URINARY TRACT

INFECTION
Lloyd F. Alias, MD
3rd resident
Department of Family and Community
Medicine
Definition
 Urinary tract infection (UTI) is a common and
painful human illness that, fortunately, is
rapidly responsive to modern antibiotic
therapy
 may be asymptomatic or symptomatic. Thus,
the term urinary tract infection encompasses
a variety of clinical entities.
Etiology:
 UTIs are commonly caused by:
Escherichia Coli
Staphylococcus saprophyticus
Klebsiella species
Proteus species
Citrobacter species
Epidemiology:
 It is the 15th most common condition seen by family
physicians
 Between 1 year and 50 years of age, UTI and recurrent
UTI are predominantly diseases of females.
 As many as 50–80% of women in the general population
acquire at least one UTI during their lifetime
 After 50 years of age, obstruction from prostatic
hypertrophy becomes common in men, and the
incidence of UTI is almost as high among men as among
women.
Risk factors:
 Female
 Frequent sexual intercourse
 Previous history of UTI
 Urinary incontinence
 Diabetes mellitus
 Anatomic abnormality of the urinary tract
 Uncircumcised
 Classification of UTI

European association of Urology,

Case 1:
 Patient LS, 19 yrs old, male, single, came in for
medical certificate as a requirement for his
enrollment. No symptomatic complain at the
time of consultation, no fever, no cough and
colds, no dysuria and no hypogastric pain
noted. All laboratories were normal except for
his urinalysis, which result revealed urine WBC of
15/hpf and urine bacteria of 229/UL.
 Physical examination: UNREMARKABLE
WHAT IS YOUR DIAGNOSIS?

 Salient features:
No symptoms noted Asymptomatic
(-) fever bacteriuria
(-) dysuria
(-) hypogastric pain
Urine wbc of 15/hpf
Urine bacteria of
229/UL
TREATMENT AND
DIAGNOSIS
Asymptomatic bacteriuria
DEFINITION

 Bacteriuria is defined as
 for asymptomatic women, two consecutive voided urine
specimens with isolation of the same bacterial strain in
quantitative counts ≥100,000 cfu/mL
 In men, a single, clean-catch voided urine specimen with one
bacterial species isolated in a quantitative count ≥100,000
cfu/mL.
 In both, a single catheterized urine specimen with one bacterial
species isolated in a quantitative count ≥100 cfu/mL
Asymptomatic bacteriuria

 OptimalScreening Test
 Urine culture - gold standard for diagnosing ASB

 In the absence of urine culture, significant pyuria (>10

wbc/hpf) or a positive gram stain of unspun urine (>2
microorganisms/OIF) in two consecutive midstream
urine samples is sufficient
Asymptomatic bacteriuria
 Screening and treatment
 Routine screening and treatment for asymptomatic bacteriuria is NOT
recommended for healthy adults.
 Likewise, periodic screening and treatment for asymptomatic bacteriuria is NOT
RECOMMENDED in the following:
 Patients with DM
 Elderly patients
 Spinal cord injury patients
 Patients with indwelling catheter
 Solid organ transplant patients
 HIV patients
 Patients with urologic abnormalities.
Asymptomatic bacteriuria
 Screening and treatment for asymptomatic
bacteriuria is recommended in the following:
All pregnant women
Patients who will undergo genitourinary
manipulation and instrumentation
Asymptomatic bacteriuria
 Antibiotics that can be used for asymptomatic
bacteriuria in pregnancy
Antibiotic Recommended dose and duration FDA Risk Category
Cephalexin 500 mg BID for 7 days B
Cefuroxime axetil 500 mg BID for 7 days B
Fosfomycin trometamol 3 g single dose B
Amoxicillin-clavulanate 625mg BID for 7 days B
Nitrofurantoin* macrocrystal 100 mg QID for 7 days; B
100 mg BID for 7 days for monohydrate
macrocrystal formulation

Trimethoprim- 160/800 mg BID for 7 days C (avoid in 1st and 3rd

sulfamethoxazole trimester)
Asymptomatic bacteriuria
Asymptomatic bacteriuria

Non pharmacologic treatment and advise

Oral hydration
➢ Oralwater hydration (2-2.5 Liters/day) may be done to
prevent UTI.
Case 2:
 Patient C.M, 28 yrs old, female, married, currently
residing at Carig sur, Tuguegarao city, consulted at
FM OPD clinic last August 14, 2020.

 Chief complain: Dysuria (“masakit po pag umiihi

ako”)
History of present illness
3 days PTC. Pt. had dysuria accompanied by
hypogastric pain, with a pain scale of 3-4/10,
characterized as dull and non radiating. Patient
denied of having fever and chills. No flank pain, no
vaginal discharged noted. No consult was done
and no medication was taken. Few hours prior to
consult, above condition still persisted, this now
prompted pt. to seek for consult at CVMV family
medicine opd clinic for further evaluation and
management.
 OB history:
 G1P1 (1001)
 LMP: July 27, 2020
 Menstrual cycle: regular, monthly cycle with
moderate flow consuming 3 pads per day
moderately soak, lasting to 5-6 days.
 Currently taking oral contraceptive

 Past medical history:

 (-)hypertension, (-) DM, (-) heart disease, (-) kidney
disease, (-) lung disease, (-) history of surgery
 Personal and social history:
 Non-smoker, occasional alcoholic drinker
(at least once a month, consuming 1-2
bottles of san mig light). College
undergraduate, currently working as a
cashier in a department store.

 Family history: no heredo familial diseases

such as hypertension and diabetes
Physical examination:
 Vital signs: BP: 120/80, RR: 18, PR: 78, temp: 37.3 degree Celsius.
 Awake, conscious, not in cardio respiratory distress
 Anicteric sclera, pink palpebral conjunctiva, (-)
tonsillopharingitis
 (-) pallor, (-) rashes, (-) jaundice
 Symmetrical chest expansion, clear breath sound, no retraction
 Soft, flat, non tender, normo active bowel sound
 (-) kidney punch test
 Full pulses
WHAT IS YOUR DIAGNOSIS?
 Salient features:
 Female
 Dysuria
Acute uncomplicated
cystitis
 Hypogastric pain
 No fever
 No vaginal discharged
 No flank pain
 (-) kidney punch test
TREATMENT AND
DIAGNOSIS
Acute uncomplicated cystitis in women
Diagnosis of Acute Uncomplicated Cystitis
❖ Clinically, AUC is suspected in premenopausal non-pregnant
women presenting with acute onset of the following
symptoms:
 Dysuria

 Frequency

 Urgency

 Gross hematuria
*and without vaginal discharge
Diagnosis of Acute Uncomplicated
Cystitis
❖Urinalysis is not necessary to confirm the
diagnosis of AUC in women presenting
with one or more of the above
symptoms of urinary tract infection in
the absence of vaginal discharge and
complicating conditions.
Approach to Treatment

❖ Empiric antibiotic therapy is the most cost-

effective approach in the management of AUC
❖ Pre-treatment urine culture and sensitivity is not
recommended
❖ Standard urine microscopy and dipstick leukocyte
esterase and nitrite tests are not prerequisites for
treatment

Strong recommendation, High quality of evidence

❖ Nitrofurantoin monohydrate/macrocrystals (100mg
twice daily for 5 days) is recommended as the first-line
treatment for acute uncomplicated cystitis due to its
high efficacy, minimal resistance, minimal adverse
effects, low propensity for collateral damage and
reasonable cost. However the nitrofurantoin
monohydrate is not locally available. Thus, the locally
available nitrofurantoin macrocrystal formulation 100
mg is recommended, but it should be given four times
a day for five days.
*strong recommendation, high quality of evidence
❖ Ampicillinor Amoxicillin should NOT be used for
empirical treatment given the relatively poor efficacy
and the very high prevalence of antimicrobial
resistance to these agents worldwide.
*strong recommendation, high quality of evidence
❖Trimethoprim-sulfamethoxazole 800/160 mg BID for
three days should be used only for culture-proven
susceptible uropathogens due to the high prevalence
of local resistance and high failure rates.
*strong recommendation, high quality of evidence
❖ Quinolones should NOT be used as a first line drug for
acute uncomplicated cystitis despite their efficacy
due to its high propensity for collateral damage.
*strong recommendation, high quality of evidence

❖Beta –lactam agents, including amoxicillin-

clavulanate, cefaclor, cefdinir, cefpodoxime-proxetil,
ceftibuten and cefuroxime are appropriate
alternative choices for therapy when the primary
recommended agents cannot be used.
*strong recommendation, high quality of evidence
Duration of Treatment for elderly women with
AUC
❖ In otherwise healthy elderly women with AUC,
the recommended duration of treatment for
elderly women is the same as the general
population.
*strong recommendation, high quality of evidence
Course of action for patients who don’t respond to
treatment
❖Patients whose symptoms worsen or do not improve
after completion of treatment should have a urine
culture done, and, the antibiotic should be
empirically changed pending result of sensitivity
testing.
*strong recommendation, low quality of evidence
Post-Treatment Diagnostics
❖ Routine post-treatment urine culture and
urinalysis in patients whose symptoms have
completely resolved are not recommended as
it does not provide any added clinical benefit.
*strong recommendation, low quality of evidence
ALGORITHM FOR TREATING UNCOMPLICATRED CYSTITIS
Case 3:
 Patient R.A, 49 yrs old, female, widow, currently
residing at Iguig, Cagayan, consulted at Ambulatory
care clinic last August 7, 2020.

 Chief complain: Flank pain

History of present illness
2 days PTC. Pt. had flank pain, with a pain scale of 4-
5/10, characterized as dull and radiating to the
hypogastric area accompanied by dysuria, no
vaginal discharged note. Patient also complains of
having undocumented fever and chills. No consult
was done. Pt. took paracetamol 500mg which
provided temporary relief of fever. Few hours prior to
consult, above condition still persisted, this now
prompted pt. to seek for consult at CVMV family
medicine opd clinic for further evaluation and
management.
 OB history:
 G5P5 (5005)
 Menopause at 45 yrs/old

 Past medical history:

 (-)hypertension, (-) DM, (-) heart disease, (-) kidney
disease, (-) lung disease, (-) history of surgery
 Personal and social history:
 Non-smoker, non alcoholic drinker. high
school undergraduate, currently working as
a farmer.

 Family history: no heredo familial diseases

such as hypertension and diabetes
Physical examination:
 Vital signs: BP: 130/80, RR: 20, PR: 88, temp: 38.4 degree Celsius.
 Awake, conscious, not in cardio respiratory distress
 Anicteric sclera, pink palpebral conjunctiva, (-)
tonsillopharingitis
 (-) pallor, (-) rashes, (-) jaundice
 Symmetrical chest expansion, clear breath sound, no retraction
 Soft, flat, non tender, normo active bowel sound
 (+) kidney punch test
 Full pulses
Kidney punch test:

 Itis performed by striking

the fist of one hand
against the dorsal surface
of the other hand, which is
placed flat along the
posterior CVA margin.
Normally, percussion in
CVA should not elicit
tenderness.
WHAT IS YOUR DIAGNOSIS?
 Salient features:
 Female
 Flank pain
Acute uncomplicated
pyelonephritis
 Dysuria
 Hypogastric pain
 (+)fever and chills
 No vaginal discharged
 (+) kidney punch test
TREATMENT AND
DIAGNOSIS
Acute uncomplicated pyelonephritis
DEFINITION

 Classic Syndrome of fever (T ≥38°C) chills, flank pain, CVA

tendernesss, nausea and vomiting, ± signs of lower UTI
 no clinical or historical evidence of anatomic or
functional urologic abnormalities
 Laboratory findings include
 pyuria (≥5 WBC/HPF of centrifuged urine) on urinalysis
and
 bacteriuria with counts of ≥10,000 CFU/mL on urine
culture
Acute uncomplicated pyelonephritis

PRE-TREATMENT DIAGNOSTIC TESTS

 urine GS/CS
 Blood cultures are NOT routinely recommended except in
patients with signs of sepsis
 Temperature >38°C or <36°C,
 Leukopenia (WBC<4,000) or leukocytosis (WBC>12,000),
 Tachycardia (HR>90 bpm),
 Tachpynea (RR>20/min or PaCO2<32 mmHg),
 Hypotension (SBP< 90mmHg or >40mmHg drop from
baseline
Acute uncomplicated pyelonephritis

INDICATIONS FOR ADMISSION

 Inability to maintain oral hydration or take

medications;
 Concern about compliance;
 Presence of possible complicating conditions;
 Severe illness with high fever, severe pain, marked
debility, and signs of sepsis
Acute uncomplicated pyelonephritis
ANTIBIOTIC TREATMENT

 Aminopenicillins (ampicillin or amoxicillin) and First

Generation Cephalosporins are NOT recommended
because of the high prevalence of resistance and
increased recurrence rates in patients given these beta-
lactams
 Because of high resistance rates to TMP-SMX, this drug is
NOT recommended for empiric treatment but it can be
used when the organism is found to be susceptible on
urine culture and sensitivity
Acute uncomplicated pyelonephritis

ANTIBIOTIC TREATMENT

 For AUP not requiring hospital admission:

 Quinolones are recommended as the FIRST LINE
treatment
 an initial single IV/IM dose of ceftriaxone or
aminoglycoside may be considered followed by any
recommended oral antibiotics
 For AUP requiring hospital admission, ceftriaxone,
fluoroquinolones, or aminoglycosides are recommended
as empiric FIRST-LINE treatment.
Acute uncomplicated pyelonephritis

ANTIBIOTIC TREATMENT

 Intravenous antibiotics can be shifted to any of the listed

oral antibiotics once the patient is afebrile and can
tolerate oral drugs guided by the urine culture and
sensitivity results.
 For suspected enterococcal infection, ampicillin may
be combined with an aminoglycoside
 Carbapenems and piperacillin-tazobactam should be
reserved for acute pyelonephritis caused by multi-drug
resistant organisms that are susceptible to either drug
Acute uncomplicated pyelonephritis
 ANTIBIOTIC TREATMENT
Acute uncomplicated pyelonephritis
 ANTIBIOTIC TREATMENT
Acute uncomplicated pyelonephritis
WORK-UP FOR UROLOGIC ABNORMALITIES

 Routine urologic evaluation and routine use of imaging procedures

are NOT recommended.
 Consider early radiologic evaluation if the patient has
 history of urolithiasis
 urine pH ≥ 7.0 or
 renal insufficiency
 To rule out the presence of nephrolithiasis, urinary tract obstruction,
renal or perinephric abscesses, or other complications of
pyelonephritis, consider radiologic evaluation if
 the patient remains febrile within 72 hours of treatment or
 symptoms recur
Acute uncomplicated pyelonephritis

FOLLOW-UP URINE CULTURE & SENSITIVITY

 In patients who are clinically responding to therapy

(usually apparent in <72 hours after initiation of
treatment), a follow-up urine culture is NOT necessary.
 Routine post-treatment cultures in patients who are
clinically improved are also not recommended.
 In women whose symptoms do not improve during
therapy and in those whose symptoms recur after
treatment, a repeat urine culture and sensitivity test
should be performed.
Acute uncomplicated pyelonephritis

RECURRENCE OF SYMPTOMS

 Recurrence of symptoms requires antibiotic

treatment based on urine culture and sensitivity test
results, in addition to assessing for underlying
genitourologic abnormality.
 The duration of re-treatment in the absence of a
urologic abnormality is two weeks.
 For patients whose symptoms recur and whose
culture shows the same organism as the initial
infecting organism, a four- to six-week regimen is
recommended
Sexually transmitted infection

The term sexually transmitted

infection (STIs) refers to a variety of
clinical syndromes and infections
caused by pathogens that can be
acquired and transmitted through
sexual activity.
Case:
 patient RN, 21 y/o, male, single, Filipino, Roman Catholic,
born on November 21, 1995, currently residing at Solana
cagayan, who came in for consult for the first time last
August 10, 2020.

 Chief complain: Penile discharged

History of present illness
 The patient’s condition started 1 week prior to consult, where he
started to experience painful urination, with the pain scale of
6/10. No associated symptoms noted. The patient did not take
any medications nor sought consult.
 Until 4 days prior to consult, still with painful urination,
accompanied with yellowish to greenish penile discharge. The
patient self medicated with Amoxicillin 500mg/tab for one day
but no consult done.
 His symptoms persisted, until few hours prior to consult, with
persistence of painful urination and penile discharge, the patient
sought consult at our institution for further evaluation and
management.
 Past medical history: Patient denied previous hospitalization
nor history of allergy to food nor medications, no previous
surgery, no history of viral hepatitis, nor previous treatment
for STD

 Personal and social history: Smoker for 5 pack years, an

occasional alcoholic beverage drinker. The patient denies
any use of illicit drugs, with inconsistent use of condom and a
sexually active person with 2 sexual partner.

 The family history were unremarkable.

Physical examination:
 Vital signs: BP: 130/80, RR: 20, PR: 88, temp: 37.9 degree Celsius.
 Awake, conscious, not in cardio respiratory distress
 Anicteric sclera, pink palpebral conjunctiva, (-) tonsillopharingitis, No
oral lesions noted
 (-) pallor, (-) rashes, (-) jaundice
 Symmetrical chest expansion, clear breath sound, no retraction
 Soft, flat, non tender, normo active bowel sound
 (+) yellowish-greenish penile discharged, no lesions noted, no scrotal
swelling
 Full pulses
WHAT IS YOUR DIAGNOSIS?
 Salient features:
 penile discharged
 Painful urination
Gonococcal urethritis
 Sexually active
 Multiple sexual partner
 Yellowish-greenish
penile discharged
Gonococcal infection
 Risk Factors
 Multiple
or new sex partners or inconsistent
condom use
 Urban residence in areas with disease
prevalence
 Adolescent
 Lower socio-economic status
 Use of drugs
 Exchange of sex for drugs or money
Gonococcal infection
 Transmission
 Efficiently transmitted by
Male to female via semen
Vagina to male urethra
Rectal intercourse
Fellatio/oral sex (pharyngeal infection)
Perinatal transmission (mother to infant)

 Gonorrhea associated with increased transmission

of and susceptibility to HIV infection
Gonorrhea

 Pathogenesis:
 Etiologic agent: Neisseria gonorrhoeae
 Gram-negative intracellular diplococcus
 Infects mucus-secreting epithelial cells
 Evades host response through alteration
of surface structures
Genital Infection in Men

 Urethritis – Inflammation of
urethra

 Epididymitis – Inflammation
of the epididymis
Genital Infection in Men
 Gonococcal urethritis
 Symptoms
Typically purulent or mucopurulent urethral
discharge
Often accompanied by dysuria
Discharge may be clear or cloudy
 Asymptomatic in a minority of cases
 Incubation period: usually 1-14 days for symptomatic
disease, but may be longer
Genital Infection in Men

 Gonococcal Epididymitis
 Symptoms: unilateral testicular pain and swelling
 Infrequent, but most common local complication
in males
 Usually associated with overt or subclinical
urethritis
Genital Infection in Women

 Most infections are asymptomatic

 Cervicitis – inflammation of the cervix

 Urethritis – inflammation of the urethra

Genital Infection in Women
 Cervicitis
 Non-specific symptoms: abnormal vaginal discharge,
intermenstrual bleeding, dysuria, lower abdominal pain, or
dyspareunia
 Clinical findings: mucopurulent or purulent cervical discharge,
easily induced cervical bleeding
 At least 50% of women with clinical cervicitis have no
symptoms
 Incubation period unclear, but symptoms may occur within 10
days of infection
Genital Infection in Women
 Urethritis
 Symptoms:dysuria, however, most women are
asymptomatic

 70%–90% of women with cervical gonococcal

infection may have urethral infection
Syndromes in Men and Women

 Anorectal infection
 Usually acquired by anal intercourse
 Usually asymptomatic
 Symptoms: anal irritation, painful defecation, constipation, scant
rectal bleeding, painless mucopurulent discharge, tenesmus, and
anal pruritus
 Signs:mucosa may appear normal, or purulent discharge,
erythema, or easily induced bleeding may be observed with
anoscopic exam
Syndromes in Men and Women
 Pharyngeal infection
 May be sole site of infection if oral-genital contact is the
only exposure
 Most often asymptomatic, but symptoms, if present, may
include pharyngitis, tonsillitis, fever, and cervical adenitis
 Conjunctivitis
Usually a result of autoinoculation in adults
Symptoms/signs: eye irritation with purulent conjunctival
exudate
Syndromes in Men and Women
 Disseminated gonococcal infection (DGI)
 Systemic gonococcal infection
 Occurs infrequently.
 More common in women than in men
 Associatedwith a gonococcal strain that produces
bacteremia without associated urogenital symptoms
 Clinical
manifestations: skin lesions, arthralgias,
tenosynovitis, arthritis, hepatitis, myocarditis,
endocarditis,and meningitis
Diagnostic Methods
 Culture tests
 Advantages: low cost, suitable for a variety of specimen sites, antimicrobial
susceptibility can be performed
 Anatomic sites to test
 In men:
 urethra in all men;
 pharynx and rectum (depending on exposure history or symptoms)
 In women:
 cervix should be tested;
 pharynx and rectum depending on symptoms and exposure history;
 Bartholin’s or Skene’s glands may be cultured if overt exudate is expressed
Diagnostic Methods
 Non-culture tests
 Amplified tests (NAATs)
Polymerase chain reaction (PCR) (Roche Amplicor)
Transcription-mediated amplification (TMA) (Gen-
Probe Aptima)
Strand displacement amplification (SDA) (Becton-
Dickinson BD ProbeTec ET)
 Non-amplified tests
DNA probe (Gen-Probe PACE 2, Digene Hybrid
Capture II)
 Gram-stained smear
Treatment for Uncomplicated Gonococcal
Infections

Recommended

Ceftriaxone 250 mg IM Once

PLUS
Azithromycin 1g Orally Once

OR
Twice a day for
Doxycycline 100 mg Orally
7 days
Quinolones are no longer recommended in the United States for the treatment of
gonorrhea and associated conditions, such as PID
 Management

Treatment for Uncomplicated 80

Gonococcal Infections

Alternative 1: If Ceftriaxone is not available

Cefixime 400 mg Orally Once

PLUS
Azithromycin 1g Orally Once
OR
Twice a day for
Doxycycline 100 mg Orally
7 days
PLUS
Test of cure in 1 week
Treatment for Uncomplicated
Gonococcal Infections

Alternative 2: If patient is cephalosporin-allergic

Azithromycin 2g Orally Once

PLUS
Test of cure in 1 week
Follow-Up
A test of cure is not recommended if
recommended regimen is administered
 A test of cure is recommended if an alternative
regimen is administered
 If symptoms persist, perform culture for N.
gonorrhoeae
Any gonococci isolated should be tested for
antimicrobial susceptibility at site of exposure
Screening
 Pregnancy:
 A test for N. gonorrhoeae should be performed at the1st prenatal
visit for women at risk or those living in an area in which the
prevalence of N. gonorrhoeae is high
 Repeat test in the 3rd trimester for those at continued risk
 U.S. Preventive Service Task Force recommends screening all
sexually active women for gonorrhea infection if they are at
increased risk of infection
 Sexually active men who have sex with men: CDC recommends
screening at least annually at all anatomic sites of exposure
Partner Management

 Evaluate and treat all sex partners for N.

gonorrhoeae and C. trachomatis infections, if
contact was within 60 days of symptoms or
diagnosis
 If a patient’s last sexual intercourse was >60 days
before onset of symptoms or diagnosis, the
patient’s most recent sex partner should be
treated
 Avoid sexual intercourse until therapy is completed
and both partners no longer have symptoms
Prevention: