URINARY TRACT INFECTION

• Second most common

infection following
respiratory infections

• UTI occur when bacteria

(E. coli) from the
digestive tract get into
the opening of the
urinary tract and
multiply

• Bacteria first infect the

urethra, then move to
the bladder and finally
to the kidneys

• UTI tend to occur more

in women than men
URINARY TRACT INFECTION

Urinary tract is normally

sterile due to the fact that
bacteria moving upwards
are regularly washed out
by urination

Normal flora found in the

urethra consist of
lactobacillus and
staphylococcus to name a
few
Figure 23.2
Figure 23.3
What are UTIs?
 A significant bacteriuria in the presence of symptoms

 Bacteria most often of faecal origin

 Common causes of acute UTIs:

 50-70% = E. coli strains
 5-15% = Klebsiella pneumoniae
 5-15% = Enterobacteriaceae or enterococci

6
Epidemiology
 Second only to respiratory infections (>6 million visits
to doctors per year – USA)
 Large majority of adult cases are females - 30:1
 Women generally don't have many problems with
UTI's until they become sexually active.
 Postmenopausal:
 bladder or uterine prolapse
 loss of estrogen that causes a change in the vaginal flora
 loss of lactobacilli in the vaginal flora which results in periurethral
colonisation

 Males experience a rapid increase in the incidence

UTI's sometime in their 50’s - benign prostatic
hypertrophy.
7
Predisposing factors
•Sexual activity in females
(75–90%)
•Abnormality of the UT
that obstructs or slows the
flow of urine (i.e. kidney
stone)
•Elderly males: prostatic
hypertrophy
•Pregnancy
•Catheterisation
•Surgery, e.g.
prostatectomy
•Diabetes mellitus
•Immunosuppressed
patients
•Congenital abnormalities in
infants that sometimes
require surgery, e.g. vesico-
uretic reflux
•Women who use the
diaphragm and spermicides
•Patients with a neurogenic
bladder or bladder
diverticulum
Routes of spreads
 Ascending transurethral route
 From the lower UT is the
commonest
 At first there is colonisation
of the distal
urethra & introitus in female
by coliform
bacteria
 Hematogenous
 Through blood stream e.g.
septicaemia
 Lymphatics
 Direct extension from vesico
colic fistula
Hematogenous Infection

Chronic infections (skin, respiratory tract)

blood circulation kidney (cortex)
small abscess renal tubular
renal pelvis renal papillary
 Ascending Infection

The ability of host defense

Urinary tract mucosal cells damaged
The power of bacterial adhesions(toxicity)
organisms urethra,periurethral tissues
bladder ureters renal pelvis
renal medulla
Classification
 Lower urinary tract infection (Urethritis, Cystitis, Prostatitis)
 Upper urinary tract (Pyelonephritis)
Complicated UTI
 Is considered to be present when there are underlying factors that
predispose to ascending bacterial infection.
Uncomplicated UTI
 Occurs without underlying abnormality or impairment of urine flow.

13
URINARY TRACT INFECTION

TYPES

LOWER TRACT INFECTION UPPER TRACT INFECTION

URETHRITIS PYELONEPHRITIS

PROSTATITIS

CYSTITIS PERI NEPHRIC ABSCESS

Symptoms of UTIs
Cystitis and urethritis Pyelonephritis Prostatitis

• Abrupt onset of • Fever > 38⁰ • Pain in lower back ,

frequency of • Loin pain perirectal area and
micturition testicles
• Dysuria • High fever, chills and
• Lower back pain, symptoms similar to
abdominal pain, and bacterial
tenderness over • Inflammatory
bladder swelling of prostate,
• Suprapubic pain which can lead to
during and after urethral obstruction
voiding • Urinary retention,
• Urgency which can cause
• Urine may appear abcess formation or
cloudy and seminal vesiculitis
unpleasant smell
• haematuria
Findings on Exam in UTI
 Physical Exam:
 CVA tenderness (pyelonephritis)
 Urethral discharge (urethritis)
 Tender prostate on DRE (prostatitis)
 Labs: Urinalysis
 + leukocyte esterase
 + nitrites
 More likely gram-negative rods
 + WBCs
 + RBCs
 Uncomplicated (simple) Cystitis
 Definition
 Healthy adult woman (over age 12)
 Non-pregnant
 No fever, nausea, vomiting, flank pain

 Risk factors:
 Sexual intercourse
 May recommend post-coital voiding or prophylactic
antibiotic use.

 Treatment
 Trimethroprim/Sulfamethoxazole for 3 days
 Fluoroquinolone (ciprofoxacin or levofloxacin) in
patient with sulfa allergy, areas with high rates of
bactrim-resistance
 Complicated Cystitis
 Definition
 Females with comorbid medical conditions
 All male patients
 Indwelling foley catheters
 Urosepsis/hospitalization
 Diagnosis
 Urinalysis, Urine culture
 Further labs, if appropriate.
 Treatment
 Fluoroquinolone (or other broad spectrum
antibiotic)
 7-14 days of treatment (depending on severity)
 May treat even longer (2-4 weeks) in males with UTI
 Special cases of Complicated cystitis
 Indwelling foley catheter
 Try to get rid of foley if possible!
 Only treat patient when symptomatic (fever, dysuria)
 Leukocytes on urinalysis
 Patient’s with indwelling catheters are frequently colonized with
great deal of bacteria.
 Should change foley before obtaining culture, if possible
 Candiduria
 Frequently occurs in patients with indwelling foley.
 If grows in urine, try to get rid of foley!
 Treat only if symptomatic.
 If need to treat, give fluconazole (amphotericin if
resistance)
 Recurrent Cystitis

 Want to make sure urine culture and

sensitivity obtained.
 May consider urologic work-up to
evaluate for anatomical abnormality.
 Treat for 7-14 days.
 Pyelonephritis
 Infection of the kidney
 Associated with constitutional symptoms – fever, nausea,
vomiting, headache
 Diagnosis:
 Urinalysis, urine culture, CBC, Chemistry
 Treatment:
 2-weeks of Trimethroprim/sulfamethoxazole or fluoroquinolone
 Hospitalization and IV antibiotics if patient unable to take po.
 Complications:
 Perinephric/Renal abscess:
 Suspect in patient who is not improving on antibiotic therapy.
 Diagnosis: CT with contrast, renal ultrasound
 May need surgical drainage.
 Nephrolithiasis with UTI
 Suspect in patient with severe flank pain
 Need urology consult for treatment of kidney stone
 Prostatitis
 Symptoms:
 Pain in the perineum, lower abdomen, testicles, penis, and with
ejaculation, bladder irritation, bladder outlet obstruction, and
sometimes blood in the semen
 Diagnosis:
 Typical clinical history (fevers, chills, dysuria, malaise,
myalgias, pelvic/perineal pain, cloudy urine)
 The finding of an edematous and tender prostate on physical
examination
 Will have an increased PSA
 Urinalysis, urine culture
 Risk Factors:
 Trauma
 Sexual abstinence
 Dehydration
 Treatment:
 Trimethoprim/sulfamethoxazole, fluroquinolone or other
broad spectrum antibiotic
 4-6 weeks of treatment
 Urethritis
 Chlamydia trachomatis
 Frequently asymptomatic in females, but can present with dysuria, discharge
or pelvic inflammatory disease.
 Send UA, Urine culture (if pyuria seen, but no bacteria, suspect Chlamydia)
 Pelvic exam – send discharge from cervical or urethral os for chlamydia PCR
 Chlamydia screening is now recommended for all females ≤ 25 years
 Treatment:
 Azithromycin – 1 g po x 1
 Doxycycline – 100 mg po BID x 7 days

 Neisseria gonorrhoeae
 May present with dysuria, discharge, PID
 Send UA, urine culture
 Pelvic exam – send discharge samples for gram stain, culture, PCR
 Treatment:
 Ceftriaxone – 125 mg IM x 1
 Cipro – 500 mg po x 1
 Levofloxacin – 250 mg po x 1
 Ofloxacin – 400 mg po x 1
 Spectinomycin – 2 g IM x 1
 You should always also treat for chlamydia when treating for
gonnorhea!
Antibiotics used in the management of urinary tract
infections
 Treatment based on organism
Organism Treatment

Escherichia coli Trimethoprim, cephalexin, Gentamicin

Proteus spp. Trimethoprim, cephalexin, Gentamicin

Klebsiella spp. Trimethoprim, cephalexin, Gentamicin

Pseudomonas aeruginosa Ciprofloxacin, Gentamicin

Enterococcus spp Amoxicillin, Vancomycin

Staphylococcus aureus Trimethoprim, cephalexin, Gentamicin

Coagulase-negative staphylococci Trimethoprim, cephalexin, Gentamicin

 Treatment of UTIs-Antibiotic doses
Lower Urinary Tract Acute Pyelonephritis Bacterial Prostatitis Prophylactic
Infection therapy
Trimephoprim 200mg twice a day for 200mg twice a day for 7-14 200mg twice a day 100mg at night
three days days for 4-6weeks

Nitrofurantoin 50mg four times a day 50mg twice a day for 7-14 - 50-100mg at
for three days days night
Co-amoxiclav 375mg 8-hourly for 375mg 8-hourly for 7-14 days - -
three days
Ciprofloxacin 100mg 12-hourly for 250mg-500mg every 12- 250mg 12-hourly for -
(adjust dose in three days hourly for 7-14 days 4-6 days
renal impairment)

Norfloxacin (adjust 400mg 12-hourly for 400mg 12-hourly for three 400mg 12-hourly for -
dose in renal three days days 4-6 days
Impairment)

Ceufuroxime 125mg 12-hourly for 250mg 12-hourly or 750mg - -

(adjust dose in renal three days 6-8hourly IV in seriously ill
impairment) patient, for 7-14 days

Cefalexin 500mg 12-hourly for 500mg 12-hourly for three - 125mg at night
three days days
 Measures to prevent UTIs
 Keep Hydrated (fluid intake at least 2L per day)
 Encourage regular complete emptying of the bladder
 Good personal hygiene
 For women, avoid feminine hygine sprays
 Encourage front toback cleansing
 Showers preferable to baths
 Cranberry juice maybe effective
 Frquently change those who use incontinence pads
SELAMAT BELAJAR