URINARY TRACT
INFECTIONS
MODERATOR: Dr M G HERAKAL
PRESENTER:DR VAMSEE B
INTRODUCTION
• Urinary tract infection (UTI) is an age-old common
problem seen in outpatient clinics as well as inpatient
departments.
• Globally, >150 million people are diagnosed with UTI
each year. The prevalence of UTI’s in India ranges
between 10 and 30%.
• UTIs are more common among females compared to
males in the age-group of 1-50 years.
The recurrence rate is also high, with
approximately 27% recurrence within 6 months
in women with a history of UTI.
• With the discovery of antibiotics, it became an
ailment that responds dramatically to antibiotics
• However, over time, generous and inappropriate
use of antibiotics has resulted in the emergence
of antibiotic resistance.
• The recent trends of the pathogens and their
susceptibility to various antimicrobials are
prerequisites to lay down standards for the
empirical treatment of UTIs while anticipating
the culture sensitivity to prevent the emergence
of multidrug-resistant bugs.
Classification based on
complexity
•Uncomplicated uti
Cystitis in young healthy adult female in reproductive age
group
•Complicated uti
Male uti
Childhood uti
Post menopausal uti
Uti in patients with structural abnormalities of urinary tract and
kidneys
Diagnostic criteria include:
1. Clinical Presentation
Lower UTI (Cystitis) Symptoms:
• Dysuria (painful urination)
• Urinary frequency
• Urgency
• Suprapubic pain or discomfort
• Cloudy or malodorous urine
• Hematuria (sometimes)
Upper UTI (Pyelonephritis) Symptoms:
• Flank pain
• Fever (>38°C or 100.4°F)
• Chills/rigors
• Nausea/vomiting
• Costovertebral angle tenderness
2. Laboratory Diagnosis
Urinalysis (Dipstick or Microscopy):
•Positive leukocyte esterase (indicates pyuria)
•Positive nitrites (suggests presence of nitrate-
reducing bacteria, usually Enterobacteriaceae)
•Pyuria: ≥10 white blood cells (WBCs)/mm³
•Bacteriuria: presence of bacteria on microscopy
Urine Culture:
•Clean-catch midstream sample:
•≥10⁵ CFU/mL of a single uropathogen:
significant bacteriuria (traditional threshold)
•≥10³ CFU/mL: accepted in symptomatic women and in
catheterized specimens
•≥10² CFU/mL: may be significant in symptomatic women
or with pyuria
Asymptomatic Bacteriuria:
• Positive urine culture without
symptoms
• Treated only in specific populations:
• Pregnant women
• Patients undergoing urologic
procedures
4. Additional Tests (When Indicated):
• Blood cultures (if sepsis or
pyelonephritis suspected)
• Imaging (CT, ultrasound) if:
• Suspected obstruction
• Recurrent infections
• Unusual or severe presentations
• LOWER UTI:Infection limited to the lower urinary tract,
• Cystitis (bladder), Urethritis
• UPPER UTI:
• Infection involving kidneys and ureters
• Acute pylonephritis
• Chronic polynephritis
• Interstitial nephritis
Renal abcess
URETHRITIS
Inflammation of the urethra, often presenting with
symptoms such as painful urination and urethral
discharge
• Gonococcal Urethritis (GU): Caused
by Neisseria gonorrhoeae.
Nongonococcal Urethritis (NGU):
Caused by pathogens other than
N.gonorrhoeae, including:
• Chlamydia trachomatis
• Mycoplasma genitalium
• Trichomonas vaginalis
• Ureaplasma urealyticum
• Herpes simplex virus (HSV)
• Adenoviruses
• Other bacteria (e.g., Escherichia coli)
• Non-infectious causes (e.g., mechanical irritation)
CLINICAL SIGNS:
• Urethral discharge
• Dysuria (painful urination)
• Itching or irritation inside the penis
COMPLICATIONS
•Men: Epididymitis
Reiter’s syndrome
•Women (female sex partners):
Pelvic inflammatory disease,
Ectopic pregnancy and
Infertility
TREATMENT
Depends on the identified or suspected pathogen: CDC
• Gonococcal Urethritis:
• Ceftriaxone 500 mg
intramuscularly in a single dose.
• If chlamydial infection has not been excluded,
add doxycycline 100 mg orally twice daily for 7 days.
CDC
Nongonococcal Urethritis:
• Doxycycline 100 mg orally twice daily for 7 days.
• Alternative: Azithromycin 1 g orally in a single dose.
Persistent or Recurrent NGU:
• Consider testing for Mycoplasma genitalium
and Trichomonas vaginalis.
• Treatment may include moxifloxacin 400 mg orally once
daily for 7-14 days, especially if M. genitalium is
detected.
TREATMENT IN SPECIAL POPULATIONS
Pregnant Women
• Preferred: Nitrofurantoin (before 38 weeks),
Amoxicillin, Cephalexin,Fosfomycin
• Duration: 4-7 days
• Avoid: Fluoroquinolones, TMP-SMX (in first trimester or near term)
Postmenopausal Women
• Same regimen as premenopausal women
• Consider topical vaginal estrogen for prevention if
recurrent UTls
PROSTITIS
TYPES OF PROSTATITIS
1. Acute Bacterial Prostatitis: A sudden
bacterial infection of the prostate, often
presenting with severe urinary symptoms and
systemic signs like fever.
2. Chronic Bacterial Prostatitis: A persistent
bacterial infection of the prostate, leading to
recurrent urinary tract infections and pelvic
discomfort.
EMPIRIC ANTIBIOTIC THERAPY
Initiate promptly, targeting likely pathogens such as
Escherichia coli and other gram-negative bacteria.
• FLUOROQUINOLONES: Ciprofloxacin or levofloxacin
are commonly used due to their prostate penetration.
• TRIMETHOPRIM-SULFAMETHOXAZOLE
(TMP-SMX): An alternative in certain cases.
CLASSIFICATION OF
PYELONEPHRITIS
A. UNCOMPLICATED PYELONEPHRITIS
• Typically in healthy, nonpregnant
women with no structural/functional urinary tract
abnormalities
UNCOMPLICATED
PYELONEPHRITIS
Ciprofloxacin,500 mg PO BID OR 1000 mg ER QD,7
days,First-line if <10% resistance
Levofloxacin,750 mg PO daily,5 days,Short course,
good compliance
TMP-SMX (if susceptible),160/800 mg PO BID,14
days,Confirm susceptibility first
• Beta-lactams (e.g., amoxicillin-clavulanate),Dose
varies,10–14 days,Less effective, use only if others not
suitable
B. COMPLICATED PYELONEPHRITIS
• Includes:
Male patients
Pregnant women
Urinary tract obstruction
Indwelling catheter
Diabetes
Immunocompromised status
Hospital-acquired intection
COMPLICATED PYELONEPHRITIS
TREATMENT
Outpatient Treatment (Mild to moderate cases):
• Suitable for otherwise healthy, non-pregnant
individuals who can tolerate oral medications.
First-line oral antibiotics:
• Ciprofloxacin 500 mg PO twice daily for 7 days (if local
fluoroquinolone resistance <10%)
• Levofloxacin 750 mg PO once daily for 5 days
• Trimethoprim-sulfamethoxazole
(TMP-SMX) DS 1 tablet PO twice daily for 14 days
Inpatient Treatment (Severe cases, vomiting,
pregnant, elderly, comorbidities):
• Begin with IV antibiotics, transition to oral when
clinically stable.
Common empiric IV options:
• Cefperazone sulbactum1.5 gm IV BD
• Piperacillin-tazobactam 4.5 gm Q6H
• Ertapenem or Meropenem (for
ESBL-producing organisms)
• Adjust based on culture results and clinical response.
RECURRENT UTI
Two or more infections within 6
months or
3 or more infections within 1 year
2 TYPES
-Reinfection
-Relapse
REINFECTION
• Most common type of recurrent uti
• occurs after a successful treatment
• patients present with same symptoms after a brief
period of about 2 weeks
• urine culture to be sent
• Management
• -Nitrofurantoin 50mg or cotrimoxazole (80/400) OD is
given
RELAPSE
More dangerous and complicated
It occurs due to partially cured infection
Patients present within 2 weeks of treatment initiation
• USG – to detect structural abnormalities
COMPLICATIONS OF PYELONEPHRITIS
RENAL ABSCESS
•Clinical Features:
Fever, chills, flank pain
Costovertebral angle tenderness
•Antibiotic Therapy (Empiric)
Start broad-spectrum IV antibiotics, then tailor based on
cultures:
Empiric Options:
•Third-gen cephalosporin (e.g., ceftriaxone) + metronidazole
OR
•Piperacillin–tazobactam
OR
•Carbapenem (e.g., meropenem) for ESBL risk
•Vancomycin if MRSA or hematogenous source suspected
Duration: 4–6 weeks total IV for 2–3 weeks, then switch to oral based
on clinical response
-
Indications for drainage
Percutaneous drainage (CT- or US-guided) if:
• Abscess >3–5 cm
• Poor response to antibiotics within 48–72 hours
• High fever/persistent sepsis
• Immunocompromised patient
• Obstruction or debris present
SURGICAL INTERVENTION
Indications:
•Failure of percutaneous drainage
•Obstructive uropathy requiring correction
•Extensive renal parenchymal destruction
•Life-threatening sepsis
•Multiple or multiloculated abscesses
Nephrectomy is rarely needed but may be life-saving in
uncontrolled infection.
TREATMENT MODALITY INDICATIONS
IV antibiotics alone Abscess <3cm, stable patient
Percutaneous drainage Abscess>/=3-5cm,
No response to IV meds
Surgical drainage or Refractory
Nephrectomy Multiloculated or
Complicated
EMPHYSEMATOUS PYELONEPHRITIS (EPN)
•It is a severe, necrotizing infection of the renal
parenchyma and surrounding tissues, characterized by
gas formation within or around the kidneys.
• It is a urologic emergency and often life-threatening.
Key Features
•Cause: Usually due to gas-forming bacteria (e.g.,
Escherichia coli, Klebsiella pneumoniae)
•Predisposing Factors:
•Diabetes mellitus (most common)
•Urinary tract obstruction
•Immunosuppression
Clinical Presentation:
•High-grade fever, flank pain
•Nausea, vomiting
•Signs of sepsis (tachycardia,
hypotension)
•Altered mental status in severe cases
Diagnosis
•CT Scan (gold standard):
Shows gas in the renal parenchyma
collecting system, or
perirenal space.
Classification (Huang & Tseng system
based on CT finding
Class 1: Gas in collecting system only (i.e., emphysematous
pyelitis)
Class 2: Gas in renal parenchyma without extension
Class 3A: Extension of gas/abscess to perinephric space
Class 3B: Extension to pararenal space
Class 4: Bilateral EPN or in solitary kidney
MANAGEMENT
Depends on the severity and patient
condition:
•Medical Therapy:
•IV broad-spectrum antibiotics (e.g.,
carbapenems, 3rd-gen cephalosporins)
•Glycemic control (insulin)
•Fluids and electrolyte correction
•Close monitoring for sepsis
Interventions:
•Percutaneous drainage (preferred for
localized collections)
•Nephrectomy: For extensive disease or failed
conservative therapy
• Xanthogranulomatous Pyelonephritis
(XGP)
• is a rare, chronic, and destructive granulomatous
infection of the kidney, typically associated with
long-standing obstruction and infection.
• It often mimics malignancy both clinically and
radiographically.
Etiology and Risk Factors
•Chronic urinary tract infection (e.g., Proteus, E. coli)
•Obstructive uropathy, often from staghorn calculi
•Diabetes mellitus
•Immunosuppression
•Female > Male (middle-aged women most affected)
Pathology
•Replacement of renal parenchyma by lipid-laden foamy
macrophages (xanthoma cells) and inflammatory tissue
•Typically unilateral, but bilateral cases are reported
(rare)
Diagnosis
Clinical Features:
• Fever, malaise, weight loss
• Flank or abdominal pain
• Palpable renal mass
• Hematuria or pyuria
• Often appears like renal cell carcinoma
Laboratory:
• ESR , CRP
• Positive urine cultures (often
polymicrobial)
• Pyuria and bacteriuria on urinalysis
Imaging:
•CT scan is the imaging modality of choice:
•“Bear paw sign”: Dilated calyces with low-attenuation
areas
•Renal enlargement, staghorn calculus
•Perinephric stranding, abscess formation
•Ultrasound and MRI may also help but are less definitive
Staging (Malek and Elder Classification)
•Stage I: Confined to renal parenchyma
•Stage II: Extends to perinephric fat
•Stage III: Involves pararenal space or adjacent
structures
Management guidelines
Initial Management:
•Empiric IV antibiotics: Broad-spectrum,
targeting common uropathogens
e.g., piperacillin-tazobactam, ceftriaxone ±
metronidazole
•Adjust based on culture results
•Stabilize patient (fluids, transfusions if anemic, sepsis
management)
Definitive Management:
•Surgical nephrectomy (gold standard):
•Total nephrectomy for most patients
•Partial nephrectomy or conservative management in
rare focal cases (especially in bilateral disease or solitary
kidney)
Drainage Procedures:
•Indicated if abscess is present or patient is
unstable
•Percutaneous nephrostomy or drainage of
perinephric collection may be performed
preoperatively
A CAUTI is a urinary tract infection that occurs in a
patient with an indwelling urinary catheter that has been
in place for more than 2 calendar days, and:
• The catheter was in place on the day of or the day
before the event.
• There is no evidence that the infection was present
before catheter insertion.
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