Urinary tract infection

By Anoud Ibrahim
Supervisor: loai Al -muhtaseb
Defenition:

• Urinary tract infections (UTIs) are infections of

the bladder, urethra, ureters, or kidneys.
Predisposing factors:
• Host-dependent factors:
– Structural or functional abnormalities of the
urinary tract
• Prevent bladder emptying and/or result in urinary stasis
• Examples include:
– Benign prostatic hyperplasia
– Congenital malformations causing vesicoureteral reflux
– Urinary bladder diverticulum
– Neurogenic bladder
– Urinary tract calculi
• Sex:
– Female individuals: anatomically predisposed because the urethra is
shorter and anal and genital regions are in close proximity → bacteria
spreading from the anal region → colonization of vagina → ascending
UTIs
– Male individuals: higher risk in uncircumcised male infants
• Pregnancy: hormonal changes during pregnancy → urinary stasis and
vesicoureteral reflux → increased risk of UTIs
• Postmenopause: ↓ estrogen → ↓ vaginal lactobacilli → ↑ vaginal pH
→ ↑ colonization by E. coli
• Prior conditions:
– Previous UTI
– History of kidney surgery
– Immunosuppression
– Diabetes mellitus
– Medication: recent use of antibiotics
• Sexual intercourse
– Postcoital cystitis (honeymoon cystitis
• Catheter-associated urinary tract infection (CAUTI)
pathogens:
• Infection ascends from the urethra to the bladder.
• Can ascend further to the ureters and the renal pelvises
• Bacteria that cause UTI
– Escherichia coli: leading cause of UTI (approx. 80%)
– Staphylococcus saprophyticus: 2nd leading cause of UTI in sexually active
women
– Klebsiella pneumoniae: 3rd leading cause of UTI
– Proteus mirabilis
• Produces ammonia, giving the urine a pungent or irritating smell
• Associated with struvite stone formation
– Nosocomial bacteria: Serratia marcescens, Enterococci spp., and Pseudomonas
aeruginosa are associated with increased drug resistance.
– Enterobacter species
– Ureaplasma urealyticum
Viruses
• Immunocompromised patients and children are particularly susceptible to viral UTIs. [2]
• Adenovirus, cytomegalovirus, and BK virus are commonly involved in hemorrhagic cystitis.

Fungi [4]
• Yeast: rare (usually Candida species) [5]
• Disseminated fungal infections .
 Classification of urinary tract
infections

• By clinical presentation
• By location
• By severity
• By source of infection
• By frequency
 By clinical
By location
presentation

Asymptomatic
Lower UTI
bacteriuria
(cystitis)
(ASB)

Urinary tract Upper UTI

infection (UTI) (pyelonephritis)
 nonpregnant,
premenopausal women
Uncomplicated without further risk factors
UTI for infection, treatment
failure, or serious outcomes

patients with risk factors for

infection

Infection associated with

Complicated
By severity UTI (cUTI)
recent instrumentation or
medical device

Healthcare-associated UTIs

UTI associated with a

dysregulated immune
Urosepsis response that can potentially
lead to life-threatening organ
dysfunction
 UTI acquired in a healthcare
setting

Healthcare-associated UTI

Nosocomial UTI
most common : CAUTI
By source of infection

UTI acquired outside of a

healthcare setting and/or
Community-acquired UTI UTI that manifests within 48
hours of hospital admission

≥ 3 episodes of
symptomatic, culture-
By frequency Recurrent UTI proven UTI in one year
or ≥ 2 episodes in 6
months
Clinical features:
• IN Upper UTI :
– Fever, chills
– Flank pain
– Costovertebral angle tenderness: pain upon percussion of the flank
(usually unilateral, may be bilateral)
– Dysuria
– Weakness, nausea, vomiting (diarrhea may also be present)
– Possible abdominal or pelvic pain
– Symptoms of lower UTI
• Clinical features of lower UTI:
Diagnosis:
• Approach:
– Uncomplicated lower UTI in women
• Typical symptoms : Treatment may be initiated without further diagnostics.
• Atypical or unclear symptoms: Perform urinalysis using a urine dipstick test and/or
microscopy.
– Positive urinalysis (proof of pyuria and bacteriuria): Initiate treatment.
– Negative urinalysis but persisting suspicion: Obtain urine culture.
– Complicated lower UTI in women
• Obtain urinalysis and urine culture.
• Consider the need for further diagnostics, depending on history and clinical
presentation.
– Lower UTI in men
• Obtain urinalysis and urine culture.
• First febrile UTI: Perform CT or ultrasound of the urinary tract.
• Consider referral to urology (e.g., in case of unclear diagnosis, hematuria, voiding
difficulties, or recurrent UTI)
• Concomitant prostatitis:
Laboratory studies:
• Urinalysis:
– Indications: best initial test for all patients
– Procedure: visual, chemical (dipstick), and microscopic
examination of urine
– Specimen collection method
• Clean-catch midstream sample:
• Straight catheterization of the bladder
• Suprapubic aspiration:
• Pyuria: presence of white blood cells (WBCs) in the
urine
– Positive leukocyte esterase: an enzyme produced by WBC
– ≥ 5 WBC/HPF or ≥ 8–10 WBC/mm3
• Bacteriuria: presence of bacteria in the urine
– Positive urinary nitrites: indicate bacteria that convert
nitrates to nitrites (most commonly gram-negative
bacteria; e.g., E.coli)
– Direct visualization by gram stain (seldom performed)
• Other findings
– Leukocyte casts may indicate pyelonephritis.
– Micro- or macroscopic hematuria may be present.
– Alkaline urine (pH > 8) and struvite crystals in
sediment: indicate urease-producing organisms
(e.g., Proteus, Klebsiella, Staphylococcus
saprophyticus)
– The presence of squamous epithelial cells can be a
sign of contamination.
• Urine culture:
• Indications
– Suspicion for complicated UTI or healthcare-associated UTI
– Suspicion for pyelonephritis or urosepsis
– Suspicion for uncomplicated cystitis with either of the
following:
• History of recurrent UTIs
• Equivocal urinalysis
• Atypical symptoms
• Concern for multiresistant pathogens, e.g., due to recent antibiotic
use
• Age ≥ 65 years
– Follow-up cultures for test of cure in the following cases:
• Nonresolving symptoms despite antibiotic treatment
• Anatomic or functional abnormalities of the urinary tract
• Continued pathological findings on urinalysis
• Interpretation
• Cultures are
considered positive if
either of the following
is present:
– Significant bacteriuria: defined
as ≥ 10^5CFU/mL in a clean-
catch specimen
– Any organisms in a specimen
obtained by suprapubic
aspiration
• Additional diagnostics :
– Pregnancy test: indicated in women of childbearing age
– Testing for sexually transmitted infections (STIs)
• Indicated in patients with STI risk factors and/or symptoms of
an STI
• At-risk patients should be tested for Chlamydia trachomatis
and Neisseria gonorrhoeae.
– Blood tests
• Not routinely performed in patients with lower UTI
• Blood cultures (2 sets): should be performed in all patients with
suspected complicated pyelonephritis
• Additional blood tests
– CBC: leukocytosis
– Inflammatory markers: ↑ CRP, ESR
– BMP: may be normal or show elevated BUN and creatinine
• Imaging:
– Imaging is not routinely indicated in patients with
suspected acute uncomplicated pyelonephritis.
– Imaging serves to identify obstruction, abscess, or
emphysematous pyelonephritis.
– Consider in the following situations:
• Complicated pyelonephritis
• Sepsis or septic shock
• Known or suspected nephrolithiasis
• New decline in eGFR to < 40
• Recurrent pyelonephritis
• No response to therapy within 2 days
• CT abdomen and pelvis with and without IV
contrast:
– Modality of choice in nonpregnant patients who
need imaging

• Ultrasound of the kidneys and bladder

• Indications: patients with contraindications to
CT scan (e.g., allergy to contrast)
Treatments:
• Antibiotic treatment is recommended for all patients with
symptomatic UTI.
• The optimal therapy depends on disease severity, local
resistance patterns, and patient characteristics (e.g., allergies).
– Initial treatment is with an empiric regimen, which is maintained for
uncomplicated cystitis.
– In unclear or complicated cases, the regimen may subsequently
have to be adjusted based on urine culture data.
• Consider the need for supportive treatment.
– Phenazopyridine, a urinary analgesic, can be used for symptomatic
relief for a maximum of 2 days.
– Oral analgesia, e.g., with NSAIDs, can provide additional relief
• Empiric antibiotic treatment of uncomplicated
lower UTIs
• First-line treatment
– Nitrofurantoin for 5 days
– Trimethoprim/sulfamethoxazole (TMP/SMX) for 3
days
– Fosfomycin (single dose)
• Second-line treatment:
– beta-lactam antibiotics for 5–7 days
• Aminopenicillins plus beta-lactamase inhibitors, e.g.,
amoxicillin/clavulanic acid
• Oral cephalosporins, e.g., cefpodoxime , cefdinir , or
cefaclor
– Alternatives: Consider fluoroquinolones, e.g.,
ciprofloxacin for 3 days for patients with previous
infections with bacteria resistant to other drug
classes.
2. Pregnant women with UTI.

a. Treat with ampicillin, amoxicillin, or oral cephalosporins for 7 to 10 days.

b. Avoid fluoroquinolones (can cause fetal arthropathy).

• Antibiotic treatment of complicated lower UTIs :
– Antibiotic therapy must be adapted to culture results and is
commonly given for 7–14 days.
– Options for the initial empiric treatment of complicated lower
UTIs include:
• Fluoroquinolones PO or IV: e.g., ciprofloxacin or levofloxacin
• Beta lactams
– Second-generation or third-generation cephalosporins: e.g., ceftriaxone
– Extended-spectrum penicillins: e.g., ampicillin/sulbactam
• Aminoglycosides (e.g., gentamicin ): treatment option if
fluoroquinolones or beta lactams are contraindicated or as an
addition to beta lactam
• Uncomplicated pyelonephritis:
• Empiric antibiotic therapy for uncomplicated
pyelonephritis
– Most patients can be treated with an oral fluoroquinolone
(e.g., ciprofloxacin, levofloxacin ) for 5–7 days
– Alternatives
• Trimethoprim/sulfamethoxazole, for 10–14 days .
• Amoxicillin/clavulanate for 10–14 days
• Cefpodoxime for 10–14 days
• Consider a single dose of a broad-spectrum parenteral
antibiotic prior to the administration of oral antibiotics,
especially when the local rates of drug-resistant E. coli
are unknown or known to be > 10%.
– Ceftriaxone
– OR gentamicin
• Complicated pyelonephritis
• Patients with complicated acute pyelonephritis should be admitted to the hospital
and started on parenteral empiric antibiotic therapy as soon as possible.
• The choice of empiric antibiotic therapy should be decided based on:
– Clinical severity (i.e., presence of sepsis)
– The presence of risk factors for infection with multidrug-resistant
bacteria
• Age ≥ 65 years
• Recent stay in hospital or long-term care facility
• Recent antibiotic use
• Indwelling urinary tract devices
• Known abnormalities of the urological tract or urinary tract obstruction
• Previous resistant infection
• Recent travel to an area with high antibiotic resistance (e.g., Asia, Mexico)
• Supportive care
– Analgesics as needed
– Antiemetics as needed
• Subsequent management
– Duration of antibiotic therapy: 10–14 days
– Antibiotic therapy should be adjusted once blood and
urine culture sensitivity reports are available.
– Consider repeat urine culture in pregnant women and
those with recurrent pyelonephritis 2–4 days after
completion of the antibiotic course.
– Identify and treat the underlying cause.
• Recurrence of UTI:
• Antibiotic prophylaxis
• Indication: may be considered in all women with recurrent uncomplicated UTIs
• Continuous prophylaxis
– Typically taken for 3–12 months with periodic reassessment
– Regimens:
• Trimethoprim (TMP) daily
• TMP/SMX daily
• Cephalexin daily
• Nitrofurantoin daily
• Fosfomycin every 10 days
• Intermittent or postcoital prophylaxis
– Recommended for women who have recurrent UTIs associated with sexual activity
• TMP/SMX
• Cephalexin
• Nitrofurantoin
Complications:
• General
– Pyelonephritis
– Perinephric abscess
– Urosepsis
– Emphysematous pyelonephritis
• In male individuals
– Urethral stricture
– Epididymitis
– Prostatitis
– Orchitis
• In pregnant women
– Increased risk of preterm labor and birth
– Hypertension and preeclampsia
– Chorioamnionitis
 Catheter-associated UTI
(CAUTI):
• Definitions
– Catheter-associated UTI (CAUTI): symptomatic UTI
occurring in a patient with an indwelling urinary
catheter OR within 48 hours after removal of a
urinary catheter
– Epidemiology: CAUTIs are among the most
common healthcare-associated infections.
• Microbiology
– Causative organisms are likely to have antibiotic resistance.
– In patients with long-term catheterization (≥ 30 days), UTIs
are typically polymicrobial.
• Treatment
• Catheter removal or replacement
– Remove if no longer necessary.
– Replace if still necessary and present for > 2 weeks.
• Antibiotic therapy
– Guided by culture results and local resistance patterns
– Duration: typically 7–14 days depending on the resolution of
symptoms
Prostatitis:

• Prostatitis is an inflammation of the prostate gland

that is of either infectious (acute bacterial prostatitis
and chronic bacterial prostatitis) or noninfectious
(chronic pelvic pain syndrome) origin
• Epidemiology:

– Common urologic diagnosis in men < 50 years of age

– In men, there is an ∼ 8% lifetime risk of developing
prostatitis.
– Bacterial prostatitis (2–5% of cases): most commonly
men between 20 and 50 years of age
– Chronic pelvic pain syndrome (90–95% of cases):
primarily men between 40 and 60 years of age
• Etiology
– Acute prostatitis
• E. coli (most common)
• Other bacteria that cause UTI
• Sexually transmitted infections (e.g., C. trachomatis and N. gonorrhoeae)
• Rarer pathogens: mycobacteria, fungi, staphylococci, streptococci
– Chronic prostatitis
• Bacterial
– E. coli
– Other Enterobacteriaceae
• Nonbacterial
– Immune response to a prior UTI
– Nerve damage in the pelvic region
– Chemical irritation (chemical prostatitis)
– Pelvic floor muscle dysfunction
– Parasitic or viral infections
• Other causes for acute or chronic bacterial prostatitis
– Other genitourinary tract infections (e.g., urethritis, cystitis, epididymitis)
– Genitourinary tract interventions (e.g., indwelling catheter, transurethral
surgery, prostate biopsy)
– Voiding dysfunction and bladder outlet obstructio n
• Clinical features:
– Acute prostatitis
• Constitutional symptoms: Spiking fevers, chills, Malaise
• Genitourinary tract symptoms: Acute dysuria, Frequency,
Urgency, Cloudy urine
• Genitourinary pain
– Severe
» Lower back, Perineal, Pelvic, With defecation
• Prostate
– Tender, boggy
– Warm, swollen
• Chronic bacterial prostatitis:
– Constitutional symptoms: Commonly absent, Low-grade
fever in some patients.
– Genitourinary tract symptoms: Dysuria. Frequency,
Urgency, Erectile dysfunction, Possibly bloody semen

– Genitourinary pain: mild

– Prostate:
• Often normal
• May be enlarged and tender
• Approach of Diagnosis:
– . Bacterial prostatitis is a clinical diagnosis based on history and physical
examination, including digital rectal examination (DRE).
– Obtain urine studies to support the diagnosis and identify the causative
pathogen.
– Urine studies
• Urinalysis (midstream urine) may show characteristic urinalysis findings of UTI (e.g.,
↑ WBC).
• Urine Gram stain may be used to visualize bacteria.
• Urine culture: E. coli is most common pathogen (approx. 80% of cases).
• Additional evaluation
• Localization tests for chronic bacterial
prostatitis (based on fractional urine
examination)
– Two-glass test (preferred): cultures of two urine
samples obtained before and after prostatic
massage
– Four-glass test (historical): cultures of four urine
samples obtained before, during, and after
prostate massage
• Treatment :
– Mild acute and chronic infections

• Oral fluoroquinolones (e.g., ciprofloxacin, levofloxacin)

• Trimethoprim/sulfamethoxazole
• Duration
– 2–4 weeks for mild acute infections
– 4–12 weeks for chronic infections
• Suspected STI: Ceftriaxone followed by doxycycline
– Severe acute infections

• IV fluoroquinolones (e.g., ciprofloxacin OR levofloxacin) with

or without an aminoglycoside (e.g., gentamicin)
• IV beta-lactam (e.g., piperacillin/tazobactam OR ceftriaxone)
with or without an aminoglycoside (e.g., gentamicin)
• Duration: 4–6 weeks
• Complications:
– Prostatic abscess
• Clinical features: genitourinary symptoms similar to
acute bacterial prostatitis
• Rectal exam finding: fluctuant prostate
• Treatment: antibiotics and transrectal ultrasound-guided
drainage
– Acute urinary retention
– Pyelonephritis and sepsis
– Epididymitis