256.
 TREATMENT
• Trimethoprim-sulfamethoxazole
• Inhibition of microbial DNA synthesis by inhibiting the folic acid synthesis and consequently the purines
required for DNA
• Fluoroquinolones
• Inhibition of microbial DNA synthesis by blocking DNA gyrase and topoisomerase IV needed for
successful DNA replication and transcription.
• Nitrofurantoin
• The mechanism is not fully understood, but it directly causes selective damage to microbial DNA, which
metabolises the toxic intermediates of nitrofurantoin more rapidly than human cells. 
Resistance patterns in Mexico of common gram negative bacteria

A snapshot of antimicrobial resistance in Mexico. Results from 47 centers from 20 states during a six-month period
Elvira Garza-GonzálezRayo Morfín-Otero... Adrián Camacho-Ortiz
 
 PREVENTION

Hooton TM. Clinical practice. Uncomplicated urinary tract

infection. N Engl J Med. 2012 Mar 15;366(11):1028-37. doi:
10.1056/NEJMcp1104429. PMID: 22417256.
Hooton TM. Clinical practice. Uncomplicated urinary tract infection. N Engl J Med. 2012 Mar 15;366(11):1028-37. doi: 10.1056/NEJMcp1104429. PMID: 22417256.
Hooton TM. Clinical practice. Uncomplicated urinary tract infection. N Engl J Med. 2012 Mar 15;366(11):1028-37. doi: 10.1056/NEJMcp1104429. PMID: 22417256.
Questions?
 Clinical Case

A 27-year-old woman presents to her primary care physician with a report of urinating more frequently and pain
with urination. She denies blood in her urine, fevers, chills, flank pain, and vaginal discharge. She reports
having experienced similar symptoms a few years ago and that they went away after a course of antibiotics. The
patient has no other past medical problems. Pertinent history reveals she has been sexually active with her
boyfriend for the past 4 months and uses condoms for contraception. She reports 2 lifetime partners and no past
pregnancies or sexually transmitted diseases. Her last menstrual period was 1 week ago.
 On physical exam, the patient is afebrile, normotensive, and non-tachycardic. She appears well on
observation. She has a soft, nondistended abdomen with normoactive bowel sounds. On palpation, she has
moderate discomfort in her suprapubic region but no costovertebral angle (CVA) tenderness. A pelvic exam
is normal with no evidence of abnormal vaginal or cervical discharge or inflammation.
 What Is the Differential Diagnosis for This Patient? Which Diagnosis Is Most Likely and Why?
 Is Laboratory Testing Required To Confirm the Diagnosis in This Patient?
 Which Populations Are at Higher Risk of Contracting a UTI? Why? (Discuss the Terms “Uncomplicated
UTI” Versus “Complicated UTI”)
 Which Laboratory Studies Can Be Performed on Urine To Evaluate a Potential UTI? What Is the Diagnostic
Value of Each Test?
 Which Microorganisms Most Commonly Cause Acute Cystitis?
 CLINICAL CASE

 23-year-old woman was married a year ago. Since then, she has experienced five attacks of acute cystitis, all
characterized by dysuria, increased frequency, and urgency. Each case was diagnosed on the basis of the clinical
picture and a laboratory urinalysis finding of bacteriuria. The urine bacterial counts in these cases ranged from
104 to 106 organisms/mL. Lab tests indicated that the first, second, and fifth infections were caused
by Escherichia coli, while the third infection was caused by an enterococcus and the fourth infection was
caused by Proteus mirabilis. Each infection responded to short-term treatment with trimethoprim-
sulfamethoxazole. The recurrences occurred at intervals of 3 weeks to 3 months following completion of
antibiotic therapy.
 For the past two days, she has once again been experiencing dysuria, increased frequency, and urgency, so
she goes to see her physician. Her vital signs are T = 37.2°C, P = 100/min, RR = 18/min, and BP = 110/70
mm Hg. Physical examination reveals a mild tenderness to palpation in the suprapubic area, but no other
abnormalities. A bimanual pelvic examination reveals a normal-sized uterus and adnexae with no apparent
adnexal tenderness. No vaginal discharge is noted. The cervix appears normal.
 What is the differential diagnosis for this set of symptoms? What is your preliminary diagnosis?
 What tests should you order to confirm your preliminary diagnosis?
Test Results: Laboratory tests indicate a Hgb of 13.6 g/dL, Hct 40.7%, MCV 84, and WBC count
10,910/microliter. White blood cells and bacteria are evident in the urine sediment. A urine culture indicates
approximately 106 bacterial cells/mL. A Gram stain of the urine reveals Gram-positive cocci. The Gram-
positive bacterium is isolated and is found to be catalase positive and coagulase negative.
Do the test results support your preliminary diagnosis? What is the most likely identity of the causative
agent in this case?
How should this case be treated?