Urinary Tract Infections:

Introduction:
- Clinical Syndromes:
- Urethritis (urethra)
- Cystitis (bladder)
- Prostatitis (prostate gland)
- Pyelonephritis
- Definition:
- UTI: Presence of microorganisms in urine

Types of UTIs:
- Lower Tract Infections:
- Cystitis
- Urethritis
- Prostatitis
- Upper Tract Infections:
- Pyelonephritis =Upper tract infections involve the kidney

Classification:
- Uncomplicated UTIs:
- No structural or functional abnormalities that may interfere with the normal flow of urine or the voiding mechanism.

- Complicated UTIs:
- Result of predisposing lesions

Recurrent UTIs:
- Definition: characterized by multiple

- Two or more UTIs within 6 months or three or more within 1 year symptomatic episodes
with asymptomatic
periods occurring

- Causes: between these episodes.

- Reinfection: Different organism

- Relapse: Repeated infections by same initial organism

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Pathophysiology of Urinary Tract Infections (UTIs)
Origin of UTI Bacteria:
- Originate from bowel flora of the host

Routes of Entry into Urinary Tract:

1. Ascending pathway
2. Hematogenous (descending) pathway
3. Lymphatic pathway

Common Causative Organisms for uncomplicated UTIs:

- Escherichia coli (E. coli) (80%-90%)
- Staphylococcus saprophyticus
- Streptococcus pneumoniae
- Proteus spp.
- Pseudomonas aeruginosa
- Enterococcus spp.
- Klebsiella pneumoniae

Complicated or Nosocomial Infections:

- Pathogens may include:
- E. coli (<50%)
- Proteus spp. Enterococci represent the

- Klebsiella pneumoniae second most frequently

isolated organisms in
hospitalized patients.
- Enterobacter spp.
- Pseudomonas aeruginosa
- Staphylococci
- Enterococci

Infection Characteristics:
- Most UTIs caused by a single organism
- Exceptions:
- Patients with stones
- Indwelling urinary catheters multiple organisms
- Chronic renal abscesse
Clinical Presentation of Urinary Tract Infections (UTIs)

Lower UTI Symptoms:

- Dysuria
- Urinary urgency
- Urinary frequency
- Nocturia
- Suprapubic heaviness
- Gross hematuria

Upper UTI Symptoms:

- Flank pain
- Fever
- Nausea
- Vomiting
- Malaise
- Costovertebral tenderness

Reliability of Symptoms:
- Symptoms alone are unreliable for UTI diagnosis
- Diagnosis relies on demonstrating significant numbers of microorganisms in urine specimen

Symptoms in Older Patients:

- Older patients may not experience specific urinary symptoms
- Present with:
- Altered mental status
- Change in eating habits
- Gastrointestinal (GI) symptoms

Diagnosis:
- Most reliable method: Quantitative urine culture
Treatment Goals of Urinary Tract Infections (UTIs)
Goals:
- Eradicate invading organisms
- Prevent or treat systemic consequences of infection
- Prevent recurrence of infection
- Decrease potential for collateral damage with broad antimicrobial therapy

Initial Antimicrobial Selection:

- Based on:
- Severity of signs and symptoms
- Site of infection
- Complicated or uncomplicated UTI

Other Considerations:
- Antibiotic susceptibility
- Side-effect potential
- Cost
- Current antimicrobial exposure
- Comparative inconvenience of therapies

Treatment Goals of Urinary Tract Infections (UTIs)

NonPharmacologic Therapy Pharmacologic Therapy

‫ﻣﺎﻛﻮ‬
Pharmacologic Therapy for Urinary Tract Infections (UTIs)
Eradication of Bacteria:
- Directly related to:
- Sensitivity of the organism
- Achievable concentration of antimicrobial agent in urine

First-Line Treatments for Acute Uncomplicated Cystitis:

- Trimethoprim–sulfamethoxazole:
- Most E. coli remain susceptible, but resistance is increasing
- Nitrofurantoin
- Fosfomycin
- Aim to decrease overuse of broad-spectrum antimicrobials

Acute Uncomplicated Cystitis

Predominantly Caused by E. coli:
- Antimicrobial therapy should target E. coli initially

Short-Course Therapy:
- 3-day therapy with:
- Trimethoprim–sulfamethoxazole
- Fluoroquinolone (e.g., ciprofloxacin, levofloxacin) Except moxifloxacin
Superior to single-dose therapy for uncomplicated infection

Reserve Fluoroquinolones:
- For patients with suspected or possible pyelonephritis
- Due to collateral damage risk

First-Line Therapy Options:

- 3-day course of trimethoprim–sulfamethoxazole
- 5-day course of nitrofurantoin
- One-time dose of fosfomycin
- Consider in place of fluoroquinolones

Resistant E. coli (>20% Resistance to Trimethoprimsulfamethoxazole)

Alternative Therapies:
- Nitrofurantoin
- Fosfomycin
Complicated Urinary Tract Infections - Acute Pyelonephritis
Presentation:
- High-grade fever (>38.3°C)
- Severe flank pain

Management:
- Hospitalization for severely ill patients; IV antibiotics initially
- Outpatient management for milder cases with oral antibiotics

Diagnostic Tests at Presentation:

- Gram stain of urine
- Urinalysis
- Urine culture and sensitivities

Duration of Treatment:
- Oral therapy: 7–14 days depending on agent used

First-line Oral Antibiotics for Mild-to-Moderate Pyelonephritis:

- Fluoroquinolones (ciprofloxacin or levofloxacin) for 7–10 days
- Trimethoprimsulfamethoxazole for 14 days

Treatment Based on Gram Stain Results:

- Gram-positive cocci (S. faecalis): Ampicillin

Initial Therapy for Seriously Ill Patients:

- IV fluoroquinolone
- Aminoglycoside ± ampicillin
- Extended spectrum cephalosporin ± aminoglycoside

Considerations for Hospitalized Patients, Catheterized Patients, or Nursing Home Residents:

- Possibility of P. aeruginosa, enterococci, and multiple-resistant organisms
- Recommended Antibiotics: Ceftazidime, ticarcillin-clavulanic acid, piperacillin, aztreonam, meropenem, or imipenem, in combination with an aminoglycoside

Follow-up:
- Obtain urine cultures 2 weeks after completion of therapy for response assessment and to detect possible relapse
Urinary Tract Infections in Men
Therapy:
- Prolonged treatment required in men
- Obtain urine culture before treatment due to unpredictable causes

Choice of Antibiotics:
- Presumed gram-negative bacteria:
- Trimethoprim–sulfamethoxazole or fluoroquinolone
- Initial therapy: 10–14 days

Recurrent Infections:
- Cure rates higher with 6-week regimen of trimethoprim–sulfamethoxazole

Urinary Tract Infection in Pregnancy

Treatment Recommendation:
- Symptomatic or asymptomatic treatment recommended for females with significant bacteriuria to avoid pregnancy complications

Choice of Antibiotics:
- Preferred Agents:
- Cephalexin
- Amoxicillin
- Amoxicillin/clavulanate
- Duration: 7 days

Avoidance of Certain Antibiotics:

- Tetracyclines: Avoid due to teratogenic effects
- Sulfonamides: Avoid in the third trimester to prevent kernicterus and hyperbilirubinemia
- Fluoroquinolones: Avoid due to potential inhibition of cartilage and bone development in the newborn
Recurrent Urinary Tract Infections
Definition:
- Recurrent episodes of UTI (reinfections and relapses) are significant

Patient Groups:
- Group 1: Fewer than two or three episodes per year
- Group 2: More frequent infections

Treatment Approach:
- Group 1:
- Treat each episode separately with short-course therapy for symptomatic lower tract infections
- Group 2:
- Consider long-term prophylactic antimicrobial therapy for 6 months
- Monthly urine cultures to monitor response

Prevention Strategies:
- Voiding after intercourse may help prevent infection in females with symptomatic reinfections associated with sexual activity
- Self-administered single-dose prophylactic therapy with trimethoprim–sulfamethoxazole after intercourse reduces recurrent infections

Relapse Management:
- Relapse after short-course therapy:
- Administer a 2-week course of therapy
- Relapse after 2 weeks:
- Continue therapy for another 2–4 weeks
- Relapse after 6 weeks:
- Perform urologic examination
- Consider therapy for 6 months or longer

Catheterized Patients
Asymptomatic Short-Term Catheterization (<30 days):
- Bacteriuria:
- Remove catheter as soon as possible
- Withhold systemic antibiotic therapy
- Symptomatic:
- Remove catheter
- Start treatment as for complicated infections

Prophylactic Antibiotics:
- Short-Term Catheterization (4–7 days):
- Reduce incidence of infection

Long-Term Catheterization:
- Antibiotics:
- Postpone development of bacteriuria
- Lead to emergence of resistant organisms