APPROACH TO UTI
Dr. Lokesh.K.V
Significance:
• Urinary tract infection (UTI) is the second
most common clinical indication for
empirical antimicrobial treatment in primary
and secondary care
• Urine samples constitute the largest single
category of specimens examined in most
medical microbiology laboratories.
Why treat?
• For patients with symptoms of urinary tract
infection and bacteriuria the main aim of treatment
is relief of symptoms.
• Secondary outcomes are adverse effects ie,
including Clostridium difficile infection (CDI) or
methicillin resistant Staphylococcus aureus (MRSA)
infection, and the development of antibiotic-
resistant UTIs or the treatment or recurrence of
symptoms.
• For asymptomatic patients the main outcome from
treatment is prevention of future symptomatic
episodes.
Causative organisms:
• E.Coli is the main organism
• Staphylococcus saprophyticus
• Proteus mirabilis
• Rarer:
• Klebseilla
• Enterobacter
• Acinetobacter
• Pseudomonas aeruginosa
• Staph aureus
• Enterococcus faecalis
Definitions:
• Bacteriuria
• presence of bacteria in urine revealed by quantitative culture or microscopy.
• Asymptomatic bacteriuria
• presence of bacteriuria in urine revealed by quantitative culture or
microscopy in a sample taken from a patient without any typical symptoms
of lower or upper urinary tract infection (should be confirmed by two
consecutive urine samples)
• Symptomatic bacteriuria
• presence of bacteriuria in urine revealed by quantitative culture or
microscopy in a sample taken from a patient, or
• the typical symptoms of lower or upper urinary tract infection.
• The presence of symptomatic bacteriuria can be established with a single
urine sample.
• Significant Bacteriuria
• For laboratory purposes the widely applied definition in the UK is 10*4 cfu/ml.
For some specific patient groups there is evidence for lower thresholds:
women with symptomatic UTI ≥10*2 cfu/ml
men ≥10*3 cfu/ml (if 80% of the growth is due to a single organism).
Cont’d…
• Classic symptoms of urinary tract infection
(UTI)
• dysuria, frequency of urination, suprapubic
tenderness, urgency, polyuria, haematuria.
• Upper urinary tract infection (UUTI)
• evidence of urinary tract infection with symptoms
suggestive of pyelonephritis (loin pain, flank
tenderness, fever, rigors or other manifestations of
systemic inflammatory response).
• Lower urinary tract infection (LUTI)
• evidence of urinary tract infection with symptoms
suggestive of cystitis (dysuria or frequency without
fever, chills or back pain).
Cont’d…
• Pyuria
• occurrence of ≥10*4 white blood cells (WBC)/ml
in a freshly voided specimen of urine.
• Pyuria in the absence of bacteriuria:
• the presence of a foreign body, for example, a urinary
catheter
• urinary stones
• neoplasms,
• lower genital tract infection
• renal tuberculosis.
Cont’d
Mild urinary tract infection Less than three of the classical
symptoms of UTI.
Severe urinary tract infection Three or more of the classical
symptoms of UTI.
Empirical treatment Treatment based on clinical
symptoms or signs unconfirmed
by urine culture.
Long term catheter An indwelling catheter left in
place for over 28 days.
Medium term catheter An indwelling catheter left in
place for 7-28 days.
Short term catheter An indwelling catheter left in
place for 1-7 days.
RISK FACTORS FOR ASYMPTOMATIC
BACTERIURIA
• Female sex
• Sexual activity
• Comorbid diabetes
• Age
• Institutionalization
• Presence of catheter
Note:
• There is a risk of false positive results in all
tests for diagnosis of bacteriuria other than the
gold standard:
• The gold standard test for diagnosis of bacteriuria is
culture of bladder urine obtained by needle aspiration
of the bladder as it minimises the risk of
contamination of the urine specimen.
• All other techniques (urethral catheter and midstream
specimens of urine) carry a higher risk of
contamination and therefore produce some false
positive results
• Routine urine culture is not required to manage
LUTI in women:
• Women with symptomatic LUTI should receive
empirical antibiotic treatment
• If dysuria and frequency are both present,
then the probability of UTI is increased to
>90% and empirical treatment with antibiotic
is indicated.
• Urine turbidity has been shown to have a
specificity of 66.4% and sensitivity of 90.4%
for predicting symptomatic bacteriuria.
• Use dipstick tests to guide treatment
decisions in otherwise healthy women under
65 years of age presenting with mild or ≤2
symptoms of UTI.
Antibiotic Treatment: Symptomatic
Bacteriuria LUTI
• Resistance…
• Narrow spectrum: trimethoprim or nitrofurantoin.
• Reduced the use of cephalosporins, quinolones
and co-amoxiclav.
• Guidelines from the Infectious Diseases Society of
America (IDSA) and Health Protection Agency
(HPA) recommend
• Three days treatment with trimethoprim for LUTI.
• There is more direct evidence for three days
treatment with co-trimoxazole
(trimethoprim/sulphamethoxazole) but
trimethoprim alone is considered to be as
effective as co-trimoxazole in treatment of LUTI.
• Three days of treatment with
nitrofurantoin or trimethoprim has been
shown to be effective in non-pregnant
women with uncomplicated UTI.
• Nitrofurantoin is contraindicated in the
presence of significant renal impairment.
• Advise women with LUTI, who are
prescribed nitrofurantoin, not to take
alkalinising agents (such as potassium
citrate).
• Take urine for culture to guide change of
antibiotic for patients who do not respond
to trimethoprim or nitrofurantoin.
Symptomatic Bacteriuria: UUTI
• Upper urinary tract infection can be accompanied by
bacteraemia, making it a life threatening infection.
• Hospitalisation of patients:
• with acute pyelonephritis if there is no response to antibiotics
within 24 hours, due to the risk of antibiotic resistance.
• unable to take fluids and medication or showing signs of sepsis.
• Where hospital admission is not required, take a
midstream urine sample for culture and begin a course of
antibiotics.
• The Health Protection Agency and the Association of
Medical Microbiologists recommend ciprofloxacin
(7days) or co-amoxiclav ( 14 days) for the empirical
treatment of acute pyelonephritis.
Asymptomatic Bacteriuria:
• There is no evidence that treatment of asymptomatic
bacteriuria in adult non preganant women
significantly reduces the risk of symptomatic
episodes.
• In women with diabetes, antibiotic treatment of
asymptomatic bacteriuria significantly increases the
risk of adverse events without significant clinical
benefit, and also increases resistance.
• In elderly women (over 65 years of age), treatment of
asymptomatic bacteriuria does not reduce mortality
or significantly reduce symptomatic episodes.
Non- Antibiotic Treatment
1. Cranberry Products:
• cranberry products significantly reduce the incidence of UTIs at
12 months compared with placebo/control.
• Cranberry products were more effective in reducing the incidence of
UTIs in women with recurrent UTIs, than in elderly men and women
or people requiring catheterisation.
• Advise women with recurrent UTI to consider using cranberry
products to reduce the frequency of recurrence.
• Advise patients taking warfarin to avoid taking cranberry products
unless the health benefits are considered to outweigh any risks.
2. Oestrogens:
• Do not use oestrogens for routine prevention of recurrent UTI in
postmenopausal women.
3. Analgesia:
• Advise women with uncomplicated UTIs that they may use over-the-
counter remedies such as paracetamol or ibuprofen to relieve pain.
Management of bacterial UTI in pregnant
women: SYMPTOMATIC BACTERIURIA
• Diagnosis:
• Important because there is proved link to pre-labour, premature rupture
of membranes (PPROM) and pre-term labour.
• Untreated upper urinary tract infection in pregnancy: risks of morbidity,
and rarely, mortality to the pregnant woman.
• GOLD STD:
• Culture of urine obtained by suprapubic needle aspiration.
• Dipstick testing (LE or nitrate):
• is not sufficiently sensitive to be used as a screening test
at the first or subsequent antenatal visits.
• Used only for proteinuria and glucosuria.
• Urine culture should be the investigation of
choice.
• Standard quantitative urine culture should be performed routinely at first
antenatal visit.
• Confirm the presence of bacteriuria in urine with a second urine culture.
Antibiotic treatment in Symptomatic
Bacteriuria in pregnancy
• Treat symptomatic UTI in pregnant women with an
antibiotic.
• Take a single urine sample for culture before
empiric antibiotic treatment is started.
• Refer to local guidance for advice on the choice of
antibiotic for pregnant women.
• A seven day course of treatment is normally
sufficient.
• Given the risks of symptomatic bacteriuria in
pregnancy, a urine culture should be performed
seven days after completion of antibiotic treatment
as a test of cure.
Asymptomatic Bacteriuria in Pregnancy:
• Antibiotic treatment of asymptomatic bacteriuria in
pregnancy reduces the risk of upper urinary tract
infection, pre-term delivery and low birth weight
babies.
• The evidence suggests that 3-7 days treatment is as
effective as continuous antibiotic therapy.
• There is no need for empirical treatment in this group
of patients as all women have urine culture before
treatment.
• Penicillins or Cephalosporins are the commonly
prescribed.
• Do not prescribe trimethoprim for pregnant women
with established folate deficiency, low dietary folate
intake, or women taking other folate antagonists.
Screening in pregnancy:
• Women with bacteriuria confirmed by a
second urine culture should be treated and
have repeat urine culture at each antenatal
visit until delivery.
• Women who do not have bacteriuria in the
first trimester should not have repeat urine
cultures.
Management of bacterial UTI in adult men:
• Diagnosis:
• Urinary tract infections in men are generally viewed as
complicated because they result from an anatomic or
functional anomaly or instrumentation of the genitourinary
tract.
• Think about prostatitis, chlamydial infection and epididymitis
as differential diagnosis of men with acute dysuria or
frequency and appropriate diagnostic tests should be
considered.
• In all men with symptoms of UTI a urine sample should be
taken for culture.
• In patients with a history of fever or back pain the possibility
of UUTI should be considered.
• Obtaining a clean-catch sample of urine in men is easier
than in women and a colony count of ≥10*3 cfu/ml may
be sufficient to diagnose UTI in a man with signs and
symptoms as long as 80% of the growth is of one
Antibiotic Treatment:
• The HPA suggests that a seven day course of
trimethoprim or nitrofurantoin may be considered for
those with symptoms of uncomplicated lower UTI.
• Treat bacterial UTI empirically with a quinolone in
men with symptoms suggestive of prostatitis for 4
weeks.
• Refer men for investigation if:
• they have symptoms of upper urinary tract infection,
• fail to respond to appropriate antibiotics or
• have recurrent UTI (two or more episodes in three months)
Management of bacterial UTI in
patients with catheters
• Diagnosis:
• All patients with long term indwelling
catheter are bacteriuric often with two or
more organisms.
• The longer the catheter is in place the
greater the likelihood of infection.
• Intermittent catheterisation is associated
with a lower incidence of asymptomatic
bacteriuria.
• Catheter-associated UTI is the source for
8% of hospital acquired bacteraemia.
Think of UTI and it warrants antibiotics if:
• new costovertebral tenderness
• rigors
• new onset delirium
• fever greater than 37.9°C or 1.5°C above baseline on
two occasions during 12 hours.
• You may not get the classical signs and symptoms of UTI
in catheterized patients.
• The absence of fever does not exclude UTI, though it is
the most common symptom.
Investigations:
• Do not use laboratory microscopy to
diagnose UTI in patients with catheters.
• Do not use dipstick testing to diagnose UTI
in patients with catheters.
• Pyuria is common but has no predictive
value in differentiating symptomatic
from asymptomatic UTI in catheterised
patients.
Antibiotics:
• Prophylaxis:
• Do not routinely prescribe antibiotic prophylaxis to prevent
symptomatic UTI in patients with catheters.
• Are not routinely required when changing catheters in patients
at increased risk of endocarditis such as those with a heart
valve lesion, septal defect, patent ductus, or prosthetic valve.
• Consider prophylaxis only in:
• patients for whom the number of infections are of such
frequency or severity that they chronically impinge on function
and well-being.
• When changing catheters, should only be used for people with
a history of catheter-associated urinary tract infection following
catheter change.
• In a hospital setting, when prophylaxis for catheter
change is required, consider using a narrow spectrum
agent such as gentamicin rather than ciprofloxacin to
minimise the risk of C. difficile infection.
Treatment:
• Symptomatic Bacteriuria:
• Patients should be admitted to hospital if
systemic symptoms, such as fever, rigors, chills,
vomiting or confusion appear.
• Change long term indwelling catheters before
starting antibiotic treatment for symptomatic UTI.
• IDSA guidelines:
• recommend a seven day course for patients with
symptomatic catheter-associated UTI who have
prompt resolution of symptoms,
• or 10-14 days where there is a delayed response.
• Asymptomatic Bacteriuria:
• Single dose antibiotic treatment of women
with asymptomatic bacteriuria after short
term catheterisation significantly reduces the
risk of symptomatic episodes in the following
two weeks.
• Do not screen women with asymptomatic
bacteriuria after short term catheterisation.
• Do not treat catheterised patients with a
symptomatic bacteriuria with an antibiotic.
• In patients with urinary stomas send
urine culture only if the pt has clinical
sepsis and not because of the
appearance or smell of urine.
UTI in a Child:
• Infants and children presenting with unexplained fever of
38°C or higher should have a urine sample tested after 24
hours at the latest.
• The following risk factors for UTI and serious underlying pathology
should be recorded:
– poor urine flow
– history suggesting previous UTI or confirmed previous UTI
– recurrent fever of uncertain origin
– antenatally-diagnosed renal abnormality
– family history of vesicoureteric reflux (VUR) or renal disease
– constipation
– dysfunctional voiding
– enlarged bladder
– abdominal mass
– evidence of spinal lesion
– poor growth
– high blood pressure
• Infants younger than 3 months with a possible UTI
should be referred immediately to the care of a
paediatric specialist: IV Antibiotics initiated.
• For infants and children 3 months or older with
acute pyelonephritis/ upper urinary tract infection:
consider referral to a paediatric specialist
treat with oral antibiotics for 7–10 days. The use of
an oral antibiotic with low resistance patterns is
recommended, for example cephalosporin or co
amoxiclav
if oral antibiotics cannot be used, treat with an
intravenous (IV) antibiotic agent such as
cefotaxime or ceftriaxone for 2–4 days followed by
oral antibiotics for a total duration of 10 days.
• For infants and children 3 months or older with
cystitis/lower urinary tract infection:
treat with oral antibiotics for 3 days.
Trimethoprim, nitrofurantoin, cephalosporin or amoxicillin.
the parents or carers should be advised to bring the
infant or child for reassessment if the infant or child is
still unwell after 24–48 hours.
If an alternative diagnosis is not made, a urine sample
should be sent for culture to identify the presence of
bacteria and determine antibiotic sensitivity if urine culture
has not already been carried out.
• Antibiotic prophylaxis should not be routinely
recommended in infants and children following first-
time UTI.
Atypical UTI:
• Seriously ill
• Poor urine flow
• Abdominal or bladder mass
• Raised creatinine
• Septicemia
• Failure to respond to suitable antibiotics in 48 hrs
• Infection with an atypical organism ( non –E.Coli)
Recurrent UTI:
• 2 or more upper UTIs
• 1 upper plus 1 or more lower UTIs
• 3 or more lower UTIs
Children 3 years or older Use dipstick test to diagnose
UTI
If both leukocyte esterase and • Start antibiotic treatment for UTI.
nitrite are positive • If high or intermediate risk of
serious illness or past history of
UTI, send urine sample for
culture.
If leukocyte esterase is negative • Start antibiotic treatment if fresh
and nitrite is positive sample was tested.
• Send urine sample for culture.
If leukocyte esterase is positive • Send urine sample for
and nitrite is negative microscopy and culture.
• Only start antibiotic treatment
for UTI if there is good clinical
evidence of UTI.
• Result may indicate infection
elsewhere.
• Treat depending on results of
culture.
If both leukocyte esterase and • Do not start treatment for UTI.
nitrite • Explore other causes of illness.
are negative • Do not send urine sample for
Indications for culture:
• diagnosis of acute pyelonephritis/upper urinary tract
infection
• high to intermediate risk of serious illness
• under 3 years
• a single positive result for leukocyte esterase or nitrite
• recurrent UTI
• infection that does not respond to treatment within 24–
48 hours
• clinical symptoms and dipstick tests do not correlate.
Thank You:
