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Urinary Tract Infections



Sherwood Fig. 12-6a, p.530

Renal

vein

(a)

Ureter

Aorta

idne!

Renalarter!

Urethra

Urinar!

"ladder

#n$erior

vena %ava



Figure 26.1

An introduction to the UrinarySystem



Getting Clear on the Terminology

UTI

Asymptomatic

Bacteriuria

Symptomatic

UTI

Cystitis

Urosepsis

Asymptomatic

UTI

Pylonephritis

Pyuria



5

#n$e%tion#n$e%tion

Infection is defined as the entry and

multiplication of microorganism(s) in the

tissues of the host that produces injuriouseffects.



6

&!'titi'&!'titi'

Infection of the urinary tract limited to the

bladder usually in!ol!ing only the mucosal

surface " Most common type of UTI in the long-term care

setting



#

!elonephriti'!elonephriti'

Infection of the $idney usually resulting from

tra!el of the infection from the bladder to the

ureter and then to the $idney.(ascending)



%

Uro'ep'i'Uro'ep'i'

&epsis occurs 'hen bacteria ha!e entered the

bloodstream and lead to a 'idespread

(systemic) inflammatory response.rosepsis means the infection has stemmed

from an infection of the urinary tract



A'!ptoati% *a%teri+riaA'!ptoati% *a%teri+ria

*he presence of bacteria in the urine of a

person 'ithout symptoms of infection.

" Should not be called a UTI " Should not be treated with antibiotics



1+

!+ria!+ria

*he presence of 'hite blood cells in the urine.

" The body’s reaction to inasion by bacteria!

" "ne of the #ey differentiating points betweenUTI and assymptomatic bacteriuria



Getting Clear on the Terminology

Polla#isuria

Polla#isuria$dysuria

syndrome

Anuria

%ysuria

Polyuria

"liguria

Cylindruria

&ematuria



◙ The risk of uti in women 10x men.

Why?

the shorter distance between anus and

meatus urethrae externum.

◙ amost haf of a woen wi ha!e at east

one UTI in their i!es.◙ the risk of UTI in women increases after

meno"ause

U.T.I.



◙ after a UTI #0 $ %0 & wi ha!e a recurrence

◙ the recurring infections are usuay

re$infections.◙ asym"tomatic 'acteriuria in women occurs in

#.& of 1 $ #% year ods

*.+& of o!er , year ods and

#0 $ 0& of o!er -0 year ods

U.T.I.



UTI is rare in young and middle-aged men UTI in men is often associated with catheterisation

or urological procedures.

bacteriuria in elderly men occurs in

/ about 10% of those living at home, / about 0% of those living in nursing homes and

/ !0% of those who are in-patients in hospitals

urinary catheter increases the ris" almost ten-foldin hospitalised patients and those in other carehomes.

pyelonephritis is common in patients who havebeen catheterised for over a month.

RA/&



Urinary tract infection occurs when bacteriawhich colonise the anal area ascend throughurethra to the bladder

Risk factors include

/ reduced resistance oered by the mucousmembranes (e.g. after menopause

/ se!ual intercourse

/ disturbances in ureteral functioning

/ in children the re"entering of urine back into theureters (#esicoureteral re$u!% &hich predisposesthem particularly to upper UT's

athogenesis



athogenesis

#ther ris" factors$

benign prostatic hypertrophy

any illness% such as diabetes% &hich aectsthe emptying of the bladder

spinal in)ury (associated &ith disturbancesin bladder emptying or urinary catheter

catheterisation in hospital or residentialcare

other urological procedures



&a+'ative agent' o$ U#'

Escherichia coli / most common

/ about *+, of primary care infections

/ about -+, of hospital"acuired infections

/thers0

/ enterococci

/ Staphylococcus saprophyticus and

/ klebsiellas / #arious types of pseudomonas and proteus

are more rare



&opli%ated or +n%opli%ated

Uncomplicated& urinary tract infections are

/ occasional lower urinary tract infections inwomen &ith no predisposing factors to infections

'omplicated& infections are all other UTIs including lo&er UT's in

/ pregnant &omen

/ men

/ children / and catheter"induced infections

/ The in#estigations and treatment of these entailspecial features



S!pto' o$ U#' 1

'ystitis$

typical symptoms include freuency and burningsensation &hen passing urine.

(yelonephritis$

only some patients ha#e di1culties in micturition

temperature (2 3*oC and $ank or back pain

nausea in the elderly or sudden collapse in healthstatus (4o"legs4



Symptoms of UT's 5

incontinence or oensi#e urine in the elderly shouldnot be considered as UT' as such6 e#en though theymay be indicati#e signs of an infection

almost any signs of infection in infants may beindicati#e of a UT' )'*

in a small child a temperature alone% &ithout anyother signs of an infection% should raise a suspicion ofa UT'

UT' in children and the elderly may manifest itself asincontinence or retention.



iagno'i' o$ U#'

+ased on the symptoms both

a clinical diagnosis of a UT' and a dierentiation bet&een lo&er

(cystitis or upper (pyelonephritis UT'

should be made



&olle%ting a 'aple

in adults and older children a mid stream urine(7SU sample usually reliably represents theurine in the bladder.

samples collected from urinary bags orbedpans should not be used to diagnose UT'as they in#ariably &ill be contaminated

the most reliable sample is obtained #ia a

suprapubic puncture urine in bladder 28 hours (any shorter time

&ill increase the risk of false negati#e 9ndings



Clinically signi9cant pathogenconcentrations



iagno'i' o$ U#' 1

o need to do any urinalysis% if afemale patient% &ho does not belong to

any of the risk groups% clearly hasoccasional cystitis based on hersymptoms

Urine microscopy is not usuallynecessary to diagnose cystitis



ym"tomatic"atient

Uncom"icated cystitisin a woman2

no risk factorsnot a rea"se

Ty"ica sym"toms2

3 # infections 4 year2

"atient famiiar withher iness

5acteria cuture26on the s"ot6 testingto confirm diagnosis

tarttreatment'ased onresuts

7nti'ioticthera"y

4e'

/o

/o

4e'

8iagnosis agorithm



iagno'i' o$ U#' 2

+acterial culture of urine should be carried out in allcases, ecept in uncomplicated cystitis, e#en thoughthe results &ill not be a#ailable &hen medication iscommenced )+*

'n early pregnancy bacterial culture should be carried out inall pregnant women if only to diagnose asymptomaticbacteriuria )/*

'n adult febrile infections &ith generalised symptoms% and in children&s infections, C"reacti#e protein ('(concentration abo#e 8+ mg:l is suggesti#e of a kidneyinfection )'*



A'!ptoati% "a%teri+ria

esults of urine culture have repeatedlyshown

bacterial growth above 10 bacteria )cfu*2ml

possible pyuria does not aect interpretation

if se#eral bacterial strains are gro&n on culture6contamination of the sample is the likely cause

in#estigations and treatment of asymptomaticbacteriuria should be instigated only in pregnant&omen



Antimicrobial therapy in UT's ;

/cute uncomplicated cystitis$ / patient &ith typical symptoms% not belonging to any of the

risk groups% is treated &ithout laboratory in#estigations

/ if the symptoms are atypical% a strip test urinalysis may becarried out to support diagnosis

/ if the strip test is negati#e% the urine should be culturedand other reasons for the symptoms should be considered

/ 3irst choices$

/ trimethoprim for 3"- days

/ nitrofurantoin for -"< days or

/ pi#mecillinam for -"< or 3 days



Antii%ro"ial therap! in U#' 2

eserve drugs$

4uinolones (nor$o!acin% o$o!acin or cipro$o!acin for 3 days

/ if 9rst choice drugs are not suitable or

/ if the infection has not responded to 9rst choice drugs or

/ recurrent infection &ithin 8 &eeks

/ if there is a relapse% urine must be cultured and thetreatment should be continued for < days

'n special cases0

/ cefalein or cefadroil for - days (if the abo#e arecontraindicated

/ sulphatrimethoprim )567-T6* for 3 days (particularly ifthe le#el of infection is unclear

/ amoicillin for - days (particularly in enterococcalinfections



Single-do'e therap!

single"dose therapy is slightly less eecti#e thancon#entional therapy

eecti#e in infections caused by E. coli % but less soin S. saprophyticus infections

recommended particularly &hen practical reasons&arrant its use (e.g. self"care

=reparations0

/ phosphomycin 3 g

/ nor8oacin *++ mg

/ cipro8oacin -++ " <-+ mg

/ o8oacin 5++ mg as a single dose



reatent o$ p!elonephriti'

Uncomplicated pyelonephritis$

A pyelonephritis patient &ho is not unduly ill can be looked after at home )'*

Treatment &ith either a 8uoro9uinolone or

sulphatrimethoprim orally for 10-1: days

reatment o pye onep r t s



reatment o pye onep r t s5

An un&ell pyelonephritis patient &ith or &ithout hightemperature should be admitted to hospital

in hospital the treatment is commenced &ithcefuro!ime i.#. +.<-";.-g e#ery * hours or &ith an

$uorouinolone orally it is usually possible to change o#er to oral medication&ith 9rst"generation cephalosporins in 5"3 days% &henresponse to treatment is ob#ious

third"generation cephalosporins are usually not

recommended for the treatment of uncomplicatedpyelonephritis% but ceftria!one may be chosen as theinitial therapy% if either once a day or intramuscularadministration are considered bene9cial

aminoglycosides ha#e sho&n no additional bene9tso#er other forms of treatment



reatent d+ring pregnan%!

+acteriuria during pregnancy is associated with

increased ris" of premature labour andpyelonephritis

/ asymptomatic bacteriuria and cystitis are treated inthe same &ay

/ single"dose treatment is not recommended

/ drugs of choice

nitrofurantoin <- mg t&ice daily for - " < days or

beta"lactamase (mecillinam, amoicillin or 9rst"

generation cephalosporins for - > < days.

/ due to foetal risk 8uoro9uinolones should beavoided during the &hole of pregnancy% and 567-

T6 during the latter part of pregnancy



ower U#' in %hildren

treatment principles are the same as for adults

little e#idence to support short term treatment inchildren )'*

drugs of choice

/ nitrofurantoin - mg:kg:day or

/ trimethoprim * mg:kg:day

/ treatment to continue for - days )'*



ro"a"le lower U# with generali'ed

'!pto' in %hildren

treated so that any possible infection of the kidney is alsoco#ered% i.e. &ith antibiotics &ith high tissue penetrability

oral medication acceptable

drugs of choice

/ sulphatrimethoprim (trimethoprim * mg:kg:day / cefalein 3+ " -+ mg:kg:day in 3 di#ided doses

/ cefuroime aetil 5+ mg:kg:day in 5 di#ided doses or

/ mecillinam 5+ " 8+ mg:kg:day in 3 di#ided doses

/ treatment to continue for < days )'*



reatent o$ p!elonephriti' in %hildren

all infants with febrile UTI should be admitted tohospital

drugs of choice

/ cefuroime (;++ mg:kg:day in 3 di#ided doses or

/ ceftriaone (*+ mg:kg:day daily / intra#enous therapy until ob#ious response

/ &hen ob#ious response to treatment is obser#ed%medication is changed o#er to oral until the total

course of treatment% i.e. ;+ days% is completed

follo&"up treatment according to culture and sensiti#ityresults% &ith an antibiotic &ith good tissue penetrability

(e.g. sulphatrimethoprim or a cephalosporin







U#' in en

a UT' in men can be associated &ith either acute orchronic bacterial prostatitis

prostatitis or epididymitis may play a partparticularly in febrile UT'

it is ad#isable to palpate both the prostate andscrotum

chronic bacterial prostatitis% or at least the retentionof bacteria in the prostatic ducts% should besuspected in relapses &ith the same causati#ebacteria



U#' in en 2

/febrile lower urinary tract infection in men$

if the infection is not associated &ith urinary stricture orprostatitis%it is treated &ith the same drugs as cystitis in&omen% but the treatment should continue for ; - 10 days

nitrofurantoin should not be used in men as adeuateprostatic concentrations are not achie#ed )<*

3ebrile urinary tract infection in men is treated &ith

a long course of antibiotics &ith good prostatic and epididymalpenetration

9rst choice0 a 8uoro9uinolone for 5 &eeks



UT's in men 3

UTI in men associated with acute bacterialprostatitis

treatment for 8 " ? &eeks (depending ho& uicklypatient responds to treatment

to be follo&ed up &ith lo& dose prophylais &ithe.g. trimethoprim or nitrofurantoin

'hronic bacterial prostatitis

recurrent UT's and calci9cations in prostate oral 9uinolones for 5 > 3 months )<*

to be follo&ed up &ith prophylactic medication



reatent o$ U# in dia"eti%'

'ystitis in diabetics drugs of choice for initial treatment are same as for

uncomplicated UT'

antibiotic treatment must always be based on the resultsof urine culture

treatment to continue for < days

/cute pyelonephritis in diabetics

treatment is the same as for uncomplicated pyelonephritis

consider urological imaging earlier than normal% if there is noresponse to appropriately chosen medication

the causati#e agents of recurrent UT's in diabetics are oftenunusual% resistant microbes (species of pseudomonas%enterococci and enterobacter and #arious candida species.



roph!lai' o$ re%+rrent %!'titi' with

antii%ro"ial agent'

prophyla!is should be considered &henmore than ! infections per year

prophyla!is to continue for ? months if infections recur after prophylactictreatment% the prophyla!is is re"commenced for ? > ;5 months )<*



r+g' o$ %hoi%e in U# proph!lai'

3irst choice$

trimethoprim ;++ mg in the e#enings nitrofurantoin -+ " <- mg in the e#enings

5econd choice$

methenamine hippurate ; g t&ice daily

nor$o!acin 5++ mg daily or on 3 e#enings per &eek

nitrofurantoin (not if serum creatinine is abo#e ;-+ @mol:l

uinolones (in cases &here there is no response &ith otherprophylactic medication or tolerance to other medications ispoor

<uring pregnancy$

nitrofurantoin -+ mg daily or

methenamine hippurate ; g daily for the rest of the pregnancy

particularly if recurrent bacteriuria is diagnosed in earlypregnancy



edi%ation to "e ta7en a$ter inter%o+r'e

A single"dose prophyla!is taken after intercourse iseecti#e

in &omen &hose UT's are clearly associated &ith se!ual

intercourse )/*

3irst choice$

/ trimethoprim ;++"3++ mg as a single dose

/ nitrofurantoin -+"<- mg as a single dose

5econd choice$ / nor$o!acin 5++ mg% o$o!acin ;++ mg orcipro$o!acin ;++"5-+ mg

/ sulphatrimethoprim (; single"strength tablet

Th i li i i f



The main uality criteria forthe treatment of UT's

urine sample to be collected appropriately &heninfection is suspected

unnecessary culturing of urine samples to be

a#oided the in#estigation and treatment of asymptomatic

bacteriuria to be reser#ed for risk groups

diagnosing structural anomalies of the urinarytract in children

rational use of antibiotics



Antii%ro"ial therap! in a''o%iation with

a +rinar! %atheter 1

the treatment of UTI in a catheterisedpatient should always be based onthe identity and sensitivity of the

causative microbe the catheter should al&ays be remo#ed% at

least for the duration of treatment% asother&ise the bacteria &ill not be

eradicated if this is not feasible% the recommendation

is to continue treatment for < " ;+ dayse#en in lo&er UT's



Antii%ro"ial therap! in a''o%iation

with a +rinar! %atheter 2

In the following patient groups antibiotics can preventserious

infective complications caused by long-termcatheterisation $

after renal transplant (for 3 months granulocytopenic patients and

possibly in diabetics

it is recommended that drugs &hich could be of bene9t inserious infections (beta"lactamases and $uorouinolones are

not used for prophyla!is/ntibiotic prophylais is not recommended$

for repeat catheterisations

for the insertion of long"term catheter

for pyuria and bacteriuria in a patient &ith a long"term

catheter but no ob#ious infection

Antimicrobial therapy in association &ith a



Antimicrobial therapy in association &ith a

urinary catheter 3

3ungal bladder infection in a catheterised patient$

systemic 8ucona=ole is slightly more eecti#e thantopical amphotericin +

remo#al of the catheter &ill impro#e the eradication ofthe microbe during therapy

5uprapubic catheter$

its use is associated &ith a lo&er incidence ofbacteriuria in postoperati#e care

any infections are treated as any other infectionsassociated &ith urinary catheters

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