Urinary Tract infection
(UTI)
Pharmacotherapeutics II yr
QUICK RECALL ..Urinary system anatomy
Introduction
• UTI is an infection in any part of urinary system i.e kindeys, ureters,
bladder, urethra.
• Most infections involve the lower urinary tract – bladder and urethra.
• It is defined as the symptomatic presence of microorganism in the
urinary tract i.e more than 105 organisms per ml of mid stream
urine.
• Simply it is condition of symptomatic bacteriuria
• It is common and painful human illness caused due to bacterial/fungal
invasion to the urinary tract resulting in inflammatory response.
Asymptomatic bacteriuria
• Presence of 105 organisms per ml of 2 consecutive mid stream
urine in absence of symptom of UTI is called asymptomatic
bacteriuria.
• Treatment of asymptomatic bacteriuria only indicated for high risk
group such as pregnant, kidney failure, immunocompromised, heart
failure only.
UTI classification according to anatomy
• UTI comprises of various clinical entities according to part of urinary
tract involved such as:-
• Urethritis: Infection and inflammation of urethral tract.
• Cystitis: Infection/inflammation of urinary bladder LOWER UTI
• Prostatits: Inflammation of prostate.
• Pyleonephritis: Infection/inflammation of one or both kidneys and
pelvis. UPPER UTI
classification of UTI
• Uncomplicated UTI: UTI without underlying renal or neurologic
diseases:
• Complicated: UTI with underlying structural, medical or neurologic
disease.
Etiological classification / causative
organisms
• Complicated UTI:
• Pseudomonas aeruginosa, Enterobacter
• Viruses: Rubella, Mumps, HIV
• Fungi: Candida, histoplasma
• Protozoa: T. vaginalis, Schistosoma haemotabium
• Uncomplicated UTI:
• E. Coli (>80%)
• Gm-ve: Klebsiella, proteus
• Gm +ve: Streptococcus faecalis., staphylococcus
UTI -terminiologies
• Recurrent: More than 3 symptomatic UTIs within 12 month following
clinical therapy.
• Reinfection: Recurrent UTI caused by a different pathogen at any
time.
• Relapse: Recurrent UTI caused by same species causing original UTI
within 2 wks after therapy.
Risk factor
Females:
Pregnancy, Diabetes mellitus, shorter urethra, contraceptives , estrogen deficiency
Males:
prostatic hypertrophy, bacterial prostatis
indwelling catheter
Both:
urine retention
impaired immune system
incomplete bladder emptying with age
Unsafe intercourse
Pathogenesis
• There is basically four route for bacterial entry in urinary tract.
1) Ascending infection.(Most common route)
2) Blood borne route. (Few cases only)
3) Direct extension from other organs(Fistulas)
4)Lymphatogenous spread (infection through lympatic vessesls)
Contamination of pathogen in periurethral area
colonization in urethra and ascend toward bladder
Bacterial replication and biofilm formation Bacteremia and UTI
Epithelial cell damage by bacteria
Ascend toward kidney through ureters
Colonization in kidney
Host tissue damage and start inflammatory cascade
Acute kidney injury
Clinical features of UTIs: sign and symptom
• Cystitis • Prostatitis
• Dysuria, urinary frequency, urgency • Acute bacterial prostatitis presents
• Also nocturia, hesitancy, suprapubic with
• discomfort, gross hematuria may be present.
• dysuria, frequency, pain in the
• Unilateral flank or back pain indicates upper prostatic, pelvic or
• urinary tract involvement
• perineal area,fever with chill and
• Fever indicates involvement of kidney / features of
prostate
• Pyelonephritis • bladder outlet obstruction
• High rise, spiking fever with • Chronic bacterial prostatitis presents
• rigor, nausea, vomiting, flank and/or loin pain with
• [Low grade fever in mild cases • recurrent episodes of cystitis
Investigation and diagnosis
• Urine culture is the diagnostic "gold standard" for UTI
• positive dipstick test [detects nitrite]
• positive leukocyte esterase test
• pyuria in routine urine examination
• hematuria (in 30% cases)
Differential diagnoses:
• Typhoid, malaria, PID,
• Kidney, Ureter and Bladder stones,
• prostate disease,
• urethritis.
Management.
• Non pharmacological:
• Drink lots of water and fluid which might help to flush bacteria via
urination.
• Cranberry might decrease adhesion of bacteria.
• Avoid caffeine.
• Maintain Personal hygiene.
• Removal of offending agent : Cathether
Pharmacological Managment
• Specific antibiotics: Nitrofurantoin, Trimethoprim-sulfamethoxazole
(co trimoxazole), Fluroquinolones: Ciprofloxacin, ofloxacin,
• Penicillin (amoxicillin +clavaunate ), Cephalosporine: cefexime . etc
• Urine alkalizer : sodium citrate, Potassium citrate/Citric acid.
• For symptomatic relief
• To decrease painful/burning micturition/urination
• NSAID: Paracetamol, ibuprofen for pain fever etc.
Pharmacological management
• Empirical therapy: Initial empirical therapy could be start with Beta
lactam antibiotic (cephalosporin and penicillin), Fluroquinolone
(ciprofloxacin, oflaxacin) and nitrifurantion, Co-trimoxazole
(sulfamethoxazole + trimethoprim)
• In case of Nepal empirical therapy: Cefexime 200 mg BD or
Ciprofloxacin 500 mg BD
• However after urine culture report, specific sensitive antibiotic should
be used.
• For complicated UTI: Normally duration of treatment is 10-14 day
Management
Pregnant Women:
• • Amoxicillin 500mg TDS for seven days or
• • Tab cefixime 200mg PO BD for seven days or
• • Tab nitrofurantoin 100mg BD for seven days
Thank you
