URINARY TRACT INFECTION

by
Hasyim kasim MD
 Urinary Tract Infections (UTI)

Frequent clinical problem

Any site in the urinary tract may be involved : the urethra, prostate,
bladder, ureter, kidney and perinephric space.

Bacterial infection is most common, but fungi, chlamydia, viruses

and parasites may be responsible in some patients

Women >>> Men

 Terminology of Urinary Tract Infections (1)

Bacteriuria : Presence of bacteria in the urine.

Asymptomatic bacteriuria : 105 CFU/ml urine with or without pyuria, in a patient

without symptoms of UTI.

Cystitis : inflammation of the bladder

• Bacterial cystitis
• Abacterial cystitis (urethral syndrome)

Acute pyelonephritis: acute bacterial infection of the kidney characterized by

chills and fever (often high) and flank pain (usually unilateral), as well as
tenderness.

Chronic pyelonephritis : Radiological diagnosis where there is evidence of focal

scarring of the kidneys with associated calyceal abnormality indicating renal
damage due to a combination of reccurent infection with obstruction of the
pelviocalyceal system (chronic obstructive nephropathy) or vesicoureteral
reflux (reflux nephropathy).
Ribeiro RM, et al. Int Urogynecol 2002;13:198-199.
 Terminology of Urinary Tract Infections (2)

Reinfection : An infection with a different strain of microorganism or a different

serological type after (end of therapy) eradication of previous infection.
Most likely represent infections of the bladder, occur weeks to months after
treatment of the previous infection, response well to therapy,
usually associated with a normal urinary tract

Relapse : A consecutive urinary infection caused by the same strain or serotype of

bacteria, usually represent infection of the kidney or prostat, often recur
within 1 – 6 weeks after antimicrobials have been discontinued, some cases
represent persistent infection, anatomic abnormalities or renal insuficiency
are more common with relapsing or persistent infection, a long course of
antimicrobials or surgery may be required if the urine is to be permanently
sterilized

Ribeiro RM, et al. Int Urogynecol J 2002;13:198-199.

 Terminology of Urinary Tract Infections (3)

Persistence : the continued presence of the microorganisms isolated at the beginning

of the treatment, owing to resistance to antimicrobial therapy, inadequate
drug dosage, or a urological abnormality. These unresolved infections may
be also in consequence of the patient’s non-compliance in taking medication,
mixed infections with two different bacterial strains with mutually exclusive
susceptibilities, or renal insufficiency (leading to an inadequate drug
concentration in the urine).

Recurrent UTI: patients with at least two infections within 6 months or three or
more during a single year, in which the initial episode is resolved and
is followed by another infection.

Ribeiro RM, et al. Int Urogynecol J 2002;13:198-199.

 Diagnosis Urinary Tract Infection
1. Symptoms :
Lower UTI :
• Frequency, dysuria, suprapubic pain
Upper UTI :
• Fever, flank pain, and chills as well as symptoms similar to bladder
infection
2. Urinalysis
• The presence of  10 WBC / mm3 fresh un-spun midstream urine
• The presence of  10 WBC / high-power field sediment midstream
urine

3. Culture
4. Radiological evaluation
• Ultrosound
• Plain abdominal radiography
• Intravenous urography
• CT scanning
 Criteria for diagnosis of significant bacteriuria

Symptomatic women :
•  102 coliform organisms/ml urine plus pyuria, or
•  105 of any pathogenic organism/ml urine, or
• Any growth of a pathogenic organism from urine obtained by
suprapubic aspiration

Symptomatic men :
•  103 pathogenic organism/ml urine

Asymptomatic patients :
•  105 pathogenic organism/ml urine in two consecutive samples
 Classification of Urinary Tract Infection (1)

I. Lower urinary tract infection ( Cystitis )

Frequency, dysuria, suprapubic pain

II. Upper urinary tract infection ( Pyelonephritis )

Fever, flank pain, and chills as well as symptoms

similar to bladder infection
 Classification of Urinary Tract Infection (2)

I. Uncomplicated urinary tract infection

• Occurs in individuals with structurally and functionally normal genitourinary

tracts
• Most common bacterial infection that occurs in women, but is uncommon in
men
• May involve the bladder or the kidneys and may be symptomatic or
asymptomatic

II. Complicated urinary tract infection

• As acute or chronic parenchymal infection associated with a functional or

structural urinary tract abnormality
e.g. : Neurogenic bladder, urinary tract obstruction, immunocompromized
patients, diabetes mellitus, polycystic kidney disease, renal transplant
recipient.
Bacterial etiology of urinary tract infection

• E. coli : 70-95% (uncomplicated UTI), 21-54% (complicated)

• S. Saprophyticus : 5-20% (uncomplicated), 1-4% (complicated)
• Enterococci : 1-2% (uncomplicated), 1-23% (complicated)
• Proteus mirabilis : 1-2% (uncomplicated ), 1-10% (complicated)
• Klebsiella spp : 1-2% (uncomplicated), 2-17% (complicated)
• Pseudomonas aeruginosa : <1% (uncomplicated), 2-19% (complicated)
Clinical Classification of Urinary Tract Infection

1. Acute uncomplicated cystitis in women

2. Acute uncomplicated pyelonephritis in women
3. Complicated UTI in both sexes
4. Recurrent infections in women
5. Asymptomatic bacteriuria

McBryde C, Redington. Primary Care Case Rev 2001 ; 4 : 2

 Acute uncomplicated cystitis in women

Single dose or 3-day course of treatment

(trimethoprim sulfamethoxasole, quinolone, amoxycillin)

Follow-up urine culture 7-14 days later

Cured Failure or relapse Reinfection

(sterile urine) (identical pathogens) (new pathogen)

Ultrasonography urinary tract

No investigation KUB radiograph

Treatment for 2 weeks

Catel WR. Clin Drug Invest 1995 ; 9 (suppl 1) : 8-13.

Clinical Classification of Urinary Tract Infection

1. Acute uncomplicated cystitis in women

2. Acute uncomplicated pyelonephritis in women
3. Complicated UTI in both sexes
4. Recurrent infections in women
5. Asymptomatic bacteriuria

McBryde C, Redington. Primary Care Case Rev 2001 ; 4 : 2

Acute uncomplicated pyelonephritis in women

Severe illness
Moderate severity

Hospitalization with initial

Outpatients and oral parenteral therapy
therapy possible (trimethoprim-
(trimethoprim sulfametaxazol,
sulfamethoxasole, ceftriaxone, quinolone,
quinolone, amoxycillin) gentamicin
with/without ampicilin
Urologic evaluation

Resolution
No resolution in 5 days No resolution
in 5 days in 5 days

Radiologic evaluation
Treatment 14 days Oral treatment 14 days or
longer as required
Clinical Classification of Urinary Tract Infection

1. Acute uncomplicated cystitis in women

2. Acute uncomplicated pyelonephritis in women
3. Complicated UTI in both sexes
4. Recurrent infections in women
5. Asymptomatic bacteriuria

McBryde C, Redington. Primary Care Case Rev 2001 ; 4 : 2

 Complicated UTI in both sexes
Hospitalize, urine culture, blood culture

Empiric therapy with parenteral regimen

Significant clinical improvement

Yes No
5 Days

Switch to or continue Review antimicrobial susceptibility pattern

oral regimen Radiologic & urologic evaluation
For total 2 weeks Correct reversible risk factors

Review treatment plan as appropriate,

treat for total 2 weeks or longers if necessary

Follow-up urine culture after treatment

Clinical Classification of Urinary Tract Infection

1. Acute uncomplicated cystitis in women

2. Acute uncomplicated pyelonephritis in women
3. Complicated UTI in both sexes
4. Recurrent infections in women
5. Asymptomatic bacteriuria

McBryde C, Redington. Primary Care Case Rev 2001 ; 4 : 2

 Recurrent infections in women
Reccurent UTI in women

Relapse Diagnosis Reinfection

Conventional antibiotic ≥ 3  year ≤ 2  year

therapy 2-6 weeks

Sexually active Conventional antibiotic

Postmenopausal therapy 3-7 days

Estrogen substitution
Antibiotic therapy :
(oral & topical)
On demand or
Postcoital or
Longterm prophylaxis
Antibiotic therapy :
On demand or
Longterm prophylaxis
Madersbacher S, et al. Curr Opin Urol 2000 ; 10 : 32.
Drug regimens for long-term, low-dose prophylaxis of
recurrent urinary tract infection

Drug Dose*
Nitrofurantoin 50 mg

Trimethoprim 100 mg

Co-trimoxazole 0.24 g

Norfloxacin 200 mg

Ciprofloxacin 125 mg

Cephalexin 125 mg
( useful if renal insufficiency)
Hexamine hippurate 1g

* Treatment is effective if taken each night, alternate nights, three times a week,
or just after intercourse
Clinical Classification of Urinary Tract Infection

1. Acute uncomplicated cystitis in women

2. Acute uncomplicated pyelonephritis in women
3. Complicated UTI in both sexes
4. Recurrent infections in women
5. Asymptomatic bacteriuria

McBryde C, Redington. Primary Care Case Rev 2001 ; 4 : 2

Indication for the treatment of patients with
asymptomatic bacteriuria

Definitive Possible Not indicated

Pregnancy Diabetes mellitus Elderly

Before an invasive Short-term School girls and

genitourinary indwelling premanopausal women
procedure catheterization

Intermittent Children with reflux

catheterization
Renal transplant Long-term Patients with abnormal
indwelling catheter urinary tract

Raz R. Nephrol Dial Transplant 2001 ; 16 (suppl 6) : 135.

 Indication for imaging studies in
patients with Urinary Tract Infections
• Infections in a newborn
• Reccurent infection occuring in childhood
• Two or more infections in adult females
• One infection in adult males
• Elevated creatinine level
• History of urinary calculi
• Neurologic bladder dysfunction
• Persistent hematuria
• Previous genitourinary surgery
• Prolonged fever after initiation of antibiotic therapy
• Relapsing infection
• Urea-splitting organisms
• Unusual causative organism