URINARY TRACT

INFECTION
ARNAIZ, NEPTALY P.
 OBJECTIVES
• Identify risk factors predisposing to UTI
• Identify the difference between
complicated and uncomplicated UTI as
well as lower and upper UTI
• Discuss different sign and symptoms of
UTI
• Identify Types and etiology of UTI
• Discuss diagnostics of UTI
• Discuss treatment regimen of UTI
 CASE
• R.D
• 42/F
• Married, separated (2008)
• Filipino
• Roman catholic
• May 15, 1976 (Rizal)
• Rodriguez, Rizal
• November 20, 2018
 Chief complaint
• Urinary frequency
 HPI
1 week prior to consult:
(+) frequent urination
(+) incomplete voiding
(+) straining
(+) urgency

(-) hypogastric pain

(-) flank pain
(-) fever
(-) dysuria
(-) vaginal discharge
(-) hematuria

(-) no consult
(-) no medication taken

Day of consult:
Still with above symptoms, hence consulted at our
institution
PMH: FMH
• (-) Hypertension • (+) Hypertension – mother
• (-) Diabetes Mellitus
• (-) Diabetes Mellitus
• (-) Heart diseases
• (-) Kidney disease • (-) Stroke
• (-) Bronchial Asthma • (-) Kidney disease
• (-) Thyroid disorders
• (-) Tuberculosis
• (+) Bronchial asthma – father
• (-) Previous hospital • (+) Tuberculosis – father
admissions • (-) Skin diseases
• (+) BTL – 2007 (QMMC) • (-) Cancer
• (+) Peptic ulcer diseases -
• (+) allergy to “daing”
mother
AGUILAR-CONJE FAMILY
NOV. 20, 2018
EAMC FMCH

?
OBSTETRICAL HISTORY SEXUAL HISTORY
• G3P3 (3003) • Coitarche: 19 y.o
• No. of sexual partner: 1
GYNECOLOGICAL HISTORY
• LMP: October 15, 2018 • Sexuality: Male
• PMP: September 2018 • (-) Dyspareunia
• Menarche: 12 y.o
• (-) Discharges
• Interval: regular (monthly)
• Duration: 7 days • (-) Previous STI
• Amount: 3 pads/day, • (+) Contaceptive use:
moderately soaked
• Symptoms:
OCP (6 mos)
(-) dysmenorrhea
 ROS
• General: unremarkable
• Skin: unremarkable
• HEENT: unremarkable
• Pulmonary: unremarkable
• Cardiac: unremarkable
• GI: unremarkable
• GUT: (+) urinary frequency, (+) weak/slow stream, (+) urgency, (+)
incomplete voiding, (+) straining
• Hematologic: unremarkable
• PVS: unremarkable
• Endocrine: unremarkable
• Neurologic: unremarkable
• Psychiatric: unremarkable
• MSK: unremarkable
 PHYSICAL EXAMS
• BP – 120/80 mmHg
• HR – 88 bpm
• RR – 20 cpm
• Temp – 37.2 °C
• O2 sat – 98 %
• Ht. – 156 cm
• Wt. – 60 cm
• BMI – 24.6 (overweight)
• IBW – 50.4 kg
• Waist – 85 cm
• Hip – 90 cm
• W/H ratio – 0.94
 PHYSICAL EXAMS
Conscious, coherent and not in cardiorespiratory
distress

HEENT: unremarkable
LUNGS: unremarkable
HEART: unremarkable
ABDOMEN: unremarkable
EXTREMETIES: Unremarkable

ST: (-) KPT

 ASSESSMENT
• Acute Uncomplicated Cystitis
 SALIENT FEATURES

(+) frequent urination (-) hypogastric pain

(+) incomplete voiding (-) flank pain
(+) straining (-) fever
(+) urgency (-) dysuria
(-) vaginal discharge
(-) hematuria
(-) KPT
 DIFFERENTIAL DIAGNOSIS
Rule in Rule out
Acute uncomplicated (+) urinary symptoms (-)fever
pyelonephritis (-) flank pain
(-) KPT
(-) nausea and vomiting
(-) vaginal discharges
Complicated UTI (+) urinary symptoms No presence of underlying
disease
Urethritis (+) urinary symptoms (-) sexual contact
(-) urethral discharges
(-) dysuria
(-)fever
(-) vaginal discharges
DISCUSSION
URINARY TRACT INFECTION
• Presence of microorganism in the
kidney and urinary tract

• It occurs as the interaction between

bacterial virulence and host biologic
and behavioral factors
 PATHOGENESIS
Routes:

• Ascending – most common

perineal area  urethra  bladder  kidney

• Hematogenous – kidney receives 25% of total

cardiac output

• Lymphatics
 Factors Predisposing to UTI
• Gender and sexual activity
• Pregnancy
• Obstruction
• Neurogenic bladder dysfunction
• Vesicourethral reflux
• Urinary tract instrumentation
• Diabetes mellitus
• Immunosuppresion
• Urinary tract abnormalities
 LOWER UTI UPPER UTI

• Superficial or mucosal invasion • Tissue invasion

• Cystitis • Acute Pyelonephritis
• Urethritis • Intrarenal and perinephric abscess
• Prostatitis

CLINICAL SYNDROMES CLINICAL SYNDROMES

• Dysuria, frequency, urgency and gross • With or without signs and symptoms of
hematuria lower UTI
• (-) fever • (+) fever, chills, flank pain, nausea and
• Mild hypogastric tenderness vomiting
• (-) KPT • (+) KPT
• In prostatitis, (+) prostatic tenderness on
rectal examination
 UNCOMPLICATED COMPLICATED
• Infection in structurally and • Infection in urinary tract with functional
neurologically normal urinary tract and structural abnormalities including
calculi and indwelling catheter

• Infecting microorganisms are more

likely resistant to antimicrobial agents
 Uncomplicated UTI
Acute uncomplicated cystitis (AUC)
• Acute dysuria, frequency, urgency in a non-pregnant, otherwise healthy
premenopausal female

Etiology: E. coli (75-90%), S. saprophyticus (5-15%)

Preferred Regimen:
1st line:
Nitrofurantoin macrocrystals 100mg qid x 5d
OR
Fosfomycin 3g x 1 dose sachet in 3-4 oz (or 90-120ml) water

2nd line:
Cefuroxime 250mg bid x 7d OR
Cefixime 200mg bid x 7d OR
Amoxicillin-clavulanate 625mg bid x 7d
• Empiric treatment is the most cost-effective approach; urinalysis and urine
culture not pre-requisites.

• Nitrofurantoin monohydrate/ macrocrystals (100mg bid) are not locally

available.

• Amoxicillin/ampicillin and cotrimoxazole are not recommended for empiric

treatment given the high prevalence of resistance to these agents.

• Fluoroquinolones are considered as reserved drugs because of propensity for

collateral damage (e.g., selection for drug-resistant bacteria); but are
efficacious in 3-day regimens.

• The treatment is the same for otherwise healthy elderly women with AUC.
Acute uncomplicated pyelonephritis
• Fever, flank pain, costovertebral angle tenderness, nausea/vomiting, with or without signs or
symptoms of cystitis in an otherwise healthy premenopausal female

Etiology: As for AUC, E. coli is predominant, as well as other Enterobacteriaceae

Preferred Regimen:
Oral
1st line: Ciprofloxacin 500mg bid x 7-10d OR Levofloxacin 750mg qd x 5d
2nd line: Cefuroxime 500 mg bid x 14d OR Cefixime 400 mg qd x 14d OR
Amoxicillin-clavulanate 625 mg tid x 14d (when GS shows Gram+ cocci)

Parenteral
1st line: Ceftriaxone 1-2g q24h
Ciprofloxacin 400mg q12h
Levofloxacin 250-750mg q24h Amikacin 15mg/kg q24h
Gentamicin 3-5mg/kg q24 h +/- Ampicillin

2nd line: Ampicillin-sulbactam 1.5g q6h (when GS shows g+ cocci)

Reserved for multidrug-resistant organisms:
Ertapenem 1g q24h (if ESBL rate >10%)
Piperacillin-tazobactam 2.25-4.5g q6-8h
Urine analysis, gram stain, culture and susceptibility tests should be done.
Blood cultures are not routinely done unless septic. Consider giving initial
IV/IM dose of antibiotic followed by oral regimen in patients not requiring
hospitalization.

Indications for hospitalization/parenteral regimen:

1. signs of sepsis
2. inability to take oral medications/hydration
3. concern re compliance
4. presence of possible complicating conditions

Switch to oral regimen once afebrile for 24-48 hr. and able to take oral
medicines. Tailor antibiotic regimen once culture result available. Routine
urologic evaluation and imaging not recommended unless still febrile after 72
hr. Post-treatment urine culture not recommended if clinically responding to
treatment.
Asymptomatic bacteriuria (ASB)
presence of bacteria in the urine without signs and symptoms of UTI

Diagnosis:
• In women: 2 consecutive voided urine specimens with the same organism in
quantitative counts ≥100,000 cfu/mL

• In men: single, clean-catch voided urine with one bacterial species in a quantitative
count ≥100,000 cfu/mL

• In both men and women: a single catheterized urine specimen with one bacterial
species in a quantitative count ≥100 cfu/mL; pyuria, odor and color of urine not relevant
to decision to treat
Etiology: Similar to acute uncomplicated cystitis

Preferred Regimen:

No screening and treatment recommended except in:

• pregnant women
• persons undergoing invasive genitourinary tract procedures (likely to cause mucosal
bleeding)

DO NOT TREAT ASB in:

• healthy adults
• non-pregnant women
• patients with diabetes mellitus
• elderly patients
• persons with spinal cord injury
• persons with indwelling urinary catheter
• persons with HIV
• persons with urologic abnormalities
• Antibiotics do not decrease asymptomatic bacteriuria or prevent
subsequent development of UTI. The optimal screening test is a urine
culture.

• If urine culture not possible, significant pyuria (>10 wbc/hpf) or a positive

gram stain of unspun urine (>2 microorganisms/oif) in two consecutive
midstream urine samples may be used to screen for ASB.

• When indicated, treatment should be culture-guided.

• A 7-day regimen is recommended.

 RECURRENT UTI IN WOMEN

• ≥3 episodes of acute uncomplicated cystitis documented by urine culture in 1 year or ≥ 2

episodes in a 6-mo. period

Etiology: Similar to cystitis

Preferred Regimen: Treat as acute episode for uncomplicated UTI

Prophylaxis:
TMP-SMX 40/200mg or Nitrofurantoin 50-100 mg at bedtime for 6-12 mos (continuous
prophylaxis) OR
TMP-SMX 40-80/200-400mg or Nitrofurantoin 50-100 mg x 1 dose (post-coital) OR
TMP-SMX 320/1600mg x 1 dose at symptom onset

Others:
Lactobacilli is not recommended. Cranberry juice and products can be used. For post-menopausal
women, intra-vaginal estriol nightly x2 weeks then twice-weekly for at least 8 months.
Radiologic or imaging studies not routinely indicated. Screen for urologic
abnormalities in the ff:

• No response to treatment
• Gross hematuria/persistent microscopic hematuria
• Obstructive symptoms
• History of acute pyelonephritis
• History of or symptoms suggestive of urolithiasis
• History of childhood UTI
• Elevated serum creatinine
• Infection with urea-splitting bacteria (Proteus, Morganella, Providencia)
 COMPLICATED UTI

• Significant bacteriuria plus clinical symptoms occurring in the setting of:

- functional or anatomic abnormalities of the urinary tract,
- presence of an underlying disease that interferes with host defense
mechanisms
- any condition that increases the risk of acquiring [persistent] infection
and/or treatment failure.

• Cut-off for significant bacteriuria in cUTI is 100,000 cfu/mL; may be lower in

certain clinical situations, such as in catheterized patients.

Etiology: more varied and may include drug – resistant organisms (e.g., ESBL-
producing E. coli), P. aeruginosa and enterococci
Preferred Regimen:
Amikacin 15mg/kg IV q24h
Ertapenem 1g IV q24h
Meropenem 1g IV q24h
Cefepime 1-2g IV q8-12h
Ceftazidime 1-2g IV q8h
Piperacillin-tazobactam 4.g IV q8h
Ampicillin 1-2g IV q6h (for susceptible enterococcal infections)
Levofloxacin 750mg IV/PO q24h (for mild infections with no previous 3rd gen.
cephalosporin or fluoroquinolone use)

Pyuria, odorous or cloudy urine alone is not an indication for initiating

antibiotics. Whenever possible, remove indwelling catheter; if still needed,
replace with a new catheter and obtain urine for gram stain and
culture/susceptibility test prior to initiating treatment. DO NOT obtain urine for
culture if asymptomatic. Choice of empiric antibiotics is institution-specific
depending on the local susceptibility patterns and severity of illness.
 CANDIDURIA

ASYMPTOMATIC CANDIDURIA

Etiology:
Candida sp. in urine almost always represents colonization; more often in the elderly, female,
diabetic, w/ indwelling urinary device, w/ prior surgical procedure, and taking antibiotics;
colony count and presence of pyuria not helpful in differentiating colonization from infection.

Preferred Regimen:
No treatment indicated

Exceptions: When undergoing urologic procedure, treat with oral Fluconazole 400mg (6 mg/kg)
pre-and post-procedure. Treat also those at risk for dissemination (e.g., neutropenic patients).

• Elimination of risk factors (ex. indwelling urinary catheter) usually adequate to clear
candiduria.
 SYMPTOMATIC CYSTITIS
Etiology: Most common etiologic agent: C. albicans

Preferred Regimen:
Fluconazole 200-400mg PO qd x 2 weeks
For fluconazole-resistant Candida (C. krusei or glabrata):

AmB deoxycholate 0.3-0.6mg/kg x 1-7d

Do ultrasound or CT of kidneys if candiduria persists in

immunocompromised patients.
 PYELONEPHRITIS
Etiology: Most common etiologic agent: C. albicans

Preferred Regimen:
Fluconazole 200 mg PO qd x 2 wks.
For fluconazole-resistant Candida (C. krusei or C. glabrata):

AmB deoxycholate 0.3-0.6 mg/kg x 2 wks.

Consider surgical intervention to relieve obstruction if any (e.g., fungus ball).

If disseminated disease suspected, treat as if bloodstream infection is
present.
 BACTERIAL PROTATITIS

• Most cases of bacterial prostatitis are

preceded by a urinary tract infection.

• Risk factors: urinary tract instrumentation,

urethral stricture, or urethritis (usually due to
sexually transmitted pathogens)
 ACUTE BACTERIAL PROSTATITIS (ABP)
WITHOUT RISK OF STD
Etiology: Enterobacteriaceae, enterococcus, P. aeruginosa

Preferred Regimen:
1st line: Ciprofloxacin 500mg PO or 400mg IV bid OR
Levofloxacin 500-750 mg IV/PO qd

If enterococcus is suspected/documented:
Ampicillin 1-2g IV q4h; Vancomycin 15mg/kg q12 h
2nd line: TMP-SMX DS bid OR Piperacillin-tazobactam 4.5g IV q6-8h

DOT: 2 weeks; extend to 4 weeks if patient still symptomatic.

Do CBC, blood cultures, urinalysis and urine culture. Caveat: E. coli resistance to
TMP-SMX is high so TMP-SMX cannot be 1st line empiric treatment despite its high
prostatic concentration.
 ABP WITH RISK OF STD
Etiology: N. gonorrhoeae and C. trachomatis

Preferred Regimen:
Ceftriaxone 250mg IM x 1 dose PLUS
Doxycycline 100mg bid or Azithromycin 500 mg PO qd

DOT: 2 weeks

Fluoroquinolones not recommended for gonococcal infection.

 ABP WITH RISK OF ANTIBIOTIC-RESISTANT
PATHOGENS
Etiology: Fluoroquinolone-resistant Enterobacteriaceae and
Pseudomonas, ESBL or AmpC beta lactamase-producing
Enterobacteriaceae

Preferred Regimen:
1st line: Ertapenem 1g IV qd OR Meropenem 1g IV q8h (for
Pseudomonas)

2nd line: Cefepime 2g IV q12h

Consider a 4-week regimen.

 COMPLICATED ABP (E.g., bacteremia or
suspected prostatic abscess)
Etiology: Enterobacteriaceae, enterococcus, P. aeruginosa

Preferred Regimen:
1st line: Ciprofloxacin 400 mg IV q12h OR Levofloxacin 750 mg IV q24h

2nd line: Ceftriaxone 1-2g IV q24h PLUS Levofloxacin 750 mg IV q24h OR

Ertapenem 1g IV q24h OR Piperacillin-tazobactam 4.5g IV q8 h

DOT: 4 weeks
Obtain blood cultures. Consider genitourinary imaging. Drain abscess.
Switch to oral regimen once bacteremia has cleared and abscess is drained.
 CHRONIC BACTERIAL PROSTATITIS (CBP)

• Prolonged urogenital symptoms (e.g., >3 mos.)

• Hallmark: relapsing UTI

Etiology: Enterobacteriaceae, enterococci, P. aeruginosa

Preferred Regimen:
1st line: Ciprofloxacin 400 mg IV q12h OR Levofloxacin 750 mg IV q24h
2nd line: TMP-SMX DS bid

DOT: 4-6 weeks

If refractory, options are:

1. treat intermittently for symptomatic episodes;
2. suppressive treatment; or
3. prostatectomy if all other options have failed.
 CATHETER-ASSOCIATED UTI (CAUTI)

Etiology: more varied and may include drug – resistant organisms (e.g., ESBL-
producing E. coli), P. aeruginosa and enterococci

Preferred Regimen:
Amikacin 15mg/kg IV q24h
Ertapenem 1g IV q24h
Meropenem 1g IV q24h
Cefepime 1-2g IV q8-12h
Ceftazidime 1-2g IV q8h
Piperacillin-tazobactam 4.g IV q8h
Ampicillin 1-2g IV q6h (for susceptible enterococcal infections)
Levofloxacin 750mg IV/PO q24h (for mild infections with no previous 3rd gen.
cephalosporin or fluoroquinolone use)
• Pyuria, odorous or cloudy urine alone is not an indication for initiating
antibiotics.

• Whenever possible, remove indwelling catheter; if still needed, replace

with a new catheter and obtain urine for gram stain and
culture/susceptibility test prior to initiating treatment.

• DO NOT obtain urine for culture if asymptomatic.

• Choice of empiric antibiotics is institution-specific depending on the local

susceptibility patterns and severity of illness.
 UTI IN PREGNANCY

ACUTE UNCOMPLICATED CYSTITIS IN PREGNANCY

Etiology: E. coli (70%), Other Enterobacteriaceae, Group B Streptococcus

Preferred Regimen:
Cefalexin 500mg qid x 7d
Cefuroxime 500mg bid x 7d
Cefixime 200mg bid x 7d
Nitrofurantoin macrocrystals 100mg qid x 7d
Fosfomycin 3g single-dose sachet
Amoxicillin-clavulanate 625mg bid x 7d
• Start empiric antibiotic immediately, but pre-treatment urine must be submitted for
culture and susceptibility; adjust treatment accordingly.

• Document clearance of bacteriuria with a repeat urine culture 1-2 weeks post-treatment.

• Avoid amoxicillin-clavulanate in those at risk of pre-term labor because of potential for

neonatal necrotizing enterocolitis.

• Use nitrofurantoin from the 2nd trimester to 32 weeks only, if possible, because of
potential for birth defects and hemolytic anemia.

• Avoid cotrimoxazole especially during the first and third trimesters because of risk of
teratogenicity and kernicterus.

• Fluoroquinolones are contraindicated.

ACUTE PYELONEPHRITIS IN PREGNANCY

Etiology: Similar to acute cystitis in pregnancy

Preferred Regimen:

Parenteral:
1st line: Ceftriaxone 1-2 g q24 h OR Ceftazidime 2 g q8 h
2nd line: Ampicillin-sulbactam 1.5g q6h (when GS shows gram+ cocci)

Oral:
Cefalexin 500mg to complete 14d
Cefuroxime 500mg bid to complete 14d
Cefixime 200mg bid to complete 14d
Amoxicillin-clavulanate 625mg bid to complete 14d
• Urinalysis, gram stain and culture/susceptibility tests should be done. Blood
cultures are not routinely done unless septic.

• Ultrasound of KUB reserved for failure to respond to treatment.

• Indications for admission: pre-term labor and other indications as listed above
for acute uncomplicated pyelonephritis.

• Switch to oral regimen when afebrile x 48 hrs. and based on

culture/susceptibility result.

• Recommended duration of treatment is 14d. Test of cure with a urine culture

post-treatment is essential.

• Follow up with monthly urine culture until delivery.

ASYMPTOMATIC BACTERIURIA (ASB) IN PREGNANCY

Etiology: Similar to acute cystitis in pregnancy

Preferred Regimen: Cefalexin 500mg qid x 7d

Cefuroxime 500mg bid x 7d
Nitrofurantoin macrocrystals 100mg qid x 7d
Fosfomycin 3g single-dose sachet
Amoxicillin-clavulanate 625mg bid x 7d
• Treat ASB to reduce the risks of symptomatic UTI and low birth weight
neonates and preterm infants.

• Choice of regimen is based on culture/susceptibility test result. Note

caveats for use of nitrofurantoin and amoxicillin-clavulanate.

• Screen all pregnant women for ASB once between the 9th and 17th week,
preferably during the 16th week.

• The standard urine culture/susceptibility is the test of choice. Urinalysis is

inadequate for ASB screening.

• Do follow-up urine culture 1-week post-treatment and monitor every

trimester till delivery.
 THANK YOU FOR LISTENING
• RERENCE
– DOH National Guideline for Antibiotic Treatment
of UTI