URINARY TRACT INFECTION

Besut Daryanto SpB,SpU

Department of Urology
Saiful Anwar Hospital
Brawijaya Medical Faculty
D

UTI :
A UTI is a bacterial infection that affects any part of
the urinary tract

Upper UTI / pyelonephritis : kidney parenchyma

Lower UTI / cystitis

: bladder

Asymptomatic bacteriuria : urinary symptom -

ETIOLOGY

Most common organism: E. coli (80%)

Klebsiella, Proteus,
Pseudomonas,
Enterobacter
The most common type of UTI is acute
cystitis often referred to as a bladder
infection

Pathogenesis
Colonization with ascending spread
Hematogenous spread
Periurogenital spread of infection

PATHOGENESIS

Gut flora
Uropathogens
Colonization
Barrier normal mucosa
Cystitis

BACTERIA VIRULENCE
1.
2.
3.
4.
5.
6.

P-fimbrie
O & K serotype
Haemolicine
Colistine V
Aerobactin
Bactericidal action
resistant

HOSTS IMMUNE DEFENCE

2. Intrarenal Reflux
3. Urinary tract obstruction
4. Foreign bodies (cateter )
Acute Pyelonephritis
scarring Urosepsis

Ascending

1. VUR

Risk Factors
Gender
Women are more prone to UTIs than
men because in females, the urethra is
much shorter and closer to the anus
than in males
Lack the bacteriostatic properties of
prostatic secretions.

Risk Factors
Sexual activity
Related to the frequency of sex

Urinary catheters
Genetics
Others
Diabetics
Sickle-cell disease
Anatomical malformations :
enlargement

Prostate

CLINICAL
History
Acute urethritis
Acute dysuria & urinary hesitancy
Urethral discharge
Fever
Acute cystitis
Dysuria, urgency, hesitancy, polyuria,
and incomplete voids
Fever, nausea, and anorexia

CLINICAL
History
Acute pyelonephritis
Fever, costovertebral angle pain, and
nausea and/or vomiting
Hematuria
Fever and vomiting

CLINICAL
Physical
Acute cystitis

Suprapubic tenderness to palpation

Acute pyelonephritis
Fever
A pelvic examination may reveal
findings
suggestive of PID, such as cervical
motion
tenderness or vaginal discharge.

DIFFERENTIAL DIAGNOSIS
Appendicitis
Bladder Cancer

Bladder Stones
Bladder Trauma
Cystitis

Sepsis, Bacterial
Ureteropelvic
Junction
Obstruction
Urethritis
Pyelonephritis,
Acute
Pyelonephritis,
Chronic

DIAGNOSIS
Urinalysis
Bacteriuria : bacteria identified on culture

Significant bacteriuria :
bacteria > 100.000 colony /ml fresh urin

Gold standard diagnostic UTI

Urine collection

Diagnosis of UTI
Determination of the number and type of bacteria
important diagnostic procedure.
Symptomatic
105 CFU bacteria/ml
Asymptomatic
105 CFU bacteria/ml on 2 consecutive specimens
Catheterized patients
102 CFU bacteria/ml
antibiotic, high urea concentration, high osmolarity, low
pH inhibits bacterial multiplication low bacterial
colony counts

Urinalysis
Offers a number of valuable clues for an accurate
diagnosis:
- Color and cloudiness of urine
- Acidity
- White blood cells (leukocytes).
Treatment can be started without the need for further tests
if the following urinalysis results are present in patients with
symptoms and signs of UTIs:
- A high white cell count
- Cloudy urine

Laboratory test:
Urinalysis

Laboratory test:
Urine / blood / pus culture

Diagnosis
Parameter

Normal values

UTI

Appearance

Yellow

Cloudy

pH

4.5-8.5

Alkaline

Protein

Negative

Positive

Nitrite test

Negative

Positive

RBC

Negative

Positive

WBC

0-5 / hpf

> 5 / hpf

Cast

Negative

Positive

Absent

Many present

Bacteria

Treatment
Initiate immediately after culture
Reduces severity of renal scarring

Oral route preferred

7-14 day course is standard
2-4 days appears to be as effective
Not yet recommended

Goals of Therapy
Prevent or treat systemic consequences
Relieve symptoms
Eradicate invading organism
Eliminate uropathogenic bacterial strains from
fecal & vaginal reservoirs
Prevent reoccurrence of infection
Prevent long-term sequelae

Antimicrobial Selection
Empiric Therapy
- based on most probable pathogens
- local rates of resistance
- acute infection vs chronic
- reinfection or relapse
- indwelling catheter etc
Good urine concentration
Minimal effects on fecal and vaginal flora
Acceptable safety profile
Cost-effective

Antimicrobial Therapy
Cystitis - usually responds to 3 days of treatment
- effective concentrations into the urine > serum
uncomplicated pyelonephritis - 2 weeks treatment
- effective concentrations into the urine = serum
complicated infections / prostatitis - 6 weeks
IV antibiotics may be required in seriously ill
patients, but oral drugs usually effective

Antimicrobial Therapy
Acute Uncomplicated cystitis
Trimethoprim/sulfamethoxazole

(TMP/SMX)
1 DS (160/800 mg) BID x 3 days
Fluoroquinolones:
Ciprofloxacin 250 mg BID x 3 days
Levofloxacin 250mg QD x 3 days
Gatifloxacin 200 mg QD x 3 days
Nitrofurantoin: 100 mg QD x 3 days
Cephalosporins, doxycycline,
amoxicillin/clavulanate

Antimicrobial Therapy
Acute pyelonephritis
Duration on therapy= 7-14 days

TMP/SMX
1 DS (160/800 mg) BID x 14 days
Fluoroquinolone
Ciprofloxacin 500 mg BID x 14 days
Levofloxacin 250mg QD x 14 days
Gatifloxacin 250 mg QDx 14 days
Cephalosporins, doxycycline,
amoxicillin/clavulanate
For more seriously ill patients IV therapy

Prognosis
Adults

The prognosis for most women with

cystitis and pyelonephritis is good; about
25% of women with cystitis will experience
a recurrence.
The prognosis for emphysematous
pyelonephritis is not as good and is
discussed in
Special Concerns.
Infected cysts in polycystic kidney disease
respond to treatment slowly.

Prognosis

Children
In industrialized countries, kidney damage with
long-term complications as a consequence of
urinary tract infection per se is currently less
common than in the early 20th century, when
pyelonephritis was a frequent cause of
hypertension and ESRD in young women
This change is probably a result of improved
overall healthcare and close follow-up of
children after an episode of pyelonephritis.