URINARY TRACT INFECTIONS (Urethritis, Cystitis, Pyelonephritis

3rd Y Med Students
Prof. Dr. Asem Shehabi
Faculty of Medicine, University of
Urinary Tract Infections-1
 Normal urine is sterile.. It contains fluids, salts, and
waste products, but it is free of microorganisms such
as bacteria, viruses, or fungi.
 UT infection occurs when microorganisms, usually
bacteria from the intestinal tract, adhere to the
opening of the urethra and begin to multiply.
 UTI is defined as a significant bacteriuria in the
presence of Signs & Symptoms.
 UTI's associated with Inflammation of any part of Urinary
tract System.
Urinary Tract Infections-2
Dysuria / Bacteriuria.. burning , frequent & painful
urination.. Presence of pus cells (WBCs) & Bacteria in
urine, fever, abdominal pain ..urgency of urination ..
Pyuria.. Presence of pus cells
Cystitis :Inflammation of the lower urinary tract
mucosa.. This infection is related to urethra and
Bladder .. not invasive.. It is Frequently associated
with voiding small volume urine.. Fever.. Burning,
abdominal pain.. Rarely Septicemia
Pyelonephritis: Infection of upper part of UT ureter
mucosa & kidneys.. High fever.. may result in blood
sepsis & kidney failure.
Urinary Tract Infections-3
 The bacteria most often seen in UTIs are of fecal
origin.. Between 80- 90% of acute community UTIs of
patients with normal anatomic structure and function
are caused by certain strains of E. coli
 Coagulase-negative Staphylococcus ..caused 10-20
% .. other G-ve Klebsilla, Enterobacter, Proteus or
G+ve Enterococci fecalis and others (5%)
 Hospitaized patients acquired often infection with
multidrug resistance bacteria: P. aeruginosa, Proteus
spp., Kelbsiella-Enterobacter spp. Enterococcus sp..
Due to accumulation MDR bacteria in intestine &
Hospital environment.
Urinary Tract Infections-3
Hemorrhagic cystitis is characterized by large
quantities of visible blood in the urine. It can be
caused by an infection & other causes
Pyelonephritis - This infection usually results from
ascending of the bacteria to the Ureter.. Kidney from
the lower urinary tract.. It also can arise by
hematogenous spread (sepsis, pneumonia).. In
contrast to cystitis.. Pyelonephritis is an invasive
disease.. With severe consequences.
Sepsis/Bacteriamia may complicate UTI.. Common
in Children & Women, Older.. Compromised
Urinary Tract Infections-4
 UTI's.. rank second only to respiratory infections in
their general incidence. The majority of the cases
seen in outpatients clinics..Female/male ratio (30:1)
90% of all women have at least one episode of a UTI
at some time during their productive years
Pregnancy & women sexually activity increase UTIs
10 times.
Up to 20 % of young women with acute cystitis
develop recurrent UTI's.
Males exposed increasing to UTI's after > 50s. This is
mostly due to prostate gland hypertrophy..underlying
diseases, catheterization, diabetes mellitus , of the
immune system.
In children ..congenital abnormalities
Risk factors
 Catheterization by placing Foleys catheters in
the urinary bladder is one of the most common
sources of infection.. Nosocomial UTI.. 5-15%
 Diabetes mellitus and Immunosuppressed
 Most common Klebsiella pneumoniae, Proteus
mirabilis, Enterococcus sp., P.aeruginosa.
 Rarely Strict anaerobic bacteria or Candida spp. can
cause UTI.
 kidney stones in any part of the urinary tract can form
a blockage, creating the conditions for a UTI.
Lab Diagnosis-1
 Routine Microscopic Fresh Urine analysis:
- Midstream Urine should be collected.. Early morning
- Urine Should be examined with one hour of collection
or refrigerated for < 24h.
- Presence > 8 WBSc /phf.. Most probable Infection
- Presence few Red Blood Cells .. Women.. Men ?
- Presence of Bacteria.. Rare Candida.. Normal flora.
- Protein, Sugar, pH, Casts, specific gravity etc.
- Symptomatic UTI.. Acute Infection/ Significant
Bacteriuria: 100,000 colony-forming units (105CFU)
per ml.. Plus Numerous WBCs ( > 10 WBSc /phf)
Lab Diagnosis-2
 Asymptomatic /Chronic Infection: 20.000-100,000
CFU/ ml .. Midstream Urine.. 99% Pure Growth.. One
Facultative Anaerobic Bacteria species..
 Community UTIs: 80-90% E. coli, Less Staph., Others.
 Hospital UTIs: 50% Klebsilla-Enterobacter, Proteus,
Pseudomonas aeruginosa, Enterococcus
 Presence Less than 20.000.. No WBCS.. Mostly Not
 Mixed Bacterial Cultures are mostly Contamination
 Suprapubic Urine .. Any Bacterial Count.. Infant &
Young children..
 Urine culture on Blood & MacConkey agar,35-37C
Incubation ..24-48 Hrs..
E. coli – Lactose Fermenter
Gram-stain & Culture on MacConkey agar
Antimicrobial Treatment -1
 The clinical manifestations determine the initial step in
Antimicrobial Therapy.
 Community acquired infection /outpatients
– A febrile patients experiencing first time uncomplicated
symptomatic.. acute cystitis and/or urethritis are usually
treated for three days with Augumentin,trimethoprimsulfamethoxazole, nitrofurantoin, nalidix acid
,Norfloxacin/ Ciprofloxacin.
– Long-term studies have shown antibiotic prophylaxis to be
effective for up to five years with trimethoprim, trimethoprimsulfamethoxazole or nitrofurantoin..
Antimicrobial Treatment -2
- Recurrence of UTI's within 3 months require
performing Urine Culture and Antimicrobial
Susceptibility Test. Often infection associated with
R- bacteria strains.
- Hospital acquired UTI's is often associated MTD-R
bacteria.. require culture and susceptibility test.
 Pyelonephritis is more serious & difficult to cure..
reoccurrence due to relapse (treatment failure) or
reinfection .. Mostly with the same bacteria spp. or
mixed culture.. 2 bacteria spp.
 Patients experiencing high fever, shaking chills and
flank or abdominal pain, in addition to symptoms of
lower UTI, should be hospitalized and treated with
intravenous drugs.
Treatment & PREVENTION
A large number of pregnant women develop
asymptomatic bacteriuria. Up to 30% of pregnant
women with asymptomatic bacteriuria will develop
acute pyelonephritis if not treated.
 Drug treatment of asymptomatic bacteriuria in
pregnant women decreases the risk of pyelonephritis..
preterm birth or baby low birth weight.
 Urine samples should be obtained periodically from
pregnant women to determine if they have bacteriuria.
 Augmentin, Co-trimoxazole, Amoxacillin, Ciropfloxcin /
levofloxacin, Nitrofurantioin , Nalidixic acid, Ceftriaxion
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