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Definitions:
Pyuria leukocytes in urine, can be infections but can also be non-inflammatory
Sterile pyruria leukocytes in urine without growth or culture
Bacteriurea bacteria in urine
o Asymptomatic bacteriuria: patient without symptoms of UTI
o Significant bacteriurea: >105 bacteria/ml of urine (+/- symptoms)
Uncomplicated UTI an UTI in a structurally and functionally normal urinary tract
Complicated UTI an UTI in a structurally or functionally abnormal urinary tract
o Some argue any UTI in men, children or pregnant women is complicated, as are those caused by urinary
catheters or urinary tract stones
Mainly caused by bacteria art of endogenous gut flora
Pathogenesis:
Renal tract above level of urethra is normally sterile
Ascending route (most common) bladder infection first reflux
kidney infection
Haematogenous spread (rare) not really UTI but Staph bacteremia
infection that has spread to kidney
Most are caused by endogenous bacteria rather than acquired bacteria
or fomites
Causative organisms:
Gram negative bacteria Gram positive bacteria less common in UTI
Escherichia coli (E. coli) (main) Staphylococcus spp.
Other Enterobacteriaceae (gut bacteria) o S. saprophyticus (affects healthy, young
o Klebsiella spp. women)
o Proteus spp. o S. aureus (rare, involved via
o Serratia, Citrobacter, Enterobacter, haematogenous route)
Morganella Enterococcus spp.
Pseudomonas aeruginosa (opportunistic Group B Streptococcus
pathogen common in catheterisation, once
colonises can cause infection, but doesnt tend to
cause infection in community)
Uropathogenic E. coli
Complication of UTI:
Septicemia
Perinephric abscess
Renal scarring
Renal failure
Premature labour
Low birth weight
Rejection of renal transplant
Diagnosis
Diagnosis: specimens
Adults
o Mid stream urine
o * first catch urine for STI because there are vestidious and present in low numbers
Children
o Clean catch urine
o Urine collection bag high change of contamination
Catheter specimen
o In-out catheter if catheter difficult, use this technique introduce into bladder then immediately
take out when sample collected
o Indwelling catheter if long standing, can cause UTI
o *If worried about catheter infection, get a fresh one and take new sample
Suprapubic aspirate straight into bladder
Ureteric aspirate into ureter
Nephrostomy urine into renal pelvis, can be left for weeks
Urine is usually sterile BUT must be collected properly to avoid contamination by urethral and genital flora
o Early morning specimens are best (concentration overnight)
o Midstream urine:
Retract foreskin/labia discard first 30ml urine take next 30ml into sterile container
S4 C7
o Transport ASAP culture within 2hrs of collection
o Can refrigerate specimen if delay > 2hrs
No UTI
S4 C7
leuk: infection/inflammation
RBC: bleeding
Normal epithelial cells, unlikely
contamination
E.coli growth
=UTI
Leuk:
RBC:
Unlikely contaminiation (normal
epithelial)
Klebsiella pneumoniae growth
= UTI
Slightly Leuk
RBC, epithelials
Sterile pyuria:
Prior antibiotic therapy
Foreign body, e.g. catheter, stone
Recent surgery
Glomerulonephritis
S4 C7
Vaginal discharge
Urethral syndrome
STI, esp. gonorrhoea
Renal tract tuberculosis
Fastidious organisms organism that will only grow when specific nutritional components are available in its diet
(uncommon)
Management of UTI:
1. Uncomplicated cystitis
a. Non-pregnant women
i. Empiric short course (3-5days) of oral antibiotics
1. Cephalexin
2. Trimethoprim
3. Amoxicillin + clavulanic acid
4. Nitrofurantoin
ii. Cultures not mandatory in this group, unless:
1. Recurrent UTI, recent antibiotics, recent international travel due to increased risk of
multi-resistant organisms
b. *If cystitis is suspected in the following groups (men, pregnant women, aged care facility residents,
children) always obtain culture prior to treatment + consider ultrasound
c. Pregnant women
i. While awaiting results, empirical antibiotics (as above) 5 day course
ii. Would not use Trimethoprim targets folate, affect baby
d. Men same empirical agents as above, but 7 day course
2. Acute pyelonephritis
a. Always obtain urine culture (and blood culture in hospitalized patients) prior to antibiotics
b. Mild infection oral antibiotics for 10-14 days
i. Empirical agents as above, N/B: Nitrofurantoin is only used in uncomplicated cystitis
c. Severe infection initial IV therapy
i. Consider imaging to rule out structural abnormality
ii. Ampicillin and Gentamicin; IV
iii. Switch to oral antibiotics (as above) ASAP
iv. 10-14 days in total
3. Recurrent UTI
a. Only investigate and treat if symptoms of UTI present
b. If symptomatic, always culture before antibiotics
c. Investigate for structural or functional abnormality
i. Ultrasound renal tract
ii. Prophylactic antibiotics in very rare circumstances
iii. Stand-by therapy
4. UTI in children
a. May be associated with mechanical abnormality VUR found in 30-50%
b. Need early diagnosis + prompt treatment
c. Always culture before antibiotics
d. Imaging infants, all children with severe/recurrent UTI
i. If required, ultrasound is first line
ii. If USS is normal, no further imaging needed
iii. If USS suggest VUR micturition cystourethrogram
5. Asymptomatic bacteriuria (ABU)
a. Defined as bacterial concentration >108 cfu/L without symptoms of UTI
b. Screening/treatment for ABU not recommended, except for:
i. Pregnant women risk of adverse pregnancy outcomes if bacteriuria progresses to
pyelonephritis
ii. Patients undergoing elective urological procedures
c. For other patient groups, there is no evidence that screening/treatment of ABU has benefit
d. Inappropriate treatment also has risks medication side effects + antimicrobial resistance
Summary:
S4 C7
Diagnosis of UTI is based on the presence of symptoms
Bacteriuria in properly collected urine, usually associated with pyuria, confirms the diagnosis
Treatment choice depends on the UTI syndrome and patient demographics i.e. Pregnant, male, child
Asymptomatic bacteriuria occurs frequently in elderly people and those with urinary catheters
Screening for, or treatment of, ABU is not recommended except in specific circumstances
o Pregnancy
o Prior to elective urological procedures