9/25/23

DEFINITION
• is the microbial invasion
of any tissue of the
URINARY TRACT INFECTION urinary tract, extending
from the urethral
meatus to the renal
cortex

1 2

Urinary Tract Infection Urinary Tract Infection

• According to anatomic site • According to Degree:
of involvement:
Ø Upper urinary tract • 1. Uncomplicated: occur in individuals who
Infections: lack structural or functional abnormalities in
– Pyelonephritis the Urinary Tract that interfere with the
Ø Lower urinary tract normal flow of urine
infections
– Cystitis (“traditional” UTI) • Mostly it is community acquired infections
– Urethritis (often sexually- • Mostly occur in healthy females of
transmitted)
– Prostatitis childbearing age

3 4

Urinary Tract Infection Urinary Tract Infection

• 2. Complicated : predisposing lesion of the • 3. Recurrent UTI
Urinary Tract such as congenital abnormality, • Multiple symptomatic infections with
or distortion of the Urinary tract, a stone, a asymptomatic periods
catheter, prostatic hyperthrophy, obstruction, üReinfection: Caused by different organism than
or neurological deficit, pregnancy, DM originally isolated and account for majority of
recurrent UTIs.
• All can interfere with the normal flow of urine
and urinary tract defenses üRelapse: repeated infections with the same
initial organism and usually indicate a
persistent infectious source

5 6

1
 9/25/23

Symptoms of Urinary Tract Infection

Findings on Exam in UTI
• Dysuria • Physical Exam:
– CVA tenderness
• Increased frequency (pyelonephritis)
– Urethral discharge (urethritis)
• Hematuria – Tender prostate on DRE
(prostatitis)
• Fever
• Labs: Urinalysis
• Nausea/Vomiting (pyelonephritis) – + leukocyte esterase
– + nitrites
• Flank pain (pyelonephritis) • More likely gram-negative rods
– + WBCs
– + RBCs

7 8

Lower Urinary Tract Infection -

Culture in UTI Bladder Cystitis
• Positive Urine Culture = >105 CFU/mL • Uncomplicated (Simple) cystitis
• Most common pathogen for cystitis, – Is an infection of the bladder. Most
prostatitis, pyelonephritis: common form of bacterial UTI
– Escherichia coli
– Staphylococcus saprophyticus – In healthy woman, with no signs of
– Proteus mirabilis systemic disease
– Klebsiella • Complicated cystitis
– Enterococcus
– In men, or woman with comorbid
• Most common pathogen for urethritis medical problems.
• Chlamydia trachomatis
• Neisseria Gonorrhea • Recurrent cystitis

9 10

Uncomplicated (simple) Cystitis Uncomplicated (simple) Cystitis

• Definition • Treatment
– Healthy adult woman (over age 12) – Trimethroprim/Sulfamethoxazole for 3
– Non-pregnant days
– No fever, nausea, vomiting, flank pain – May use fluoroquinolone (ciprofoxacin
or levofloxacin) in patient with sulfa
• Diagnosis allergy, areas with high rates of
– Dipstick urinalysis (no culture or lab bactrim-resistance
tests needed) • Risk factors:
– Sexual intercourse
• May recommend post-coital voiding or
prophylactic antibiotic use.

11 12

2
 9/25/23

Complicated Cystitis Special cases of Complicated cystitis

• Definition • Indwelling foley catheter

– Females with comorbid medical conditions – Try to get rid of foley if possible!
– All male patients – Only treat patient when
– Indwelling foley catheters symptomatic (fever, dysuria)
– Urosepsis/hospitalization • WBCs in urinalysis
• Diagnosis • Patient’s with indwelling catheters are
– Urinalysis, Urine culture frequently colonized with great
numbers of bacteria.
– Further labs, if appropriate.
• Treatment – Should change foley before
– Fluoroquinolone (or other broad spectrum antibiotic)
obtaining culture, if possible
– 7-14 days of treatment (depending on severity)
– May treat even longer (2-4 weeks) in males with UTI

13 14

Recurrent Cystitis
• Candiduria • Want to make sure urine culture and
– Frequently occurs in patients with indwelling sensitivity obtained.
foley.
– If grows in urine, try to get rid of foley! • May consider urologic work-up to
– Treat only if symptomatic. evaluate for anatomical abnormality.
– If need to treat, give fluconazole • Treat for 7-14 days.
(amphotericin if resistance)

15 16

Prostatitis Prostatitis
• Symptoms: • Treatment:
– Pain in the perineum, lower abdomen, testicles, penis, and with – Trimethoprim/sulfamethoxazole, fluroquinolone or
ejaculation, bladder irritation, bladder outlet obstruction, and
sometimes blood in the semen other broad spectrum antibiotic
• Diagnosis: – 4-6 weeks of treatment
– Typical clinical history (fevers, chills, dysuria, malaise, myalgias, • Risk Factors:
pelvic/perineal pain, cloudy urine)
– Trauma
– The finding of an edematous and tender prostate on physical
examination – Dehydration
– Will have an increased PSA
– Urinalysis, urine culture

17 18

3
 9/25/23

Urethritis Urethritis
• Chlamydia trachomatis
• Neisseria gonorrhoeae
– Frequently asymptomatic in females, but can – May present with dysuria, discharge, PID
present with dysuria, discharge or pelvic
inflammatory disease. – Send UA, urine culture
– Send UA, urine culture (if pyuria seen, but no – Pelvic exam – send discharge samples for gram stain,
culture
bacteria, suspect Chlamydia) – Treatment:
– Pelvic exam – send discharge from cervical or • Ceftriaxone – 125 mg IM x 1
urethral os for Chlamydia PCR • Cipro – 500 mg po x 1
– Chlamydia screening is now recommended for • Levofloxacin – 250 mg po x 1
all females ≤ 25 years • Ofloxacin – 400 mg po x 1
– Treatment: • Spectinomycin – 2 g IM x 1
• Azithromycin – 1 g po x 1 – You should always also treat for chlamydia when
• Doxycycline – 100 mg po BID x 7 days treating for gonorrhea!

19 20

• Bacterial infection of the

structures of the kidney:
– the renal pelvis
– renal tubules
– interstitial tissue
• Potentially organ- and/or
life-threatening infection
PYELONEPHRITIS à some scarring of the
kidney and may lead to
significant damage to the
kidney

21 22

Complicated UTI Etiology (%) Etiology

• Escherichia coli 21 – 54 • Usually seen in association with:
• Klebsiella pneumoniae 1.9 – 17 – Pregnancy
• Enterobacter species 1.9 – 9.6
– diabetes mellitus
• Citrobacter species 4.7 – 6.1
– Polycystic
• Proteus mirabilis 0.9 – 9.6
– hypertensive kidney disease
• Providencia species 18
– insult to the urinary tract from
• Pseudomonas aeruginosa 2 – 19 catheterization, infection, obstruction or
• Enterococci species 6.1 – 23 trauma

23 24

4
 9/25/23

Pathophysiology and aetiology Pathogenesis

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

26

25 26

Acute pyelonephritis
• Pyelonephritis may be acute or chronic Symptoms develop rapidly In addition symptoms of
(<24 hours) lower tract involvement
• Kidneys enlarge • Acutely ill • Dysuria
• Interstitial infiltration of inflammatory • Chills • Frequency
cells • Fever >38°C
• Flank pain and
• Abscesses on the capsule and at
• Nausea/vomiting
corticomedullary junction • Renal angle tenderness
• Result in destruction of tubules and the • Confusion in elderly
glomeruli • Leukocytosis
• When chronic, kidneys become scarred, • Pyuria
contracted and nonfunctioning • Bacteriuria

27 28

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

29 30

5
 9/25/23

Diagnosis
• prostate disease (e.g. benign prostatic • Is not always straightforward
hyperplasia) in men • A number of studies using immunochemical
• bladder tumours markers have shown that many women, who
• urethral strictures initially present with lower tract symptoms,
actually have pyelonephritis
• diabetes mellitus, immunocompromised
states • 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

32

31 32

Laboratory Diagnosis of
Radiological investigations
pyelonephritis
Urinalysis • CT scan
• 10 WBC/hpf is the usual upper limit of normal
• IVP(intra venous
• Positive result on leukocyte esterase dipstick
test correlates well for detecting >10 WBC/hpf, pyelogram) à the
with a specificity of 65%–95%, and sensitivity of presence of obstruction
75%–95% or degenerative
• Positive nitrate reduction test dipstick test result changes caused by the
for bacteriuria is only moderately reliable; false- infection process
negative results are common
Urine culture and sensitivity • Radionucleotide
Blood culture imaging with gallium
BUN and Creatine levels of the blood and urine may citrate and indium-111-
be used to monitor kidney function labeled WBCs
33

33 34

Medical Management Problem

• Treated as outpatients if there is no nausea,
• Chronic or recurring symptomless
vomiting or dehydration and other signs and
symptoms of sepsis infection persisting for months or years
• Very ill patients and all pregnant women are • Another 6 weeks course if relapse
hospitalized at least for 2 to 3 days for
• Follow up urine culture 2 weeks after
parenteral therapy
• 2 weeks course completion of therapy
• Bactrim [trimethoprim /sulpha
• Ciprofloxacin
• Gentamicin with or without amoxicillin

35 36

35 36

6
 9/25/23

Chronic Pyelonephritis Assessment and diagnostic findings

Repeated bouts of acute pyelonephritis may • IVP
lead to chronic pyelonephritis • Serum creatinine
Clinical manifestations • Blood urea
• No symptoms of infection unless an acute • Culture and sensitivity
exacerbation occurs
• Fatigue, head ache. poor appetite
• Polyuria. excessive thirst Complications
• Weight loss
ESRD=end stage renal disease
• elevated BP
Hypertension
• Vomiting, diarrhea
Kidney stones
Progressive scarring à renal failure
37 38

37 38

Management Treatment of Pyelonephritis

• Eradicate pathogens in kidney and urothelium,
• Fluid balance – I / O chart and treat/prevent bacteremia
• Fluids encouraged unless contraindicated Hospitalized patients:
• Antibiotics à C&S result • IV antibiotic first 48–72 hours followed by 7 days of oral
antibiotic therapy
• Drugs carefully titrated if renal function is – Fluoroquinolone IV, then PO
impaired
– Aminoglycoside ± ampicillin IV, then Trimethoprim (TMP)/
• Bed rest Sulfamethazole (SMX) PO
• Teach how to prevent recurrent infections : – Third-generation cephalosporin IV, then TMP/SMX PO
adequate fluids, emptying the bladder Ambulatory patients: 7–14 days of PO therapy with :
regularly and performing recommended • Fluoroquinolone
perineal hygiene taking antibiotics as
• TMP/SMX, if uropathogen is known to be susceptible
prescribed
• If Gram-positive pathogen: amoxicillin or amoxicillin-
clavulanate
40

39 40

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

41 42

41 42