MANAGEMENT OFURINARY
TRACT INFECTION (UTI)
By Dr. Uba
OUTLINE
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Introduction
Epidemiology
Pathophysiology
Classification and definitions
Aetiology
Risk factors
Clinical features
Diagnosis
Treatment
Complications
References
• Urinary Tract infection : A common medical
condition in which micro organisms are
established and multiplying within the urinary
tract.
• Bacterial invasion of the urinary tract
• Diagnosis requires demonstration of the
organism in urine.
• A bacteria count of ˃105 /ml in a clean catch
mid stream urine sample.(Kass 1956)
EPIDEMIOLOGY
• FEMALES- 3% at age 20
increases by 1% each subsequent
decade
MALES – Uncommon, except in <1yr and
>50yrs
In Nigeria
• Prevalence of urinary tract infections (UTI)
among patients attending Dalhatu Araf
Specialist Hospital: Of the 300 specimens
examined in this study, They were made up of
150 males and 150 females and aged between
15-30 years, 180 (60%) showed significant
bacteriuria; 120 (66.67%) were females while
60 (33.33%) were males.
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Urinary tract infection in a rural community of Nigeria. Study area was in
Okada, Edo state
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Study population : A total of five hundred and fourteen patients with signs and
symptoms of urinary tract infection were recruited for this study. They
consisted of 465 females, and 49 males, with age ranging from 12 to 76 years.
The prevalence of urinary tract infection was significantly higher in females
compared to males (female vs. male: 42.80% vs. 10.20%)
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The prevalence of UTI was highest within the 21 – 30years age group
(44.67%), and was least within the age range of 51 – 60 years (24.32%),
although age did not significantly affect the prevalence of UTI.
PATHOPHYSIOLOGY
There are 3 main mechanisms responsible for
UTIs:
• Colonization with ascending spread
• Hematogenous spread
• Periurogenital spread
PATHOPHYSIOLOGY
• E.coli – activates both complement pathways,
Iron chelators producing hemolysin a
virulent factor
• Urease production – splits urea into CO2 and
NH3 which is toxic to the
kidneys e.g.Proteus
Anatomical Classification
• Lower urinary tract infection – urethritis,
cystitis, prostatitis
• Upper urinary tract infection – pyelonephritis
(acute or chronic)
SPECTRUM OF UTI
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Asymptomatic bacteriuria
Symptomatic acute urethritis and cystitis
Acute prostatitis
Acute pyelonephritis
Complicated and Uncomplicated UTI
DEFINITIONS
• Bacteriuria : bacteria in urine
• Significant bacteriuria : bacteria count ≥ 105 cfu / ml of
urine
• Asymptomatic bacteriuria :two separate consecutive
clean-voided urine specimens both with ≥ 105 cfu/ml of the
same uropathogen in the absence of symptoms.
asymptomatic infection identified by a screening urine
culture unrelated to the genitourinary tract
• Pyuria : presence of >5 polymorphonuclear leucocytes per
hpf of spun urinary sediment or >10/ml of unspun urine.
• Candiduria: more than 1000 CFU/mL of yeast from 2
cultures. Candida albicans, which is germ tube positive
• Pyelonephritis: symptomatic disease of the
kidney.
• Acute pyelonephritis
Inflammatory response of renal parenchyma
to bacterial invasion
• Chronic pyelonephritis
Renal scarring and destruction of the calyceal
system usually seen on imaging, due to recurrent
bacterial infection or vesicoureteral reflux
• Cystitis and urethritis: inflammation of
bladder mucosa and urethra respectively
usually from acute bacterial infection
• Prostatitis: symptomatic disease of the
prostate
• Uncomplicated UTI refers to acute disease in
nonpregnant outpatient women or men
without anatomic abnormalities or
instrumentation of the urinary tract
• Complicated UTI refers to cases with anatomic
abnormalities or instrumentation of the
urinary tract. UTI that increases the risk
for serious complications or treatment failure.
AETIOLOGY
• E.coli- serogroups- O1, O2, 04,O6, O7, O75 (75–
90% of cystitis isolates)
• Proteus spp
• Pseudomonas spp
• Streptococci
• Staph. Epidermidis and Female- saprophyticus
• Klebsiella spp
• Candida albicans
• Citrobacter spp
• Enterococcus spp.
PREDISPOSING FACTORS
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Sex:
females-shorter urethra
absence of bactericidal prostatic
secretions/Spermicidal products
• Sexual intercourse- minor trauma from intercourse
• Instrumentation- Catheter
• Family history
• Menopause
• Urinary tract abnormality- Fistula. Bladder diverticulum
• Urinary tract obstruction- Kidney stones, enlarged prostate
• Spinal injury
• Immunosuppression: DM, excessive antibiotic use
• Use of spermicides, douching
• Bad Hygiene: washing from back to front
DM AND UTI
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Renal and perirenal abscess
Emphysematous pyelonephritis and cystitis
xanthogranulomatous pyelonephritis
Papillary necrosis
CLINICAL FEATURES
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Frequency
Urgency
Nocturia
Dysuria
Suprapubic pain or flank pain
Cloudy urine
Macro or microscopic hematuria
Foul smelling urine
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Pyelonephritis –
Fever
chills and rigors
vomiting
loin pain
flank tenderness
INVESTIGATIONS
• Urinalysis – nitrites, leucocyte esterase, glucose
• Urine m/c/s- GOLD STANDARD
Specimen: suprapubic aspirate, midstream urine,
catheter specimen
• FBC
• S/E/U/Cr
• Blood culture
• Renal scan
• Intravenous Urography (IVU)
• Micturatingcystourethrography
• cystoscopy
DIAGNOSIS USING KASS CRITERIA
• SYMPTOMATIC YOUNG WOMAN
≥102 coliform organisms/ml urine plus pyuria
(>10WBC/mm3)
OR
• ≥105 any pathogenic organism/ml
OR
• Any growth of pathogenic organisms in urine by suprapubic
aspiration
• SYMPTOMATIC YOUNG MEN
• ≥103 pathogenic organisms
• ASYMPTOMATIC PATIENTS
• ≥105 pathogenic organisms/ml urine on two occassions
TREATMENT
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Nitrofurantoin 100 mg bid × 5–7 d
TMP-SMX 1 DS tablet bid × 3 d
Fosfomycin 3-g single-dose sachet
Fluoroquinolones dose varies by agent; 3-d
regimen
• β-Lactams, dose varies by agent;
• 5- to 7-d regimen
• Uncomplicated cystitis in women: Trimethoprim-sulfamethoxazole,
Nitrofurantoin, Fluoroquinolones should be used only when other
antibiotics are not suitable because of increasing resistance.
• Pyelonephritis: Fluoroquinolones-(e.g., ciprofloxacin, 500 mg PO bid
for 7 days), Oral TMX-SMX (one double-strength tablet bid for 14
days) is effective against susceptible uropathogens.
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UTI in pregnant women Nitrofurantoin, ampicillin, and the
cephalosporins are considered relatively safe in early pregnancy.
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UTI in men In men with apparently uncomplicated UTI, a 7- to 14day course of a fluoroquinolone or TMP-SMX is recommended.
• Complicated UTI/ pyelonephritis
fluoroquinolones- ciprofloxacin, levofloxacin,
cephalosporins, gentamycin
• IV for pyelonephritis/ severely ill.
• Asymptomatic bacteriuria should only be
treated in pregnancy, infants and structural
abn.
• High fluid intake is advised.
COMPLICATIONS
• Recurrent Infections leading to Chronic
Pyelonephritis
• Permanent Kidney damage
• Increased risk of delivery or low birth weight
babies
• Reinfection and relapse.
Recurrence
Reinfection:
Eradication of bacteriuria by treatment, followed
by infection with same or a different organism
after 10 to 14 days .
Relapse: Infection by the same organism within 7
days of completion of antibacterial treatment and
implies failure to eradicate infection usually in
conditions such as kidney stones, scarred kidney,
bacterial prostatitis.
In recurrence, search for and treat underlying
cause.
REFERENCES
• HARRISON’S Manual of Medicine 20th Edition
• Medscape – Urinary tract infection
• Research Article- Urinary tract infection in a rural
community of Nigeria by Bankole Henry Oladeinde, Richard
Omoregie, Mitsan Olley, and Joshua A. Anunibe.
• Research Article- Prevalence of urinary tract infections (UTI)
among patients attending Dalhatu Araf Specialist Hospital,
Lafia, Nasarawa State, Nigeria by Kolawole, A., Kolawole, O.
M., Kandaki-Olukemi, Y. T., Babatunde, S. K., Durowade K. A.
and Kolawole, C. F. Accepted May 2009.
• Google Images
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