URINARY TRACT INFECTIONS

Upper and lower

Classification

 Lower UTIs: Infections of the bladder (cystitis) ,infections of the urethra (urethritis) and prostate
(prostatitis)
 Upper UTIs: Infections of the kidneys (pyelonephritis)

Both upper and lower UTI are further divided into complicated and uncomplicated

Urethritis:

Infection of anterior urethral tract *dysuria, urgency and frequency of urination.

Cystitis:

Infection to urinary bladder *dysuria, frequency and urgency, pyuria and hematuria.

Acute pyelonephritis:

Infection of one/both kidneys; sometimes lower tract also. *pyuria, fever, painful micturition

Chronic pyelonephritis:

Particular type of pathology of kidney; may/may not be due to infection.

Epidemiology

• 150 million people per year become infected

• 20% of women between ages 20-65 suffer one attack per year

• Approximately 50% of women develop a UTI at least once.

• 1%-6% of general practitioner visits are for UTIs.

• Epidemiology of UTI Worldwide,

150 million cases year

90 cystitis,

10% pyelonephritis

75 sporadic

25 recurrent
 2% complicated

Risk factors for urinary tract infection

1.Aging: diabetes mellitus

urine retention

impaired immune system

2. Females: shorter urethra

sexual intercourse

contraceptives

incomplete bladder emptying with age

3. Males: prostatic hypertrophy

bacterial prostatitis

age

Etiology

Complicated/ Nosocomial UTI:

E.coli (gram-ve)

Klebsiella pneumoniae (gram negative enteric bacteria)

Proteus spp (gram negative enteric bacteria)

Pseudomonas aeruginosa (gram-ve)

Enterococcus spp (gram+ve)

Enterobacter spp (gram-ve)

Staphylococcus saprophyticus(gram+ve)

Uncomplicated UTI:

E.coli ( most common gram negative bacteria)

Staphylococcus saprophyticus (gram+ve)

Klebsiella pneumoniae (gram-ve)

Pseudomonas aeruginosa(gram-ve)

Enterococcus spp (gram+ve)

Most are caused by single organisms except in patients with stones, indwelling urinary catheters or chronic
renal abscesses

Signs and symptoms of a urinary tract infection include

• pain or burning when urinating (dysuria);

• frequent urination;

• sudden urge to urinate (bladder spasm);

• pain during sexual intercourse;

• fatigue;

• general feeling of being unwell (malaise);

• vaginal irritation; and

• in elderly patients, subtle symptoms such as altered mental status (confusion) or decreased activity
may be signs of a UTI.

• frequent or persistent urge to urinate without much urine passing when you go;

• sense of incomplete emptying of the bladder;

• loss of bladder control (urinary incontinence);

• a feeling of pressure or pain in the lower abdomen or pelvis;

• foul odor to the urine;

• urine that is milky, cloudy, reddish, or dark in color;

• blood in the urine;

• back pain, flank (side) pain, or groin pain;

fever or chills;

Vaginal itching is not a typical symptom of a UTI. It may be a sign of bacterial vaginosis or a vaginal yeast
infection.

If one is experiencing fever or back pain, this may be a sign of a kidney infection (pyelonephritis), which can be
a serious medical issue. Seek medical attention immediately.

Specific signs and symptoms

4 routes of bacterial entry to urinary tract.

1) Ascending infection

2) Blood borne spread

3) Lymphatogenous spread

4) Direct extension from other organs

Ascending infection

• most common route.

Hematogenous spread:

• Blood borne spread to kidneys

• Occurs in bacteraemia

• Mostly spread by Streptococcus aureus

• Men- through rectal and colonic lymphatic vessels to prostrate and bladder.

• Women- through peri-uterine lymphatics to urinary tract.

Direct extension from other organs:

• Pelvic inflammatory diseases

Genito-urinary tract fistulas

UTI- DIAGNOSIS

 Urinalysis to examine the urine for red blood cells, white blood cells and bacteria (The number of
white and red blood cells can indicate an infection.)
 Urine culture to determine the type of bacteria in the urine. This is important to help determine
the appropriate treatment.

If your infection does not respond to treatment or if you get repeated infections, your doctor may use the
following tests to examine your urinary tract for disease or injury:

 Intravenous pyelogram (IVP), a series of X-rays of the bladder, kidneys and ureters after a special
dye is injected (The dye helps the structures to show up better on the X-ray.)
 Ultrasound, a test that uses sound waves to form images of internal organs
 Cystoscopy, a test that uses a special instrument fitted with a lens and a light source (cystoscope)
to see inside the bladder from the urethra
 CT scan, a type of X-ray that takes cross sections of the body (like slices) – much more precise
than typical X-rays
Laboratory examination

Uncontaminated, midstream urine sample used.

Methods for urine collection:

1. stick on bags

2. catheterization

3. suprapubic aspiration (SPA) – gold standard for urine collection

Laboratory findings

Normal Findings

• pH - 4.6 – 8.0

• Appearance- clear

• Colour – pale to amber yellow

• Odour – aromatic

• Blood – none

• Leukocyte esterase – none

• WBC- absent

Bacteria- absent

Abnormal findings

• pH – Alkaline ( increases)

• Appearance – cloudy

• Colour - deep amber

• Odour – foul smelling

• Blood – maybe present Leukocyte esterase – present

• WBC- present •Bacteria- present

Clinical manifestations depending on site of infection

Urethritis:

• Discomfort in voiding

• Dysuria

• Urgency

• frequency

Cystitis:
 • dysuria, urgency and frequent urination

• Pelvic discomfort

• Abdominal pain

• Pyuria

Haemorrhagic cystitis:

• Visible blood in urine.

• Irritating voiding symptoms

Pyelonephritis:

• Invasive nature

• Suprapubic tenderness

• Fever and chills

• White blood cell casts in urine

• Back pain

• Nausea and vomiting

Complications include sepsis, septic shock and death

Goals of antimicrobial therapy:

 Elimination of infection

 Relief of acute symptoms

 Prevention of recurrence and long term complications

PATHOGEN SPECIFIC TREATMENT:

ORAL THERAPY
1. FLUOROQUINOLONES; CIPROFLOXACIN NORFLOXACIN LEVOFLOXACIN
2. PENCILLINS: AMOXICILLIN + CLAVULANATE [25mg +62.5mg]
3. TRIMETHOPRIM + SULPHAMETHAZOLE [1:5 dose]
4. NITROFURANTOIN [SPECIFIC DRUG FOR UTI]
5. CEPHALOSPORINS
PARENTRAL THERAPY:

1. AMINOGLYCOSIDES: AMIKACIN
2. PENCILLIN: AMPHICILLIN+SULBACTUM, PEPERICIN+TAZOBACTUM
3. CEPHALOSPORIN: CEFTRIAXONE, CEFTAZIDIME
4. CARBAPENAMS/MONOBACTAMS: IMIBENAM+CELESTINE, MEROPENAM
5. FLUROQUINALONES: CIPROFLOXACIN, NORFLOXACIN, LEVOFLOXACIN

TREATMENT REGIMEN:

1. UNCOMPLICATED UTI: TRIMETHOGLIN+ SULFOMETHOMIZONE