Urinary tract infection

UTI
Inflammatory response of urothelium to
bacterial invasion.

 Bacteruria : bacteria in urine

It can be asymptomatic or symptomatic
Bacteruria without pyuria is colonization

Pyuria :
WBCs in urine.
Infection
T.B
Bladder stone.

Complicated VS uncomplicated
Un complicated UTI:
UTI structurally &
functionally normal
urinary tract.
Female.
Respond to short
course of antibiotic

Complicated UTI:
Anatomical or
functional
abnormality.
Male.
Longer time to
respond to ttt

 Isolated UTI:
6 months between infections.

Recurrent UTI:>2 infections in 6 months

3 UTI in 12 months.
Reinfection by different bacteria.
Persistence : same organism from focus within
the urinary tract. Caused by :
Struvite stone.
Chronic Bacterial prostatitis.
Bladder Fistula
Urethral diverticulum.
Atrophic infected kidney.

 Unresolved infection:
in adequate therapy , bacterial resistance
to ttt.

Risk factors to bacteruria

Female
Age
Low estrogen
(menopause)
Pregnancy.
D.M
Previous UTI.
In-dwelling catheter

Stone
GU malignancy.
Obstruction.
Voiding dysfunction.
Institutionalized
elderly

Microbiology
Faecal-derived bacteria
Uncomplicated UTI
E.Coli, G-ve baccillus,
(85%- 50%)
Staph saprophyticus
Enterococcus faecalis
Proteus
Klebsiella.

Complicated UTI
E.coli 505
Enterococcuc faecalis.
Staph aureus
Staph epidermidis
Pseudomonas
aeruginosa

Route of infection

Ascending
Short urethra
Reflux
Impair urteric
peristalisis.
Pregnancy
Obstruction
G-ve , Edotoxins
Organism P pili

Route of infection

Haematogenous:
Uncommon.
Staph aureus.
Candida fungemia.
T.B

Lymphatics:
Rarely in
inflammatory bowel
disease,
reteroperitoneal
abscess

 Increase UTI risk

Protect against UTI

Increase bacterial
virulence

Host defences

Factors increasing bacterial

virulence

Adhesion factors
Toxins
Enzyme production.
Avoidance of host defense mechanisms

Factors increasing bacterial

virulence
Adhesion factors
G-ve bacteria, Pili
Attachment to host
urothelial cells.
Single type or different
types e.x E.coli
Defined functionally be
mediating
hemagglutination (HA) of
specific erythrocytes

Mannose sensitive
(type 1)
Produced by all strains
E.coli
Certain pathogenic types
of E.coli mannose
resistant pili
( pyelonephritis)

Factors increasing bacterial

virulence
Avoidance of host
defense mechanisms
E.coli
Extracellular capsule

Immunogenisity

Toxins:
E.coli cytokines,
pathogenic effect on
host tissues

phagocytosis

M.Tuberculosis reisit
phagocytosis by
preventing
phagolysosome fusion

Enzyme production:
Proteus ureases
Ammonia struvite
stone formation

Host defences
Protective
Mechanical (flushing of urine) antegrade flow of
urine
Tamm-Horsfall protein (mucopolysaccharide
coating bladder prevent bacterial attachment)
chemical : Low Urine PH & high osmolality
Urinary Immunoglobulin I gA inhibit adherence

Lower UTI
Cystitis: infection& inflammation of the
bladder
Frequency, small volumes, dysuria,
urgency, offensive urine SP pain,
haematuria, fever & incontinence.

Investigation
Dipstick of MSU
WBC ( pyuria )
75 -95% sensitivity
infection
False ve
False +ve
Other causes of
pyuria

Nitrite testing:
Bacteriuria.
Specificity >90%
Sensitivity 35- 85%
+ test ------- infection
--------infection

Investigation

Microscopy :
Bacteria :
False ve low bacterial count
False +ve contamination (lactobacilli &
corynebacteria ) epithelial cells
RBCs & pyuria

Investigation
Indications for further
investigations in LUTI.
Symptoms of Upper
UTI.
Recurrent UTI.
Pregnancy
Unusal infecting
organism ( proteus
suggest infection
stone)

KUB X-ray
Ultrasound
IVU
cystoscopy

DD

Non-infective cystitis:
radiation cystitis
Drug cystitis ( cyclophosphamide )
Haemorrhagic cystitis
Urethritis

Treatment
Aim :
Eliminate bacterial
growth from urine.
Empirical ttt before
culture & sensitivity
for the most likely
organism.
Adjusted according to
the culture &
sensitivity.

Resistance :
Intrinsic (proteus)
Genetically
transferred between
bacteria by R
plasmids.

Recurrent UTI
>2 in 6 months or 3 within 12 months

Reinfection

Bacterial persistence

Recurrent UTI
Reinfection ( different Bacterial persistance
bacteria)
( same organism
from a focus within
After prolonged
tract) within short
interval with a
interval
different organism
Reinfection in females Functional or
anatomical problem.
No anatomical nor
The underlying
functional pathology
problem should be
In males BOO,
treated
urethral stricture

Management Reinfection UTI

Females
KUB X-ray, Ultrasound, flexible cystoscopy to
confirm this is a simple Reinfection .
After confirming ,management is :
Avoid spermicides
Estrogen replacement therapy
Low dose antibiotic prophylaxis
(trimethoprim , cefalexin,
nitrofurantoin , flouroquinolones )

Female recurrent reinfection

Prophylactic antibiotic:
Reduce infection 90% at bed time 6-12
months
Symptomatic reinfection
Trimethoprim
Nitrofurantoin
Cephalexin
Fluoroquinolones

Management of bacterial
persistance

Investigations:
KUB X-ray , renal ultrasound.
C.T, IVU
Cystoscopy

Treatment :
For the functional or anatomical anomaly

Antibiotics
Empirical therapy.
Definitive therapy.
Bacterial resistance to drug therapy.

Acute pyelonephritis

Clinical Dx:
Flank pain
Fever.
Elevated WBCs

DD:
acute cholecystitis.
Pancreatitis.

Acute pyelonephritis

Risk factors:
VUR
UTO
Spinal cord injury
D.M
Malformation
pregnancy
FC

Acute pyelonephritis
Pathogenisis :
Initially patchy infiltration of neutrophils
and bacteria in the parenchyma.
Inflammatory bands from renal papilla to
cortex.
80% E.coli, others klebsiella, proteus&
pseudomonas.

Acute pyelonephritis
Management and treatment :1- For patients who have fever but not
unwell
outpatient mx ( urine culture and
empiric oral antibiotic e.g. ciprofloxacin)
2- If the patient is unwell
culture blood
and urine and IV antibiotics

Acute pyelonephritis
Arrange for :
KUB & ultrasound to see if there is a tract
abnormalities such as stones ,
unexplained hydronephrosis or
emphysamatous pyelonephritis
If no response with I.V antibiotic for 3
days go for CTU

Perinephric abscess
Pathogenesis : consequence of extension
of infection outside the parenchyma
Risk factors : DM, obstructing ureteric
calculus
Causes : staph. aureus , e.coli , proteus
Tx : antibiotics and drainage

Pyonephrosis
Infected hydronephrosis.
Pus accumulation within renal pelvis and
calyces
Presentation :
The patient is very unwell with loin pain
and fever
Risk factors : stones , previous UTI
surgery

Pyonephrosis
Investigations
Ultrasound, CT , KUB X-ray
Management: PCN or ureteric drainage,
I.V antibiotic, I.V fluids.

Emphysematous pyelonephritis
Severe form of acute pyelonephritis
Gas forming organism
Fever, abdominal pain with radiographic
evidence of gas within the kidney.
D.M
Urinary obstruction.
High glucose level-------fermentation,CO2
production

Emphysematous pyelonephritis

Presentation: sever acute pyelonephritis

High fever & systemic upset
E.coli, commonly,
Klebsiella & proteus less frequent

Management

KUB
Ultrasound, C.T
Patients are unwell
Mortality is high

Management

Conservative ?
I.V antibiotic , IVF
PC drainage
Control D.M

When Sepsis is poorly controlled

Nephrectomy

Xanthogranulomatous
pyelonephritis

Severe renal infection

Assciated with Renal calculi & obstruction.
Result in non-functioning kidney
E.coli & proteus common.
Macrophage full of fat deposit around the
abscess
Kidney, perinephric fat

Xanthogranulomatous
pyelonephritis
Acute flank pain
Fever & tender flank mass
C.T , Ultrasound
Stone , mass ?? RCC

Xanthogranulomatous
pyelonephritis
IV antibiotic ,
Nephrectomy

Thank you