Sahala Panggabean

Department of Internal Medicine

Faculty of Medicine, Christian University of Indonesia
10 November 2015
 Urinary Tract Infection (UTI) is the presence and
multiplication of antimicrobial pathogens within the
normally sterile urinery tract.
 UTI can be limited to the bladder (cystitis) can be painful
and annoying. But serious consequences can occur if the
infection spreads to the kidneys (acute pyelonephritis).
 Women are most at risk of developing a UTI. About half of
all women will develop an UTI episode during their
lifetimes, and many will experience more than once.
 UTI is the second most common type of infection in human,
accounts for 8.3 million doctor visits per year.
UTI can be subdivided into two general anatomic categories:
1. Lower Tract Infections ( Urethritis and
Cystitis )
2. Upper Tract Infection ( Acute
Pyelonephritis, Intrarenal and Perinephric abscesses).
Figure 23.1
 UTI usually develop first in the lower urinary tract
(urethra, bladder) and, if not treated, progress to the
upper urinary tract (ureters, kidneys).
 Bladder infection (cystitis) is by far the most common
UTI.
 Infection of the urethra is called urethritis.
 Kidney infection (pyelonephritis) requires urgent
treatment and can lead to reduced kidney function and
possibly even death in untreated due to septicemia in
severe cases.
Epidemiologically UTI’s are sub divided into:

1. Cathether-associated or nosocomial infections

2. Community-aquired infections
Acute community-aquired infections are very common and
account for more than 7 million office visits annually
3. Asymptomatic bacteriuria is more common among elderly men
and women.

.
 The urinary tract can be infected from below, bacteria
entering the urethra and trevelling upwords (ascending
infection).
In older children and adults infection most often
starts from below (ascending infection)

 Some UTI ocuurs by bacteria entering the kidneys from the

bloodstream (hematogen spread).
Infection from hematogen spreads are most often seen
in newborns with sepsis and immunocompromized
older patients.
 In many cases, bacteria first travel to the urethra from the
perineum. Bacteria multiply and infection can occur.
Infection limited to the urethra is called urethritis.

 If bacteria move to the bladder and multiply, a bladder

infection or cystitis results.

 If the infection is not treated promptly, bacteria may then

travel further up the ureters to multiply and infect the
kidneys result in kidney infection is called acute
pyelonephritis.
 Ascending transurethral route
 From the lower UT is the
commonest
 At first there is colonisation
of the distal
urethra & introitus in female
by coliform
bacteria
 Hematogenous
 Through blood stream e.g.
septicaemia
 Lymphatics
 Direct extension from vesico
colic fistula
 Gender and sexual activity
 Pregnancy
 Obstruction
 Neurogenic Bladder Dysfunction
 Vesicoureteral Reflux
 Bacterial Virulence Factors
 Genetic Factors
 A woman's urethra is shorter than a man's, which is one reason why women are
much more likely than men to get UTI's.
 For many women, sexual intercourse seems to trigger an infection.
 Any abnormality of the urinary tract that obstructs the flow of urine;
kidney stones for example sets the stage for an infection.
 Enlarged prostate gland also can slow the flow of urine, thus raising the risk of
infection.
 Common source of infection is catheters, or tubes, placed in the urethra and
bladder.
 People with diabetes have a higher risk of a UTI because of changes in the
immune system.
 According to some reports, about 2 to 4 percent of pregnant women develop a
urinary infection
Older children or an adult may experience the following
symptoms with UTI:
 Painful urination (dysuria)
 Pain in the pelvic or suprapubic area
 Flank or lower back pain (with a kidney infection)
 Frequent urination
 Inability to produce more than a small amount of urine at a
time
 Incontinensia urinae
 Cloudy urine or with unusual smell
 Uncomplicated (Simple) cystitis
 In healthy woman, with no signs of systemic disease
 Complicated cystitis
 In men, or woman with comorbid medical problems.
 Recurrent cystitis
 Definition
 Healthy adult woman (over age 12)
 Non-pregnant
 No fever, nausea, vomiting, flank pain
 Diagnosis
 Dipstick urinalysis (no culture or lab tests needed)
 Treatment
 Trimethroprim/Sulfamethoxazole for 3 days
 May use fluoroquinolone (ciprofoxacin or levofloxacin) in
patient with sulfa allergy, areas with high rates of bactrim-
resistance
 Risk factors:
 Sexual intercourse
 May recommend post-coital voiding or prophylactic antibiotic use.
 Definition
 Females with comorbid medical conditions
 All male patients
 Indwelling foley catheters
 Urosepsis/hospitalization
 Diagnosis
 Urinalysis, Urine culture
 Further labs, if appropriate.
 Treatment
 Fluoroquinolone (or other broad spectrum antibiotic)
 7-14 days of treatment (depending on severity)
 May treat even longer (2-4 weeks) in males with UTI
 Want to make sure urine culture and sensitivity
obtained.
 May consider urologic work-up to evaluate for
anatomical abnormality.
 Treat for 7-14 days.
 Infection of the kidney
 Associated with constitutional symptoms – fever, nausea, vomiting,
headache
 Diagnosis:
 Urinalysis, urine culture, CBC
 Treatment:
 2-weeks of Trimethroprim/sulfamethoxazole or
fluoroquinolone
 Hospitalization and IV antibiotics if patient unable to take po.
 Complications:
 Perinephric/Renal abscess:
 Suspect in patient who is not improving on antibiotic therapy.
 Diagnosis: CT with contrast, renal ultrasound
 May need surgical drainage.
 Nephrolithiasis with UTI
 Suspect in patient with severe flank pain
 Need urology consult for treatment of kidney stone

 Septicemia
 Symptoms:
 Pain in the perineum, lower abdomen, testicles, penis, and with
ejaculation, bladder irritation, bladder outlet obstruction, and
sometimes blood in the semen
 Diagnosis:
 Typical clinical history (fevers, chills, dysuria, malaise, myalgias,
pelvic/perineal pain, cloudy urine)
 The finding of an edematous and tender prostate on physical
examination
 Will have an increased PSA (Prostat Specific Antigen)
 Urinalysis, urine culture
 Treatment:
 Trimethoprim/sulfamethoxazole, fluroquinolone or other broad
spectrum antibiotic
 4-6 weeks of treatment
 Risk Factors:
 Trauma
 Sexual abstinence
 Dehydration
 Chlamydia trachomatis
 Frequently asymptomatic in females, but can present with dysuria, discharge
or pelvic inflammatory disease.
 Send UA, Urine culture (if pyuria seen, but no bacteria, suspect Chlamydia)
 Pelvic exam – send discharge from cervical or urethral os for chlamydia PCR
 Chlamydia screening is now recommended for all females ≤ 25 years
 Treatment:
 Azithromycin – 1 g po x 1
 Doxycycline – 100 mg po BID x 7 days
 Neisseria gonorrhoeae
 May present with dysuria, discharge, PID
 Send UA, urine culture
 Pelvic exam – send discharge samples for gram stain, culture, PCR
 Treatment:
 Ceftriaxone – 125 mg IM x 1
 Cipro – 500 mg po x 1
 Levofloxacin – 250 mg po x 1
 Ofloxacin – 400 mg po x 1
 Spectinomycin – 2 g IM x 1
 You should always also treat for chlamydia when treating for
gonnorhea!
 The most serious consern in a UTI is if to avoid its
progress to acute pyelonephritis.

 Result in scarring in the kidney tissue and sepsis

 Fortunately acute uncomplicated pyelonephritis in

rarely progresses to renal functional impairment
and chronic renal disease.
 Proteinuria, pyuria, hematuria microskopis are ususally
found in urinalysis, glomerular cast is a sign for
pyelonephritis.
 The urine culture is an important diagnostic procedure to
determine the type and number of bacterian in urine.
 Microscopic bacteriuria which is best assessed with Gram-
stained urine seiment, is found in 90% of specimens from
patients whose infections are associated with colony
counts of at least 105/mL, and this finding is very specific.
 Urine culture and antimicrobial susceptibility testing.
 Ultrasound exam to look for stones and obstruction.
 BNO – IVP to look for structural abnormality.
 Severely ill patients with vomiting should be
hospitalized and given the IVFD until they can
take fluids and drugs orally.

 Drinking plenty of water helps cleanse the urinary

tract of bacteria.
 Following principles underlie the treatment of UTIs:
 Quantitative urine culture should be ordered to confirm
infection before empirical treatment is begun, except in
acute uncomplicated cystitis in women.
 When culture results become available, antimicrobial
sensitivity testing should be used to further direct
therapy.
 Factors predisposing to infection, such as obstruction
and calculi, should be identified and corrected if
possible.
 Women who experience frequent symptomatic UTIs (3 per
year on average) are candidates for long-term
administration of low-dose antibiotics directed at
preventing recurrences.
 Such women should be advised to avoid spermicide use
and to void soon after intercourse. Daily or thrice-weekly
administration of a single dose of TMP-SMX (80/400 mg).
 Prophylaxis should be initiated only after bacteriuria has
been eradicated with a full-dose treatment regimen.
 All pregnant women should be screened for bacteriuria in
the first trimester and should be treated if bacteriuria is
demonstrated.
 Drink plenty of liquids, especially water.
 Wipe from front to back. Doing so after urinating and
after a bowel movement helps prevent bacteria in the
perineum from spreading to the vagina and urethra.
 Voiding as soon as possible after intercourse
 Avoid potentially irritating feminine products.
 Comprehensive Clinical Nephrology, 5e, by Richard J.
Johnson MD and Feehally DM FRCP.
 Buku Ilmu Penyakit Dalam, FKUI