URINARY TRACT INFECTIONS
By
Dr Dave Maharajh MD
Bacteria Preparing to Attack
URINARY TRACT INFECTIONS
MISURY
URINARY TRACT INFECTIONS
MISURY
MISURY
MISURY
PREGNANCY
CLASSIFICATIONS
• UPPER URINARY TRACT
• Complicated and Uncomplicated
• LOWER URINARY TRACT
• Complicated and Uncomplicated
• COMBINED UPPER AND LOWER TRACTS
• Complicated and Uncomplicated
Epidiemiology
• Adults: F>M 18-60 yrs (11%/yr)
• Children: F>M 5-Puberty
• Approx. 50-60% of Adult Women report a
•
•
•
•
urinary tract infection during lifetime
Adult Female: 3UTI/yr. > refer and inv.
Adult Male: 1 infection. Refer and inv.
Children: M(1) and F(>3 refer and inv.)
Children: F>M except neonates < 5yrs refer
WHEN LENGTH MATTERS
MECHANISMS OF ACTION
•
•
•
•
•
•
•
•
•
•
Direct Contamination:invasive procedures
Migration
Hematogenous ( TB and Staph. )
Ascending Infection
Foreign Bodies ( Catheters and others)
Coexisting Conditions
Fistulas, Crohn’s/UC, Diverticular disease
IBS, DM, Neurogenic bladder, Calculi.
Immunosuppression,
Nonsecretors of blood group substances (Toll-like
receptors (TLR-1 and TLR-4> Chemokines CXCL8
URINARY TRACT INFECTIONS
CLINICAL VARIATIONS
Asymptomatic
Bacteruria
Trivial Voiding
Irritation
Septic Shock
Clinical Symptoms
• Upper Tract:
• Flank Pain, Fever, Chills, nausea/vomitting
• Lower Tract:
• Frequency, Urgency, Dysuria, Hematuria,
Odour, Cloudy urine, Suprapubic pain,
Sense of incomplete emptying.
• Constitutional symptoms: Malaiase, lack of
energy and appetitite, confusion.
DIFFERENTIAL DIAGNOSIS
• Vulvovaginitis ( Yeast, Trichomonas etc)
• Urethritis ( Chlamydia, GC)
• STD’s
• Sterile Pyuria
• Postmenopausal atrophic vaginitis
LABORATORY INVESTIGATIONS
• Urinalysis:
• Urine dipstick
• MSU
• Urine Culture and Sensitivity
• Catheterized urine
• Suprapubic aspirate
• Nephrostomy tube collection
DIAGNOSTICS
• Urine dipstick: RBC/ WBC and Nitrites
• Usually detects >10/`5 colony/ml
• Beware of sterile pyuria, age of sticks
• Evaluate with clinical scenario
• Must do MSU or centrifuged urine
• Treat and await culture/sensitivity
• Repeat MSU not dipstick after Rx.
DIAGNOSTICS
• MSU:
• Colony count > 10`5 or 10`8
• Culture and Sensitivity to follow
• Contamination (Multiple bact. Identified)
• Fungi and Chlamydia need different
media, suspect if neg. culture and
symptomatic
Diagnostics
•
•
•
•
•
•
•
•
Radiological Investigations:
Ultrasound ( Kidney and Bladder)
CT Scan ( Abd/Pelvis)
VCUG
MRI
Non Radiological:
Cystoscopy
Urodynamics and Uroflow
ORGANISMS COMMONLY FOUND
• E. Coli >70%
• Klebsiella Pneumoniae
• Proteus Mirabilis
• Enterococcus Fecalis
• Staphylococcus Saprophyticus
• Enterobactae
URINARY TRACT INFECTIONS
Non Antimicrobial Therapies
• Personal Hygiene
• Avoid Bubble Baths and Hot Tubs
• Beware of Spermicide Use
• Cranberry Juice
• Increased daily Fluid Intakes
• Development of a Vaccine
Strategies to Prevent UTI
• Simple measures
• Increase Fluid intake
• Void before and after
•
•
•
•
•
intercourse
Personal Hygiene (wipe
front to back)
Avoid feminine hygiene
sprays
Take showers instead of
baths
Cranberries / Juice
Assess voiding pattern
• Cranberries
TREATMENT
Uncomplicated UTI
• Young Woman first
•
episode
Single dose
• TMP-SMZ
• 320/1600mg, 2
•
• Young Male first
•
episode
•
• Treat , investigate and •
refer
•
double strength tabs
Amoxicillin 3gm
Cephaloridine 2gm
Gentamycin 5mg/kg
Doxycycline 300mg
Quinolones
TREATMENT
Uncomplicated UTI
• Young woman first
•
•
•
•
episode
Short course 3-5days
10-14 days
Treat according to
sensitivity
Repeat urine culture
after treatment
• TMP-SMZ
• Nitrofurantoin/
•
•
•
•
Macrobid
Ciprofloxacin
Noroxin
Amoxil
Quinolones
TREATMENT
COMPLICATED UTI
• Specific Pharmacotherapy
• Investigate with Radiology
• Refer to appropriate specialty
• Consider low dose prophylaxis while
awaiting referral and diagnostics
• Admit patient if not responding to
treatment and refer
Common Scenarios
• Young female with recurrent UTI and
relapses after treatments >3
• Simple measures as discussed
• Do U/S kidney and bladder with PVR
• May need VCUG
• Refer to Specialty
• Consider low dose prophylaxis
COMMON SCENARIOS
•
•
•
•
•
•
•
•
Young Females (Pediatric age group)
Avoid excessive baths
Treat and eliminate constipation
Encourage frequent voids
Proper Potty Training
Proper Genital Hygeine
Recurrent UTI (Investigate and refer)
U/S, VCUG
Common Scenarios
•
•
•
•
•
•
•
Postmenopausal woman with recurrent UTI.
Simple measures as discussed
Treat constipation and avoid baths
Use Premarin/ estrogen cream locally
Consider low dose prophylaxis
Do U/S kidney and Bladder with PVR
Refer to Specialty
Common Scenarios
•
•
•
•
•
•
Chronic indwelling catheters
No need for Rx. Unless symptomatic
Change catheter every 4-6 weeks
Use of Silastic catheters less infection
Local hygiene to the catheter and Urethral
meatus helpful
Irrigation of the Catheter helpful in certain
situations. ( Mucus production and sediments)
Common Scenarios
• Pregnancy
• Treat all Asymptomatic Bacteruria with the
appropriate antibiotic for trimester of
Pregnancy
• Always do and U/S Kidney and bladder
with PVR
• Refer to specialty if needed
Common Scenarios
• Young and Old Males
• Treat with appropriate antibiotics
• Always do diagnostic Imaging (U/S or CT)
• Examine Genitalia and Prostate
• Refer to Specialty
Common Scenarios
•
•
•
•
•
•
•
Patients with Neurogenic Bladders
Do appropriate Imaging
Personal Hygiene
Techniques of Clean Intermittent Catherizations)
Treat with culture sensitive antibiotics
Refer to Specialty as needed
Beware Autonomic dysreflexia
References
•
•
•
•
•
•
Update in Adult Urinary Tract Infection
Lindsay Nicolle Curr. Infect. Dis.Rep
(2011) 13:552-560
Dept. Of Internal Medicine and Medical
Microbiology . U. Of Manitoba
An Update on Uncomplictaed UTI in Women
Current Opinion in Urology 2009 19:368-374
Florian. M. Wagenlehner
Urinary Tract Infections
• QUESTIONS
• Structural and functional abnormalities of the
•
genitourinary tract associated with complicated urinary
infection
ObstructionUreteric or urethral stricturesTumours of the
urinary tractUrolithiasisProstatic
hypertrophyDiverticulaePelvicalyceal obstructionRenal
cystsCongenital abnormalitiesInstrumentationIndwelling
urethral catheterIntermittent catheterizationUreteric
stentNephrostomy tubeUrological proceduresImpaired
voidingNeurogenic bladderCystoceleVesicoureteral
refluxIleal conduitMetabolic
abnormalitiesNephrocalcinosisMedullary sponge
kidneyRenal failureImmunocompromisedRenal transplant
• The diagnosis of symptomatic urinary tract infection in patients without
indwelling urological devices should be considered only when localizing
genitourinary signs or symptoms are present (AII).
• For patients with indwelling urological devices, systemic
symptoms, such as fever in the absence of localizing genitourinary
signs and symptoms, may be consistent with symptomatic urinary
tract infection (AII).
• A urine specimen should be obtained for culture and susceptibility
•
testing before institution of antimicrobial therapy for every
episode of complicated urinary tract infection (AI).
– A single urine specimen with a quantitative count of at least 108 cfu/L
(at least 105 cfu/mL) is consistent with urinary infection in
symptomatic subjects (AII).
– A quantitative count of at least 108 cfu/L (at least 105 cfu/mL) on two
consecutive specimens is the appropriate diagnostic criteria to identify
asymptomatic bacteriuria in women (BII).
– Any quantitative count of organisms is consistent with bacteriuria for
individuals with urine specimens obtained by bladder catheterization
(AII).