Simple urinary tract Infection

Diagnosis and
Treatment

Salli Roseffi Nasution

1

Uncomplicated Urinary
Tract Infection
There is general agreement
that for the best management of
patients with urinary infection,
it is important to distinguish
between complicated and
uncomplicated infection
2

Uncomplicated Urinary
Tract Infection
UTIs can be classified according to the
site and severity of the infection, such as
complicated or uncomplicated

Uncomplicated Urinary
Tract Infection

It may be simpler to define uncomplicated infection,

as that occurring in young non pregnant women
with ;
No previous urinary or vaginal infection
No family history,
No anatomical or fungtional abnormality of urinary
tract
No associated disease such as diabetes,
analgesic abuse, sickle cell disease or trait, or
AIDS
4

Clasification of complicated and

uncomplicated UTI
Excretion
Urography
Normal

No associated
disease
Cause of misery, No kidney
damage
Uncomplicat
ed

Normal or
abnormal
with
Associated disease
Diabetes
Sickle cell dis
analgesic abuse
NSAID Abuse

Abnorm
al
o Stones
o Obstruction
o
Vesicoureterc
reflux

Risk of kidney damage and

septicaemia
Complicated
5

Recurrent Infection

Relapse
Reinfection

Relapsing Infection
Recurence of bacteria with the same
organism within 3 weeks of
completing tratment, which, during
treatment, rendered the urine strile.
It can only be diagnosed by obtaining
urine sample before, during, and at
between 10 and 21 days after
treatment on recurent symptoms.
7

Reinfection
Eighty percent of recurrent infection
It is defined as eradication of bacteriuria by

appropriate treatment, followed by infection

with different organism after 7 10 days.
Distinction from relapse may then difficult, but
relapsing infection is unlikely if the patient has
remained abacteriuric and without pyuria for
21 days after completing treatment
Reinfection does not represent failure to
eradicate infection from the UTI but is due to
reinvasion of the system.
8

Diagnosis
Definitive diagnosis of urinary tract
infection requires the demonstration of
bladder bacteriuria.
Where it is impossible to obtain uncontaminated samples, or in symptomatic
patients with low ( 10 2 10 3/ml )
bacterial counts, bladder bacteriuria
should be diagnosed by the culture of
urine obtained by suprapubic aspiration.
9

Diagnosis
Clinical Presentation
Symptoms and signs

Dysuria
Urinary frequency
Urgency
Nocturia
Suprapubic discomfort
Mild incontinence
Hematuria

10

Diagnosis

Progression to upper tract infection

Fever
Chills
Malaise
Nausea
Vomiting
Flank pain
11

Diagnosis
Laboratory Diagnosis

The initial laboratory evaluation is often an office

urine kit, a "dipstick."
The presence of nitrites provides the most useful
information.
Bacteria with nitrate reductase must be present
(for example, some E. coli and Proteus)
This test is very specific (92% to 100%) but not too
sensitive (only 25%).
12

Diagnosis
Leukocyte esterase is an enzyme
present in neutrophil granules.
The sensitivity of this test is
directly related to bacterial load
(75% to 96%) and is very specific
(94% to 98%)
13

Diagnosis
Urine microscopy
There are few epithelial cells
Pyuria, >10 WBC per microliter (or 10,000 per
milliliter)
The presence of pyuria is 80% to 95% sensitive
and 50% to 75% specific for an infection
The absence of pyuria strongly suggests a noninfectious
14

Diagnosis

Observing one or more bacteria on a

gram-stained specimen correlates
highly with the presence of a UTI
(sensitivity 80%, specificity 90)

15

Diagnosis
Urine culture
The urine culture is often not necessary in

the treatment of an uncomplicated

infection.
Screening tool if the dipstick and urinalysis
are inconclusive
The traditional interpretation of urine
cultures is that it is positive for an infection
when greater than 105 cfu/mL are present.
16

Diagnosis
A newer interpretation would be to
deem a symptomatic woman with
greater than 102 cfu/mL as positive
(46% of women with symptomatic
UTIs have just 102 to 104 cfu/mL)

17

Asymptomatic bacteriuria
Uncomplicated asymptomatic bacteriuria
Non-pregnant women with normal urinary
tract
Complicated asymptomatic bacteriuria
Pregnant women and patients who have
bacteriuria associated with obstruction,
stones, diabetes mellitus, or other
complicating factor

18

Uncomplicated asymptomatic
bacteriuria

30 % develop symptomatic infection within 1

year
Is believed to be a benign condition which
does not lead to renal damage or
hypertension and only rarely to infected
stone formation.
Treatment, there is no good evidence to
suggest that treatment is required for
uncomplicated asymptomatic bacteriuria in
non-pregnant women
19

Diagnosis
Urine specimen collection
The gold standard for urine
specimen
collection is suprapubic aspiration
Midstream clean catch
Transurethral catheterization
20

Diagnosis

Catheterization itself introduces

bacteria into the bladder, resulting in
false-positive culture and leading to
infection in 1 per cent of patients.

21

Suprapubic aspiration of
urine

Patient must have a full bladder wich can be

percussed, if not percussible, give 300 ml fluid
and 20 mg frusemide orally and wait 1 hour.
With patient supine, choose site in midline 2.5
cm above symphysis pubis. Clean skin with spirit
impregnated sterile gauze.
Insert a 21 gauge 1 needle, attached to a 10
ml syringe, directly downwards and aspirate
urine
Withdraw needle and collect midstream
specimen of urine
22

Collection of midstream specimens of

urine
Female
1.Patient must have a full bladder
2.Patient remove underclothing and stand legs
either side of the toilet
3.Separate labia with left hand
4.Cleanse vulva front to back with sterile swab
5.Void downward into toilet until half done
6.Without interupting stream, catch urine in strile
pot
7.The patient then completes voiding

23

Collection of midstream specimens of

urine
Male
1.Patient must have a full bladder
2.Retract foreskin if present
3.Cleanse glans penis with sterile swab
4.Void into toilet with foreskin retracted until
half done
5.Without interupting stream, catch sample
in strile pot
6.Complete voiding

24

Differential Diagnosis
Dysuria will have a UTI, but other

diagnoses should be entertained

The presence of pyuria is not entirely
specific for a UTI. White blood cells in the
urine may also be noted in women with
vaginitis, urethritis, or with certain sexually
transmitted diseases

Persisting pyuria is of importance as an

indicator of possible stone disease, papillary

necrosis, interstitial nephritis, or tuberculous
disease.

25

Differential Diagnosis
Appropriate testing should be
undertaken to diagnose Trichomonas,
candidiasis, Chlamydia trachomatis,
Neisseria gonorrhoeae, or herpes
simplex virus

26

Treatment
General Measures
Preliminary interventions may include rest

and hydration
Short-term use of urinary analgesics is
often helpful with agents such as
phenazopyridine (Pyri dium) and urised
(Urisept).
There is some evidence that cranberry
juice or its extract may be protective in
developing cystitis via decreasing bacterial
adherence (Sobota 1984).
27

Antibiotics
Spontaneous resolution rates of 50% to

70% for lower UTIs without pharmacologic

interventions have been reported
The following factors should be considered:
Local resistance patterns,
Patient population,
Activity and pharmacokinetics of the agent,
Duration of therapy,
Side effect profile, and cost
28

 Evidence suggests that resistance patterns

vary by geographic location

In one study 20% of the cases of
community-acquired UTIs were resistant to
first-line antibiotic therapy (J Infect Dis.
2005)
although resistance is relatively low,
nitrofurantoin is only active in the urine
with poor activity against Proteus or
Pseudomonas and is not indicated in
complicated UTIs
29

 Cephalosporins are useful agents during

pregnancy; however, like nitrofurantoin

these drugs do not have activity toward
Proteus.[11] The high resistance pattern to
TMP-SMX has called in to question its role
as first-line treatment for uncomplicated
UTIs; however, the advantage of TMP-SMX
over the ?-lactams (ie, penicillins and
cephalosporins) is that it does not alter
vaginal flora, which has been implicated in
recurrent UTIs.[1]
30

Duration of therapy is also an important consideration when

deciding to treat. Men should be treated for 10 to 14 days,
and pregnant women should be treated for at least 7 days.
[5,10] In general, for women with uncomplicated UTIs 3-day
therapy has greater efficacy than 1-day therapy, but
duration of therapy remains governed by the agent used. [13]
(Refer to Table 1 for pharmacologic management of UTIs.)
For children older than 2 years, a short course of antibiotics
is adequate (35 days); however before the age of 2 years
10 to 14 days is recommended.[14,15,16] Three-day treatment
with ciprofloxacin in women 65 and older is as effective as 7
days for uncomplicated UTI[8]; however, in older women
who had symptoms for longer than 1 week conservative
treatment with antibiotic therapy for 7 to 10 days is
recommended.[17,18,19,20]
31

In conclusion, the Infectious Diseases Society of America has

recommended using fluoroquinolones as first-line therapy when
the resistance to TMP-SMX is 10% to 20% [1,9] The two most
commonly used quinolones for UTI are ciprofloxacin and
levofloxacin because moxifloxacin has limited concentration in
the urinary tract.[1] Nitrofurantoin can also be used if resistance
is present; however, it must be prescribed for 5 to 7 days, and
the clinician should remember that it does not have activity
against Proteus and Pseudomonas.[11] First-line therapy for
uncomplicated UTIs when resistance is less than 10% remains
TMP-SMX for 3 days or TMP alone. [1,11] Penicillins and
cephalosporins can be used, but they must be given for 7 days,
and, with any antibiotic therapy, resistance patterns and
organism coverage must be considered. Although fosfomycin
trometanol was designed for 1-day treatment of UTIs, it showed
lower eradication than did 7 days of TMP-SMX and is rarely
used in the treatment of UTIs.
32

33

34

35

Antibacterial treatment for acute

cystitis

Trimethoprim 200 mg twice daily for 3 days

Trimethoprim-sulfamethoxazole 160/800
mg twice daily for 3 days
Nitrofurantoin 100 mg thrice daily for 7
days
Amoxycillin 500 mg thrice daily for 3 days
Ciprofloxacin 250 mg twice daily for 3 days
36

Prophylactic regime
1. Drink sufficient fluid to void 2 ltr per
day
2. Void 2 3 hourly with double
micturition if reflux present
3. Void at bedtime and after intercourse
4. Avoid bubble baths and chemical
additives in bath water
5. Avoid constipation which may impair
bladder emptying
37

Diagnosis of upper vs lower tract

infection
Diagnosis of upper UTI is usually
based on clinical symptoms and sign.
Using ureteral cath, 50 % women with
asymptomatic bacteriuria had
infection in their upper tract,
Conversely, loin pain and tenderness
with fever may be present in 15 30
% of patients with infection confined
to the bladder.
38

Diagnosis of upper vs lower tract

infection
The need to identify the site was
based on the belief that renal
infection ,especially if repeated, led to
kidney damage, and that treatment of
upper tract infection differed from
that of cystitis.
Uncomplicated renal infection rarely
led to kidney damage, localiszation
are now rarely used.

39

Diagnosis of upper vs lower tract

infection
Treatment of upper vs lower UTI does
indeed differ, but response to
treatment is now used to distinguish
between the two.

40

Cystitis and Urethritis

Pathogens
E.coli 80 %
S.saprophyticus 10 %
Klebsiella, Proteus, enterococcus
Hospital-acquired infection, reduction
in E coli, increases in klebsiella and
Proteus, Pseudomonas aeruginosa
41

Histopathology
Is associated with inflammation
limited to superficial mucosal layer of
the bladder

42

Clinical presentation and

natural history
Symptomatic of bladder infection
related to inflammation
Frequency
Urgency
Dysuria
Feeling of lower abdominal
discomfort or heaviness
Haematuria
43

Clinical presentation and

natural history
If untreated ,symptom progress with
features suggestive of extension of
infection to the upper tract loin
pain, fever, rigors, and vomiting.

44

Recurrent Infection
Spermicidal agent may be the causal
factor facilitating E coli colonization
of the vagina.

45

The Urethral syndrome

The women with persistent or
recurrent frequency and dysuria in
whom urine culture yields fewer than
10 5 organisms/ml.

46

Urethritis and Vaginitis

10 20 % women with sexually
transmitted genital infection due to
Chlamydia trachomatis, Neiiseria
Gonorrhea complain of frequency
and dysuria due to urethritis.

47

Treatment of lower tract

infection
Single infection
The majority of abacteriuric have
low bacterial counts and are indeed
infected, it is therefore reasonable to
diagnose bladder infection on basis
of acute symptoms in young women
presenting for the first time

48

Choice of antibiotics

Sulfonamides
Ampicillin and amoxycillin
Clavulanic acid and amoxycillin
Nitrofurantoin, is inactive against
Proteus and Pseudomonas
TMP-SMX
Fluoroquinolones
Cephalosporin and fosfomycin
49

Duration of treatment
Most trials have shown 3 days
therapy to be more effective than
single-dose treatment (Warren et all
1999)
With the exception of nitrofurantoin,
there is now little justification for 7
days or longer courses of treatment.
See Table 5
50

Supportive measures
Alkalinization of urine with potasium
citrate and sodium bicarbonate may
give symptomatic relief and
enhances the effectiveness of
aminoglycosides and erythromycin.
See table 6

51

Follow up
A urine culture may be obtained 7
10 days post-treatment to ensure
there is no asymptomatic bacteriuria.

52

Low-dose prophylaxis
A single dose of antibacterial was
prescribed last thing at night.
Trimethoprim 100 mg, TMP-SMX
160/180, nitrofurantoin 50-100 mg
Duration of treatment 12 months

53

Upper urinary tract infection

Pathogenesis
Secondary to bladder infection
Spread of infection
Urodynamic factor
Virulence factor
Medullary susceptibility
Obstruction
Vesicoureteric reflux
54

Upper urinary tract infection

Acute Pyelonephritis
Bacteriuria who have
Loin pain
Fever

Flank tendernass

55

Upper urinary tract infection

In uncomplicated Pyelonephritis
The onset is commonly acute
Severe renal infection may cause
Chills
Rigors
High fever
Anorexia, nausea and vomiting ,
myalgia
56

Upper urinary tract infection

Chronic Pyelonephritis
Radiolocigal diagnosis based on the
demonstration of clubbed calyses
associated with focal or diffuse renal
scarring

57

Diagnosis of upper tract

infection
Is usually based on symptoms and
clinical sign in a patients shown to
have bacteriuria and pyuria

58

Treatment
Acutely ill patients with high fever, severe
loin pain and vomiting must be admitted to
hospital
Gentamycin IV ( 1.5 mg/kg initially followed
by 1 mg/kg 8 hourly ) is an effective
combination.
Cephalosporin iv, cefuroxime (1.5 g,6 hourly)
ceftazidime(2g,8 hourly)
Fluid intake of 2 ltr daily
59

Duration of Treatment
Uncomplicated renal infection are
best treated with a 2 weeks course of
antibacterial drugs
Relapse is commonlytreated with
more prolonged treatment (6 weeks)

60