Q.

URINARY TRACT INFECTIONS

Discuss the aetiopathogenesis, clinical features,
investigations and management of urinary tract
infection.

•UTI may be anatomically subdivided into lower tract

infections (urethritis, prostatitis and cystitis) and upper tract
infections (pyelonephritis and perinephric abscess).
DEFINITION
•UTI is associated with multiplication of organisms in the
urinary tract and is defined by the presence of more than
105 organisms/mL in the midstream sample of urine
(MSU). This is denoted as "significant bacteriuria".
The clinical presentation of UTI may be as follows:
CLINICAL FEATURES
•Asymptomatic bacteriuria:
Presence of bacteriuria (> 105/mL on two occasions in
women and on one occasion in men) indicating UTI but
without symptoms.
Commonly seen in pregnancy.
•Symptomatic:
Aetiology
Acute urethritis, cystitis.
Acute prostatitis.
Acute pyelonephritis.
Septicaemia with septic shock.
•Common microorganisms involved in UTis are
Escherichia coli (80% cases), Proteus, Klebsiella,
Enterobacter,
Pseudomonas, Serratia, Chlamydia trachomatis and
Neisseria gonorrhoeae (sexually transmitted).
•About one-third of females with dysuria and frequency
have either insignificant number of bacteria in midstream
cul-tures or completely sterile cultures. This subset of
patients has been defined as having acute urethral
syndrome. The syndrome is often due to infection with
usual organisms (where culture reveals only 102-104
bacteria) or with unusual organisms (N. gonorrhoeae,
Chlamydia trachomatis).
PATHOPHYSIOLOGY
•Bacteria gain access to the bladder via the urethra in the
vast majority of cases. Ascent of bacteria from the bladder
may then follow, which results in parenchymal infections.
•Females are more prone to the development of cystitis
due to several reasons:
•Short urethra (4 cm).
•Gram-negative enteric organisms residing near the anal
region colonise the periurethral region.
•Absence of bactericidal prostatic secretions.
•Sexual intercourse facilitates entry of introital bacteria into
the bladder.
•Susceptibility factor-i.e. the uroepithelium of these
patients has more surface receptors to which adherent
strains of E. coli become attached.
Clinical Features
•Fever with chills and rigors
•Frequency of micturition
•Dysuria or scalding micturition
•Urgency
•Haematuria
•Suprapubic pain resulting from cystitis
•Strangury results from cystitis. After the bladder has been
emptied there may be an intense desire to pass more urine
due to detrusor spasm
•Urine is cloudy with an unpleasant odour.
INVESTIGATIONS
•Dip stick tests are often used to_ detect nitrite (a
metabolic product of typical pathogens of the urinary tract)
and leuco-
cyte esterase (a marker of inflammation). Presence of
either of them increases the possibility of UTI.
•A freshly voided midstream urine specimen obtained by a
"clean-catch" technique should be examined for leuco-
cytes, leucocyte casts and red cells. Suprapubic aspiration
of bladder avoids a contaminated urine sample but is
rarely
required.
•Gram staining and bacterial colony count.
•Culture and sensitivity.
MANAGEMENT :-
•Fluid intake more than 2 L/day to initiate water diuresis, so
as to maintain a high rate of urine flow.
•If patient has a stone, catheter or other obstructions, no
antibiotics unless symptomatic.
•Regular complete bladder emptying.
•Alkalinisation of urine.
•Urinary analgesics and antispasmodics for detrusor
spasm.
•Antibiotic therapy. The choice of antibiotic depends on the
organism isolated. The commonly employed antibiot-
ics include cotrimoxazole, ampicillin, amoxicillin,
cephalosporins, nitrofurantoin and quinolones.
Aminoglycosides should be useful.