Urinary Tract Infections

dr Putra Hendra SpPD

UNIBA
 URINARY TRACT INFECTION

 DEFINITION:
TISSUE RESPONSE TO
THE PRESENCE OF
SIGNIFICANT AMOUNT
OF BACTERIA IN THE
URINE
 Definition
 Significant bacteriuria in presence of symptoms
at any level of urinary tract:

- Bladder: cystitis - Urethra: urethritis

- Renal pelvis: pyelitis - Renal parenchyma: pyelonephritis
 PATHOGENESIS

 Upper urinary tract

infection:

Pyelonephritis

 Lower urinary tract

infection:
Cystitis
 Terms
 “Upper UTI”: infection above the level of the
bladder
 “Lower UTI”: infection at or below the level of
the bladder
 “Urethral syndrome”: clinical manifestations of
lower UTI (dysuria, frequency, urgency) without
significant bacteriuria
 Urinary Tract Infection Defined
Definition

Women: Presence of at least 100,000 colony-

forming units (cfu)/mL in a pure
culture of voided clean-catch urine

Men: Presence of just 1,000 cfu/mL

indicates urinary tract infection

*Some labs do not routinely identify & determine the

sensitivity of organisms for specimens with <10,000
cfu/mL. May have to special request.
Swart, Soler & Holman, 2004
Definitions
Bacteriuria Presence of bacteria in the urine

Pyuria Presence of WBCs in the urine

Cystitis UTI associated with superficial mucosa o f bladder

Pyelonephritis UTI of renal parenchyma and or collection system

Uncomplicated UTI Infection involving structurally and functionally normal

urinary tract (simple UTI)

Complicated UTI Infection involving structurally and functionally abnormal

urinary tract

Urethritis Infection of the urethra

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 Asymptomatic bacteriuria

 In patients with asymptomatic bacteriuria

without infection, a colony count of > 105
cfu/ml defines infection

 Up to 40% of elderly men and women

have asymptomatic bacteriuria
Frequency of significant bacteriuria
 Afterone bladder catheterization: 2%
 Medical outpatients: 5%
 Pregnancy at term: 10%
 Hypertensive patients: 14%
 Diabetes mellitus: 20%
 Women with cystocoele: 23%
Overview of UTI by age and sex
 Overview of UTI

 About 2/3rds of patients are women; 40% to

50% of women have UTI at some point during
their lives
 Important complications of pregnancy, diabetes
mellitus, polycystic disease, renal
transplantation  conditions menghambat
aliran urine (structural and neurologic)
Virulence Host factors

Infection No infection

Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

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 Host defenses:
antibacterial properties of urine
 Osmolality  extremes of high or low
osmolalities inhibit bacterial growth
 High urea concentration
 High organic acid concentration
 pH
Urinary Tract
Only lower part of urethra has a
resident bacterial flora

Rest of the urinary tract is normally

sterile

Flushing effect of urine flow

Local phagocytic activity

Mucosal IgA and secretions from

prostatic and urethral glands

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 PATHOGENESIS

 Ascending infection
most UTI beyond the
newborn period are the
result of ascending
infection

 Descending infection
4 - 9 percent of children
with UTI are bacteremic
 Routes of urinary tract infection
 Ascending infection is thought to be the
common route of nearly all forms of urinary
tract infection (bacteria initially colonize
periurethral tissues)
 Descending (hematogenous) infection can be
important for a few organisms such as S.
aureus and Candida albicans, but in general
the kidney resists “metastatic infection.”
 Etiology
 Urethritis from chlamydia, gonorrhea, HSV –
acute sx female with sterile pyuria
 Ureaplasma urealyticum
 Candida or other fungal species – commonly
assoc. with cath. or DM
 Mycobacteria
 Pathogens
Type of infection Organisms

Complicated Escherichia coli

Enterococcus
Psuedomonas aeruginosa
Uncomplicated Escherichia coli
Staphylococcus saprophyticus
Enterobacter spp.
Klebsiella spp.
Proteus spp.
 Diagnosis
 Methods of urine collection
 Suprapubic aspirate (SPA)
 Bladder catheterization
 Clean-catch midstream collection
 Clean-bagged specimen: only excludes diagnosis if (-)
 Urine culture is gold standard
 Isolation of single pathogen in culture of 100,000 colonies/ml
 Urinalysis dipstick
 Hemoglobin test strip
 Leukocyte esterase: (+) WBC
 Nitrite: (+) gram-negative bacteria
 Gram stain: reliable screening tool
 LABORATORY EVALUATION

Urine:

 Dipstick
 microscopy
 Culture & sensitivity
 LABORATORY EVALUATION
Urine dipstick
88 % sensitive

 Leukocytes
 Protein
 Red blood cells
 Leukocyte esterase
 Nitrite
 White blood cell casts

 Highly
significant!
 Presence
suggests
pyelonephritis
 LABORATORY EVALUATION
Microscopic exam
 White Blood Cells: in a
centrifuged sample of
unstained urine pyuria is
defined as ≥5 WBC/high
power field , or ≥10
WBC/mm3 in an
uncentrifuged sample
 Bacteria: bacteriuria is the
presence of any bacteria per
hpf.
 Gram stain
 LABORATORY EVALUATION
Urine culture &
sensitivity
 Urine culture is the gold
standard for the diagnosis of
UTI

 Urine obtained for culture

should be processed as soon
as possible after collection
 LABORATORY EVALUATION

Urine culture
 Midstream clean catch  10⁵ colony forming
units
 Bag  85% false ₊ve
 Cathterization  10⁴ CFU
 Suprapubic aspiration any growth
 Catheter-associated UTI
 Over 1 million catheter-associated UTIs
occur in the United States each year
 Risk factors: female sex; duration of
catheterization; disconnecting the junction
between the catheter and the collecting
tube
 Prostatitis
 Relapsing acute urinary tract infection
in men caused by the same bacterial
species often suggests chronic
prostatitis with periodic spill-over into
the bladder
 Symptoms: pelvic “heaviness,” rectal or
perineal pain, urinary hesitancy,
dribbling, and burning
 A risk of catheterization
 Duplex system

 Occur in 0.9% of the population

 Obstruction most commonly in upper pole
 May be secondary to an ectopic ureter or ureterocoele
 Lower pole obstruction uncommon
 May be secondary to PUJ obstruction or VUR
 Investigation
 Ultrasound
 VCUG/Dynamic isotope study
 If asymptomatic prophylaxis only
 If UTI’s then surgical
 Horseshoe Kidney

 Incidence 1 in 400
 M:F 2:1
 Fused at lower poles
 Level of lower lumbar vertebrae
 Higher incidence of stones and UTI’s
 Clinical Manifestations
Uncomplicated Complicated
Dysuria High fever
Urgency Chills
Low-grade fever Flank and/or abdominal
Frequency pain
Suprapubic discomfort Nausea
Daytime or noctural Vomiting
enuresis +/- lower urinary tract
symptoms
 Pathogen-Specific Treatment

Pathogen Treatment options

Escherichia coli Ceftriaxone 50 mg/kg
Psuedomonas aerginosa IV/IM Qday
Enterobacter spp. Gentamicin 6-7.5 mg/kg
Klebsiella spp. IV Q8hr/Qday
Proteus spp. Ceftazidime 100-150 mg/kg/day IV
Q8hr
Enterococcus Ampicillin 100-400 mg/kg/day Q6hr
 Treatment Options
Antibiotic Dosing
Trimethoprim/sulfamethoxazole 6-12 mg TMP/kg/day
(Bactrim) BID
Nitrofurantoin 5-7 mg/kg/day
(Macrodantin) QDay
Cefixime 16 mg/kg/day x 1 day
(Suprax) 8 mg/kg/day BID
Cephalexin 25-50 mg/kg/day
(Keflex) TID or QID
Amoxicillin 40 mg/kg/day
(Amoxil) TID
 Prophylaxis
Antibiotic Prophylactic Dose
Sulfamethoxazole/ 2 mgTMP/kg/day
Trimethoprim QHS
Trimethoprim 2 mg/kg/day
QHS
Amoxicillin 10 mg/kg/day
QHS
Cephalexin 10 mg/kg/day
QHS
Nitrofurantoin 1-2.5 mg/kg/day
QHS
 PROGNOSIS
Long-term sequelae
 Approximately 40 percent
had VUR

 Renal scars developed in

approximately 8 % of
patients, 15 % of those had
abnormal DMSA scan at the
time of diagnosis.
 ISK pada Perempuan

Perempuan dengan keluhan disuria dan sering BAK

Pengobatan selama 3 hari

Follow up selama 4-7 hari

Tak bergejala bergejala

Piuria tanpa Piuria dengan atau

Keduanya negatif tanpa bakteriuria
Tak perlu invensi lebih lanjut bakteriuria

Observasi,
pengobatan Pengobatan Pengobatan
dengan analgetika untuk kuman diperpanjangg
saluran kemih klamidia