Urinary tract infection:
By
Eltahir Ahmed
MD, MD, [Link]
Urologist
Objectives:
• By the end of this lecture students should be able to:
I. Define UTI
II. Clinicopathology of UTI
III. Management of UTI
Definitions and epidemiology
Urinary tract infection (UTI):
• UTI is currently defined as the inflammatory response of
the urothelium to bacterial invasion.
• This inflammatory response causes a constellation of
symptoms.
Definitions
• Bacteriuria: is the presence of bacteria in the urine.
• Bacteriuria may be asymptomatic or symptomatic.
• Bacteriuria without pyuria indicates the presence of bacterial
colonization of the urine rather than the presence of active
infection.
Con. Definition
• Pyuria: is the presence of white blood cells in the urine (implying
an inflammatory response of the urothelium to bacterial infection
or in the absence of bacteriuria (sterile pyuria), some other
pathology such as carcinoma in situ, TB infection, bladder stones.
uncomplicated UTI
• An uncomplicated UTI: is one occurring in a patient with a
structurally and functionally normal urinary tract. The majority
of such patients are women who respond quickly to a short course
of antibiotics.
• A complicated UTI: is one occurring in the presence of an
underlying anatomical or functional abnormality (e.g. incomplete
bladder emptying secondary to BOO or DSD in Spinal Cord
Injuries), renal or bladder stones, colovesical fistula, etc.
• UTIs may be isolated, recurrent, or unresolved.
• Isolated UTI: an interval of at least 6 months between infections.
• Recurrent UTI: >2 infections in 6 months or 3 within 12 months. Recurrent UTI may be due
to re-infection (i.e. infection by different bacteria) or bacterial persistence (infection by the
same organism originating from a focus within the urinary tract).
Bacterial persistence is caused by the presence of bacteria within calculi (e.g. struvite stone),
within a chronically infected prostate (chronic bacterial prostatitis), within an obstructed or
atrophic infected kidney, or occurs as a result of a bladder fistula (with bowel or vagina) or
UD.
•
General risk factors for bacteriuria
• Female sex.
• Increasing age.
• Low Oestrogen states (menopause).
• Pregnancy.
• Diabetes mellitus.
• Previous UTI.
• Institutionalized elderly patients.
• Indwelling catheters.
• Stone disease (kidney, bladder, ureter).
• Genitourinary tract malformation.
• Voiding dysfunction (including obstruction)
Urinary tract infection: Microbiology
• Most UTIs are caused by fecal-derived bacteria that are
facultative anaerobes (i.e., they can grow under both anaerobic
and non-anaerobic conditions).
Urinary tract infection: microbiology
• Uncomplicated UTI:
• Infection in a subject with a normal functional and anatomical
urinary tract. Most UTIs are bacterial in origin. The most common
cause is Escherichia coli (E. coli), a Gram-negative bacillus, which
accounts for 85% of community acquired and 50% of hospital-
acquired infections. Other common causative organisms include
Staphylococcus saprophyticus, Proteus mirabilis, and Klebsiella.
• Complicated UTI
• Infection in a subject with a functional or anatomical abnormality
of the urinary tract, underlying risk factors, or failure to respond
to therapy. E. coli is responsible for up to 50% of cases. Other
causes include Enterococci, Staphylococci, Pseudomonas, Proteus,
Klebsiella, and other enterobacteria.
Factors increasing bacterial virulence
Adhesion mechanisms:
Many Gram-negative bacteria have pili (also known as
fimbriae) on their cell surface, which aid attachment to
urothelial cells of the host. A typical piliated cell may contain
100–400 pili. Pili are 5–10nm in diameter and up to 2μm long.
E. coli produces a number of antigenically and functionally
different types of pili on the same cell; other strains may
produce only a single type and in some isolates, no pili are
seen.
Pili are defined functionally by their ability to mediate
hemagglutination (clumping of red blood cells) of specific
types of erythrocytes. Mannose-sensitive (type 1) pili are
produced by all strains of E. coli and are associated with
cystitis.
Certain pathogenic types of E. coli also produce mannose-
resistant P pili and are associated with pyelonephritis.
S pili are associated with infection of both the bladder and
kidneys.
•Avoidance of host defense mechanisms
-General: an extracellular capsule reduces immunogenicity
and resists phagocytosis (E. coli). M. tuberculosis resists
phagocytosis by preventing phagolysosome fusion.
-Toxins: E. coli species have hemolysin activity which has a
direct pathogenic effect on host erythrocytes.
-Enzyme production: Proteus species produce ureases which
cause the breakdown of urea in urine to ammonia, which
then contributes to disease processes (struvite stone
formation).
•Antimicrobial resistance
-Enzyme inactivation: S. aureus, N. gonorrhoeae, and
enterobacteria can produce B-lactamase which hydrolyzes
the B-lactam bond within the structure of some antibiotics so
inactivating them. The B-lactam antibiotics are penicillins,
cephalosporins, and carbapenems.
-Altered permeability: access of the antibiotic to the bacteria
is prevented by alterations in receptor activity or transport
mechanisms.
-Alteration of binding site: genetic variations may alter the
antibiotic target, leading to drug resistance.
• Host defenses: factors that protect against UTI include the
following.
• General:
• Commensal flora: protect by competing for nutrients, bacteriocin
production, stimulation of immune system, and altering pH.
• Bladder surface mucin: glycosaminoglycan (GAG) layer is an
anti-adherent factor, preventing bacterial attachment to mucosa.
• Low urine pH and high osmolarity reduces bacterial growth.
• Female commensal flora: Lactobacillus acidophilus metabolizes
glycogen into lactic acid, causing a drop in pH.
• Increased rates of bladder mucosal cell exfoliation are seen during
infection, which accelerates cell removal with adherent bacteria.
UTI
UTI
May also be classified as
1. Isolated UTI
a single episode of lower tract infection occurs frequently in females and is
rarely complicated.
2. Recurrent UTI
is >2 infections in 6 months, or 3 within 12 months.
27
Lower urinary tract infection: cystitis and investigation of UTI
• Cystitis: is infection and/or inflammation of the bladder.
• Presentation: frequent voiding of small volumes, dysuria, urgency,
offensive urine, suprapubic pain, haematuria, fever and
incontinence.
INVESTIGATIONS
• Urinalysis :
• WBCs in the urine &
haematuria may be present.
• Urine culture is required to
confirm the diagnosis & identify
the causative organism.
• However, when the clinical
picture & urinalysis are
suggestive of the Dx of acute
cystitis, urine culture may not be
needed.
• 29
RADIOGRAPHIC IMAGING
• In uncomplicated infection of the bladder, radiologic evaluation is
often not necessary.
• recurrent UTI, Fever, UTI in children
• U\S
• VCUG
30
Treatment
• Management for acute cystitis consists of a
short course of oral antibiotics.
• TMP SMX
• Nitrofurantoin
• Quinolones
Short oral course 3-5 d ♀
Days for ♂ & child 7 d
31
Honeymoon Cystitis
• Is the term for a UTI that often occurs after sexual
activity. Sexual activity can push infecting bacteria
into the urethra resulting in an infection.
32
Schistosomiasis (bilharziasis)
• Urinary schistosomiasis is caused by the Schistoma haematobium.
It is endemic in Iraq, Egypt, and the Middle East.
• Fresh water bulinus snails release the infective form of the
parasite (cercariae), which can penetrate skin, and migrate to the
liver (as schistosomules), where they mature.
33
• Adult flukes couple, migrate to vesical veins, and
lay eggs , which leave the body by penetrating the
bladder and entering the urine.
The disease has two stages:
• active (when adult worms are
actively laying eggs)
• inactive (when the adult has died, and there is a
reaction to the remaining eggs). The development
of squamous cell carcinoma of the bladder is result
of the chronic inflammation.
34
Clinical features
Swimmer’s itch.
• Active inflammation results in hematuria, frequency, and terminal
dysuria.
35
Investigations
Urinalysis
Early morning urine specimen, to see ova with
terminal spine.
• Serology tests (ELISA).
IVP
may show a calcified, contracted bladder, and obstructive
uropathy.
• Cystoscopy identifies eggs in the trigone (“sandy
patches”).
36
KUB
37
Contracted bladder
38
Sandy patches: calcified dead ova with
degeneration of overlying
epithelium.
Carcinoma is common end result in
bilharziasis. Squamous celled C.A
(due to metaplasia)
39
Complication
Chronic infection can lead to obstructive uropathy,
ureteric stenosis, renal failure, and bladder contraction.
The most significant and concerning complication is the
development of squamous cell carcinoma of the
bladder that often presents at an advanced stage .
40
PYELONIPHRITIS
• Definition: pyelonephritis is an inflammation of the kidney and
renal pelvis.
• Presentation:
• Clinical diagnosis is based on the presence of fever, flank pain,
bacteriuria, pyuria, often with an elevated white cell count.
Nausea and vomiting are common.
INVESTIGATIONS AND MANAGEMENT
• For those patients who have a fever, but are not systemically
unwell, outpatient management is reasonable. Culture the
urine and start oral antibiotics according to your local
antibiotic policy (which will be based on the likely infecting
organisms and their likely antibiotic sensitivity
• EAU guidelines give several suggestions, including
1
fluoroquinolones (i.e. oral ciprofloxacin, 500 mg bd) for 7–10
days. Aminopenicillin with B-lactamase inhibitor (i.e. co-
amoxiclav) is an alternative
