URINARY TRACT INFECTION

DEFINITION
• is the microbial invasion
of any tissue of the
urinary tract, extending
from the urethral
meatus to the renal
cortex
 Urinary Tract Infection
• Upper urinary tract
Infections:
– Pyelonephritis
• Lower urinary tract
infections
– Cystitis (“traditional” UTI)
– Urethritis (often sexually-
transmitted)
– Prostatitis
Symptoms of Urinary Tract Infection

• Dysuria
• Increased frequency
• Hematuria
• Fever
• Nausea/Vomiting (pyelonephritis)
• Flank pain (pyelonephritis)
 Findings on Exam in UTI
• Physical Exam:
– CVA tenderness (pyelonephritis)
– Urethral discharge (urethritis)
– Tender prostate on DRE (prostatitis)
• Labs: Urinalysis
– + leukocyte esterase
– + nitrites
• More likely gram-negative rods
– + WBCs
– + RBCs
 Culture in UTI
• Positive Urine Culture = >105 CFU/mL
• Most common pathogen for cystitis,
prostatitis, pyelonephritis:
– Escherichia coli
– Staphylococcus saprophyticus
– Proteus mirabilis
– Klebsiella
– Enterococcus
• Most common pathogen for urethritis
• Chlamydia trachomatis
• Neisseria Gonorrhea
 Lower Urinary Tract Infection -
Cystitis
• Uncomplicated (Simple) cystitis
– In healthy woman, with no signs of
systemic disease
• Complicated cystitis
– In men, or woman with comorbid
medical problems.
• Recurrent cystitis
Uncomplicated (simple) 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)
Uncomplicated (simple) Cystitis
• 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.
 Complicated Cystitis
• 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
 Special cases of Complicated cystitis
• Indwelling foley catheter
– Try to get rid of foley if possible!
– Only treat patient when
symptomatic (fever, dysuria)
• WBCs in urinalysis
• Patient’s with indwelling catheters are
frequently colonized with great
numbers of bacteria.
– Should change foley before
obtaining culture, if possible
• Candiduria
– Frequently occurs in patients with indwelling
foley.
– If grows in urine, try to get rid of foley!
– Treat only if symptomatic.
– If need to treat, give fluconazole
(amphotericin if resistance)
 Recurrent Cystitis
• Want to make sure urine culture and
sensitivity obtained.
• May consider urologic work-up to
evaluate for anatomical abnormality.
• Treat for 7-14 days.
 Prostatitis
• 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
– Urinalysis, urine culture
 Prostatitis
• Treatment:
– Trimethoprim/sulfamethoxazole, fluroquinolone or
other broad spectrum antibiotic
– 4-6 weeks of treatment
• Risk Factors:
– Trauma
– Dehydration
 Urethritis
• 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
 Urethritis
• 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 gonorrhea!
PYELONEPHRITIS
• Bacterial infection of the
structures of the kidney:
– the renal pelvis
– renal tubules
– interstitial tissue
• Potentially organ- and/or
life-threatening infection
 some scarring of the
kidney and may lead to
significant damage to the
kidney
 Complicated UTI Etiology (%)
• Escherichia coli 21 – 54
• Klebsiella pneumoniae 1.9 – 17
• Enterobacter species 1.9 – 9.6
• Citrobacter species 4.7 – 6.1
• Proteus mirabilis 0.9 – 9.6
• Providencia species 18
• Pseudomonas aeruginosa 2 – 19
• Enterococci species 6.1 – 23
 Etiology
• Usually seen in association with:
– Pregnancy
– diabetes mellitus
– Polycystic
– hypertensive kidney disease
– insult to the urinary tract from
catheterization, infection, obstruction or
trauma
 Pathophysiology and aetiology

• Infection usually ascends from the

urethra most bacterial causes bowel
organisms eg Ecoli (70-80%)
• Hospital-acquired infections may be
due to coliforms and enterococci.
• Haematogenous spread is rare eg Staph
aureus
• Frequently due to ureterovesical reflux
 Pathogenesis
• Rectal and/or vaginal
reservoirs
• Colonization of perianal area
• Bacterial migration to
perivaginal area
• Bacteria ascend through
urethra to bladder
• Intercourse may contribute
urethral colonization
and ascending infection

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• Pyelonephritis may be acute or chronic
• Kidneys enlarge
• Interstitial infiltration of inflammatory
cells
• Abscesses on the capsule and at
corticomedullary junction
• Result in destruction of tubules and the
glomeruli
• When chronic, kidneys become scarred,
contracted and nonfunctioning
 Acute pyelonephritis
Symptoms develop rapidly In addition symptoms of
(<24 hours) lower tract involvement
• Acutely ill • Dysuria
• Chills • Frequency
• Fever >38°C
• Flank pain and
• Nausea/vomiting
• Renal angle tenderness
• Confusion in elderly
• Leukocytosis
• Pyuria
• Bacteriuria
Costovertebral Angle (CVA)
 Risk factors
• vesicoureteral reflux (VUR) especially in
young children,
• calculi
• urinary tract catheterisation
• nephrostomy
• pregnancy
• neurogenic bladder (e.g. due to spinal cord
damage, spina bifida or multiple sclerosis) and
• prostate disease (e.g. benign prostatic
hyperplasia) in men
• bladder tumours
• urethral strictures
• diabetes mellitus, immunocompromised
states
 Diagnosis
• Is not always straightforward
• A number of studies using immunochemical
markers have shown that many women, who
initially present with lower tract symptoms,
actually have pyelonephritis
• The extremes of age, the presentation may be
so atypical (feeding difficulty or fever)
• In the elderly presentation may be mental
status change or fever

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 Laboratory Diagnosis of
pyelonephritis
Urinalysis
• 10 WBC/hpf is the usual upper limit of normal
• Positive result on leukocyte esterase dipstick
test correlates well for detecting >10 WBC/hpf,
with a specificity of 65%–95%, and sensitivity of
75%–95%
• Positive nitrate reduction test dipstick test result
for bacteriuria is only moderately reliable; false-
negative results are common
Urine culture and sensitivity
Blood culture
BUN and Creatine levels of the blood and urine may
be used to monitor kidney function
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 Radiological investigations
• CT scan
• IVP(intra venous
pyelogram)  the
presence of obstruction
or degenerative
changes caused by the
infection process
• Radionucleotide
imaging with gallium
citrate and indium-111-
labeled WBCs
Medical Management
• Treated as outpatients if there is no nausea,
vomiting or dehydration and other signs and
symptoms of sepsis
• Very ill patients and all pregnant women are
hospitalized at least for 2 to 3 days for
parenteral therapy
• 2 weeks course
• Bactrim [trimethoprim /sulpha
• Ciprofloxacin
• Gentamicin with or without amoxicillin

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Problem
• Chronic or recurring symptomless
infection persisting for months or years
• Another 6 weeks course if relapse
• Follow up urine culture 2 weeks after
completion of therapy

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 Chronic Pyelonephritis
Repeated bouts of acute pyelonephritis may
lead to chronic pyelonephritis

Clinical manifestations
• No symptoms of infection unless an acute
exacerbation occurs
• Fatigue, head ache. poor appetite
• Polyuria. excessive thirst
• Weight loss
• elevated BP
• Vomiting, diarrhea

Progressive scarring  renal failure

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Assessment and diagnostic findings
• IVP
• Serum creatinine
• Blood urea
• Culture and sensitivity

Complications
ESRD=end stage renal disease
Hypertension
Kidney stones

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 Management

• Fluid balance – I / O chart

• Fluids encouraged unless contraindicated
• Antibiotics  C&S result
• Drugs carefully titrated if renal function is
impaired
• Bed rest
• Teach how to prevent recurrent infections :
adequate fluids, emptying the bladder
regularly and performing recommended
perineal hygiene taking antibiotics as
prescribed
 Treatment of Pyelonephritis
• Eradicate pathogens in kidney and urothelium,
and treat/prevent bacteremia
Hospitalized patients:
• IV antibiotic first 48–72 hours followed by 7 days of oral
antibiotic therapy
– Fluoroquinolone IV, then PO
– Aminoglycoside ± ampicillin IV, then TMP/SMX PO
– Third-generation cephalosporin IV, then TMP/SMX PO
Ambulatory patients: 7–14 days of PO therapy with :
• Fluoroquinolone
• TMP/SMX, if uropathogen is known to be susceptible
• If Gram-positive pathogen: amoxicillin or amoxicillin-
clavulanate
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Scarred and contorted kidneys

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Destruction of approximately 70% of the kidney. Numerous dilated calyces with
yellow-brown calculi. The central necrotic areas are surrounded by dense fibrosis.

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• Buku IPD PAPDI edisi VI 2014 bab ISK
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