Urinary Tract Infections
Integrated lecture with department of microbiology Dr. Champika Gamakaranage
Prof. Nelun de Silva MBBS. MD(Col). MRCP(Lond). FRCP(Lond)
Dr. Vindya Perera Specialist Physician and Senior Lecturer in Medicine
Department of Medicine
SUSL
Topics
• Anatomy
• Types/ classification of UTI
• Cystitis
• Urethritis
• Pyelonephritis
• Complications of UTI
• Investigations
• Management
Anatomy of Genito-urinary system
Anatomical susceptibility in females
• more often in women than in men, at a ratio of 8:1
• UTI accounts for 25% of all infections in females
• Why females get more UTIs
• Anatomical susceptibility – shorter urethra (M: F = 10:4), proximity to rectum
• Behavioral susceptibility – sexual behaviors/ cleaning
• Pelvic prolapse and lack of estrogen in postmenopausal women -
• Pregnancy and delivery -
Types of UTI
Cystitis (infection of the bladder/lower urinary tract)
Pyelonephritis (infection of the kidney/upper urinary tract)
Nephritis
Pyelonephritis
Upper tract
Pyelitis
Cystitis
Lower tract
Urethritis
Simple and Complicated UTI
• UTI that is presumed to be confined to the bladder – simple
• Lacks systemic and PN features – fever, fatigue, malaise, flank pain, renal angle
(costovertebral angle tenderness)
• Lacks features of Prostatitis (pelvic or perineal pain)
• If any of these signs or symptoms are present in the setting of pyuria and bacteriuria, we consider
the patient to have acute complicated UTI
• Who are at risk for complicated UTI
• Diabetes
• Immune suppression
• Urinary structural abnormalities
• Instrumentation
Classification of UTI
• Simple and complicated
• Isolated infection - when it is the first episode of UTI, or the episodes are 6 months apart
• Unresolved infection - when therapy fails because of bacterial resistance or due to infection by two
different bacteria with equally limited susceptibilities
• Reinfection - there has been no growth after a treated infection, but then the same organism
regrows two weeks after therapy, or when a different microorganism grows during any period of
time
• Relapse - when the same microorganism causes a UTI within two weeks of therapy; however, it is
usually difficult to distinguish a reinfection from a relapse
Cystitis
• In women, the pathogenesis of UTIs begins with
colonization of the vaginal introitus by uropathogens
from the fecal flora, followed by ascension via the
urethra into the bladder and, in the case of
pyelonephritis, to the kidneys via the ureters
• In men its not common – if occurred need evaluation
to find a predisposing cause
Symptoms and signs
• Irritative LUTS
• Gross haematuria
• Acute urine retention
• Lower abdominal pain and tenderness
• Could be asymptomatic
• In elderly – acute confusion (even without systemic extension)
Urethritis
• Inflammation of urethra
• Can be infectious or non-infectious
• Urethritis Typically used to describe STI
• Infectious causes eg→ N. gonorrhoea/ C. trachomatis
• Dysuria/ urethral discharge/ itching/ dysmenorrhoea/ orchalgia/
fever/ chills/ sweats/ nausea and vomiting are the symptoms
• Yet 75% could be asymptomatic
Pyelonephritis
• Pyelonephritis develops when pathogens ascend to the kidneys via
the ureters. Pyelonephritis can also be caused by seeding of the
kidneys from bacteremia. It is possible that some cases of
pyelonephritis are associated with seeding of the kidneys from
bacteria in the lymphatics
• include fever, chills, flank pain, costovertebral angle tenderness, and
nausea/vomiting
• Symptoms of cystitis - often present, not always
• If a patient with cystitis becoming ill, you need to suspect PN
Complications of UTI
• Cystitis → ascending infection →PN
• bacteremia, sepsis, multiple organ system dysfunction, shock, and/or acute renal failure
• renal corticomedullary abscess, perinephric abscess, emphysematous pyelonephritis, or papillary
necrosis
• Xanthogranulomatous pyelonephritis (rare, occur when there is obstruction) - massive
destruction of the kidney by granulomatous tissue
• Prostatitis and epidydimo-orchitis can occur in men
Investigations
• UFR • NCCT KUB
• U/Culture and ABST • Uroflowmetry
• [Link] • CECT abdomen
• SE • CT IVU
• FBC
• Cystoscopy
• CRP
• RBS
• X-ray KUB
• USS KUB
Management
• Antibiotics
• Empiric antibiotic therapy -
• National and local guidelines/ susceptibility patterns
• Severity of illness
• Risk factors for resistant organisms
• Host factors - renal impairment / allergies / pregnancy/ lactation / elderly
• Selection of antibiotics with ABST
• Common principals
• Symptomatic therapy
• Analgesics
• Antiemetics
• Supportive care
• Hydration and nutrition
• if immobilized – may need DVT prophylaxis/ pressure stockings
• Mouth, bowel, bladder, and skin care (air/ water mattress)
• If complications are there – need to manage those
• Septic shock
• AKI
• Emphysematous PN/ Xanthogranulomatous PN – may need nephrectomy
• Sometimes need to treat underlying cause
• Catheterization/ Removal of stone/ pyelolithotomy/ treat IE
Summary
• Females have anatomical and other susceptibilities to UTI
• UTI in males need careful evaluation
• Lower UTI can ascend and get complicated with PN and systemic infection
• Always take urine culture when starting antibiotics for UTI
• When deciding empiric therapy national guidelines, regional susceptibility
pattern/ severity of illness and host factors should be considered
Case scenario
• 56-year-old lady admitted to the emergency department being faintish for several hours. She had
been having fever, chills, frequency and dysuria for last 3 days. She complains there is lower
abdominal pain and for the last 6 hours she had not passed any urine. She is a diagnosed patient
with diabetes for 5 years and has hypertension and dyslipidaemia too. On admission she is febrile,
tachycardic (HR 100bpm) and had BP of 86/50 mmHg.
• What is your diagnosis
• How do you confirm your diagnosis
• How do you manage this patient
`
• Diagnosis
• UTI (PN) [urosepsis], with AKI and septic shock
• Investigations
• UFR/ U-culture/ [Link]
• Blood culture
• Management
Thank you
