Lower tract infections

Urethritis and cystitis Often superficial

Upper tract infections

Acute pyelonephritis, prostatitis, intrarenal and perinephric abscess Tissue invasion

Pathogenic microorganisms are detected Growth of > 105 organism/mm midstream clean catch 102-104/ml by suprapubic aspiration, indwelling catheter or in-out catheterization

Persistence of original infecting strain New strain Unresolved renal or prostatic infection Persistent vaginal or intestinal infection leading to reinfection of the bladder

Dysuria, frequency and urgency Unaccompanied by significant bacteriuria Actual bladder infections

Chronic interstitial nephritis Infectious causes

Females
1-3% of school girls Increasing at the onset of sexual activity More common among younger women

Males
<1year of age or for those with genital abnormality >50 years old

Elderly
Asymptomatic bacteriuria 40-50%

E. coli* 80% Proteus*, Klebsiella*, Enterobacter, and Pseudomonas

Enterococci, Staphylococcus saphrophyticus*

* found in women with urethral syndrome and low colony counts Associated with recurrent infections and urologic manipulations Found in patients with renal stones and urologic surgery/instrumentation

S. aureus bacteremic infections Chlamydia, Neisseria and HSV

in patients with (-) bacteria and who are sexually active

Ureaplasma and Mycoplasma

Unusual infections and may be seen among patients with pyelonephritis and prostatitis

Adenovirus
Acute hemorrhagic cystitis in children

Risk factors

Anatomic considerations Intercourse / sexual habits uncircumcised Use of contraceptives (spemicides) Bladder invasion by E. coli
O, K, H serogroups, fimbriae and cytotoxins Catheter associated UTI

Debilitated patients / immobilization

HIV Pregnancy Obstructions (tumors, strictures, stones or prostate) Neurologic bladder dysfunction Vesicoureteral reflux

S/Sx
Dysuria, frequency, urgency and suprapubic pain Fever nausea and vomiting Malodorous, cloudy urine Bloody urine in 30% Urethral or suprapubic tenderness, CVA tenderness Check for vaginal discharges

Pyuria, 102-104 colony counts or higher

No mitigating circumstances
Oral TMP-SMX, TMX, quinolone 3 days Nitrofurantoin 7 days

DM, >7 days of symptoms, recent UTI, use of diaphragm, >65 y/o, pregnant
Oral TMP-SMX, quinolone 7 days

S/Sx
Rapid development of fever, chills, nausea, vomiting, abdominal pain, diarrhea Cystitis (+) CVA tenderness and on deep abdominal palpation Pyuria, bacteriuria, pus casts, Hematuria*
*if persistent rule out TB, stone or tumor

Mild to moderate illness, no nausea or vomiting, OPD treatment

Quinolone 7-14 days Ceftriaxone: 1 gm single dose Gentamycin (3-5 mg/kg) IV followed by oral TMPSMX for 14 days

Severe illness, possible urosepsis, hospitalization required

Parenteral quinolone, Gentamycin (+ampicillin), ceftriaxone, aztreonam

Oral quinolone, TMP-SMX for 14 days

S/Sx
Acute dysuria, frequency and pyuria 30% with no growth or insignificant growth
r/o E. coli vs STDs

Indistinguishable from cystitis

If chronic, check:
New sexual partner with hx of transmitted dse Mucopurulent cervicitis

Chlamydial infxn
Azithromycin 1g single oral dose Doxycycline 100mg bid x 7 days

S/Sx
Minimal symptoms Gram (-) bacteremia Can be prevented through proper aseptic techniques Usually successful for those catheterized for <2 weeks

Arising from catheterization, manipulation, immunosuppression, anatomic, functional, urologic, stone obstructions, renal disease or diabetes With mild to moderate illness, no nausea or vomiting OPD Severe illness possible urosepsis requiring hospitalization
Ciprofloxacin or levofloxacin for 10-14 days

IV ampicillin and gentamicin, ceftriaxone, aztreonam, ticarcillin/clavulanate, or imipenem cilastatin then oral quinolone or TMP-SMX for 10-21 days

Asymptomatic Bacteriuria
Antibiotic oftentimes unnecessary unless with symptoms

Pregnancy
Amoxicillin, nitofurantoin, or cephalosporin Low dose prophylaxis with nitrofurantoin for those with recurrent infection

Bacterial count
Symptomatic patients: >105/ml Asymptomatic patients: >105/ml in 2 consecutive specimen with presence of a single species in both Suprapubic aspiration or catheterizatiopn: >102/ml

Microscopy
Gram stain Pyuria Leukocyte esterase dipstick test

Cultures

Women
Usually not recommended Relapsing infections Childhood infections Stones Painless hematuria Recurrent pyelopnephritis

Males
Recommended Except: AIDS, uncircumcised, recent sexual activity

Infection of the renal pyramids Risk Factors S/Sx

Diabetes, sickle cell disease, chronic alcohololism, and vascular disease Hematuria, flank or abdominal pain Chills and fever Acute renal failure, oliguria and anuria Presence of ring shadow on pyelography

Tx

Nephrectomy for unilateral papillary necrosis may be life saving

High fever, leukocytosis, renal parenchymal necrosis and presence of fermentative gases in kidneys and perinephric tissues seen in plain film/CT E. coli and enterobactericeae Surgical resection/systemic antibiotics needed

E. coli and gm (-) rods Related to bladder outlet obstruction/DM Abdominal pain, dysuria, frequency and pneumaturia. Gas with the bladder lumen and bladder wall by CT Systemic antibiotics Relief of obstruction Cystectomy

Spontaneously in young men and those with indwelling urethral catheter in older men Fever, chills, dysuria and tender, boggy prostate
E. coli or Klebsiella (for non catheter related infxn)
IV flouroquinolones 3rd gen cephalosporin or an aminoglycoside

Gram (-) rods for catheter related infxn Imipenem, aminoglycoside, flouroquinolones or a 3rd gen cephalosporin Sequelae:
Abscess formation, epidymoorchitis, seminal vesiculitis, septicemia or residual chronic bacterial prostatitis

Infrequent, relapsing infection in a middle age man Asymptomatic, with normal prostate on palpation. May produce symptoms of cystitis Presence of E. coli, Klebsiella, proteus in prostatic secretions or post massage urine TX Floroquinolones for 12 weeks Low dose antimicrobial (sulfonamide, TMP, nitrofurantoin) Total prostatectomy/transurethral prostatectomy