Urinary Tract Infections

Shareen Joyce V. Agbayani

Internal Medicine PGI
San Pedro Hospital
Urinary Tract Infections

• Asymptomatic - subclinical infection

• Symptomatic - disease
★ Cystitis
★ Pyelonephritis
Urinary Tract Infection

• Uncomplicated UTI - acute cystitis or pyelonephritis in

nonpregnant women without anatomic abnormalities or
instrumentation of the urinary tract
• Complicated UTI - all other types of UTI
Urinary Tract Infection
• UTI and ASB
★ (+) bacteria in the urinary tract
★ WBCs and inflammatory cytokines in the urine
• ASB - absence of symptoms attributable to the bacteria in the
urinary tract and usually does not require treatment
• UTI - imply symptomatic disease that warrants antimicrobial
therapy
Epidemiology

•Neonatal period - UTI is slightly higher among males than among

females
• After 50 years of age - obstruction from prostatic hypertrophy
becomes common in men, and the incidence of UTI is almost as high
among men as among women.
•Between 1 year and ~50 years of age - UTI and recurrent UTI are
predominantly diseases of females
Acute Cystitis Risk Factors

•Recent use of a diaphragm with spermicide

•frequent sexual intercourse
•history of UTI
Pyelonephritis Risk Factors

•frequent sexual intercourse

•new sexual partner
•UTI in the previous 12 months
•maternal history of UTI
•diabetes
•incontinence
Recurrent UTI Risk Factors

• frequent sexual intercourse

• spermicide use
• history of premenopausal UTI
• anatomic factors affecting bladder emptying: cystoceles, urinary
incontinence, and residual urine.
Risk Factors
• ASB during pregnancy
✦associated with maternal pyelonephritis, which in turn is associated
with preterm delivery
✦Antibiotic treatment of ASB in pregnant women can reduce the risk of
pyelonephritis, preterm delivery
• majority of men with UTI
✦have a functional or anatomic abnormality of the urinary tract
✦most commonly urinary obstruction secondary to prostatic hypertrophy.
Risk Factors
• Lack of circumcision is associated with an increased risk of UTI
• Increased duration of diabetes and the use of insulin rather than oral
medication - elevated risk of UTI among women with DM.
• Poor bladder function, obstruction in urinary flow, and incomplete
voiding are additional factors commonly found in patients with DM
that increase the risk of UTI.
• SGLT2 inhibitors used for treatment of diabetes result in glycosuria
and may be associated with small increases in the risk of UTI.
Etiology
• Escherichia coli - predominant causative agent
• others:
✦ Pseudomonas aeruginosa
✦ Klebsiella
✦ Proteus
✦ Citrobacter
✦ Acinetobacter
✦ Morganella species
✦ Gram-positive bacteria (e.g., enterococci and Staphylococcus aureus)
and yeasts
Pathogenesis
•Bacteria establish infection by ascending from the urethra to the
bladder.
•Any foreign body in the urinary tract provides an inert surface for
bacterial colonization.
•Abnormal micturition and/or significant residual urine volume
promotes infection
•Hematogenous spread accounts for <2% of documented UTIs and
usually results from bacteremia (Salmonella and S. aureus)
•Hematogenous infections may produce focal abscesses or areas of
pyelonephritis within a kidney and result in positive urine cultures.
Pathogenesis
Environmental Factor: Vaginal Ecology
•Colonization of the vaginal introitus and periurethral area with organisms from the
intestinal flora (E. coli) - critical initial step
•Sexual intercourse is associated with an increased risk of vaginal colonization with
E. coli
•Nonoxynol-9 in spermicide is toxic to the normal vaginal lactobacilli and thus is
likewise associated with an increased risk of E. coli vaginal colonization and
bacteriuria.
•topical estrogens to prevent UTI in postmenopausal women is controversial; given
the side effects of systemic hormone replacement, oral estrogens should not be
used to prevent UTI.
Pathogenesis
Environmental Factor: Anatomic and Functional
Abnormalities
• stones or urinary catheters provide an inert surface for bacterial colonization
and formation of a persistent biofilm
• vesicoureteral reflux, ureteral obstruction secondary to prostatic hypertrophy,
neurogenic bladder, and urinary diversion surgery create an environment
favorable to UTI.
•Inhibition of ureteral peristalsis and decreased ureteral tone leading to
vesicoureteral reflux are important in the pathogenesis of pyelonephritis in
pregnant women.
• distance of the urethra from the anus—are considered to be the primary reason
why UTI is predominantly an illness of young women rather than of young
men.
Diagnostic tools
•Dipstick testing
★Can detect an enzyme (leukocyte esterase) in polymorphonuclear leukocytes in the
host’s urine, whether the cells are intact or lysed.
★can confirm the diagnosis of uncomplicated cystitis
•Urine microscopy - reveals pyuria in nearly all cases of cystitis and hematuria
•Urine culture
✦diagnostic gold standard for UTI
✦results do not become available until 24 h after the patient’s presentation
•women with symptoms of cystitis
✦colony count threshold of ≥102 bacteria/mL
•men
✦minimal level indicating infection appears to be 103/mL.
Diagnostic Approach to UTI
Diagnostic Approach to UTI
Approach to the Patient:
Asymptomatic Bacteriuria

Systemic signs:

Fever

Altered mental status

Leukocytosis in the setting of a positive urine culture

Approach to the Patient:
Cystitis
Unilateral back or flank pain - upper urinary tract involvement

Fever - invasive infection

Typical signs/symptoms

Dysuria

Urinary frequency

Urgency

Others: nocturia, hesitancy, suprapubic discomfort, hematuria

Approach to the Patient:
Pyelonephritis
Mild - low grade fever with or without lower back or costovertebral angle
pain

Severe - high fever, rigors, nausea, vomiting, flank pain or loin pain

Fever - main feature distinguishing cystitis from pyelonephritis

High spiking picket-fence pattern

Resolves over 72h of therapy

Approach to the Patient:
Pyelonephritis

DM - obstructive uropathy associated with acute papillary necrosis

Emphysematous pyelonephritis - severe form; production of gas in renal

and perinephritic tissues; occurs in DM patients

Xanthogranulomatous pyelonephritis - chronic urinary obstruction (staghorn

calculi) with chronic infection leads to supportive destruction of renal tissue.
Approach to the Patient:
Prostatitis
Acute

Dysuria

Frequency

Prostatic pelvic or perineal pain

Chronic

Recurrent episodes of cystitis

Pelvic and perineal pain

Approach to the Patient:
Complicated UTI

Symptomatic episode of cystitis or pyelonephritis

Anatomic predisposition to infection, with a foreign body, or with factors

predisposing to a delayed response to therapy
Treatment:
Acute Complicated Cystitis in Women
Treatment:
Acute Complicated Cystitis in Women
•Nitrofurantoin - highly active against E. coli and most non–E. coli isolates.
•Most fluoroquinolones are highly effective as short-course therapy for
cystitis
•Urinary analgesics are appropriate in certain situations to speed resolution
of bladder discomfort.
•Combination analgesics containing urinary antiseptics (methenamine,
methylene blue), a urine-acidifying agent (sodium phosphate), and an
antispasmodic agent (hyoscyamine) also are available.
Treatment:
Uncomplicated Pyelonephritis
• Fluoroquinolones
✦first-line therapy for acute uncomplicated pyelonephritis
✦7-day course of therapy with oral ciprofloxacin (500 mg twice daily,
with or without an initial IV 400-mg dose) was highly effective for the
initial management of pyelonephritis
• Oral TMP-SMX
✦one double-strength tablet twice daily for 14 days - uropathogen is
known to be susceptible.
✦If the pathogen’s susceptibility is not known and TMP- SMX is used
- initial IV 1-g dose of ceftriaxone is recommended.
Treatment:
Uncomplicated Pyelonephritis
• Parenteral therapy - fluoroquinolones, an extended-spectrum
cephalosporin with or without an aminoglycoside, or a carbapenem.
• Combinations of a β-lactam and a β-lactamase inhibitor (e.g.,
ampicillin-sulbactam, ticarcillin- clavulanate, piperacillin-
tazobactam) or a carbapenem (imipenem- cilastatin, ertapenem,
meropenem) - more complicated histories, previous episodes of
pyelonephritis, anticipated antimicrobial resistance, or recent urinary
tract manipulations
Treatment:
UTI in Pregnant Women
•Nitrofurantoin, ampicillin, and the cephalosporins - safe in early pregnancy.
•Ampicillin and cephalosporins - drugs of choice for the treatment of asymptomatic or
symptomatic UTI.
•ASB are treated for 4–7 days in the absence of evidence to support single-dose therapy.
•For pregnant women with overt pyelonephritis - parenteral β-lactam therapy with or
without aminoglycosides is the standard of care.
•Sulfonamides - avoided
✦first trimester (because of possible teratogenic effects)
✦near term (because of a possible role in the development of kernicterus).
•Fluoroquinolones -avoided because of possible adverse effects on fetal cartilage
development.
Treatment:
UTI in Men
•Fluoroquinolone or TMP-SMX
✦7- to 14-day course - uropathogen is susceptible.
•Suspected acute bacterial prostatitis
✦antimicrobial therapy should be initiated after urine and blood are
obtained for cultures.
•Therapy can be tailored to urine culture results and should be continued for
2–4 weeks.
•Documented chronic bacterial prostatitis
✦4- to 6-week course of antibiotics
•Recurrences - 12-week course of treatment.
Treatment:
Complicated UTI

•Xanthogranulomatous pyelonephritis - nephrectomy

•Emphysematous pyelonephritis - percutaneous drainage and can be
followed by elective nephrectomy as needed.
•Papillary necrosis with obstruction - relieve the obstruction and to
preserve renal function.
Treatment:
Asymptomatic Bacteruria

•pregnant women and patients undergoing urologic procedures -

directed by urine culture results.
•does not decrease the frequency of symptomatic infections or
complications except in pregnant women, persons undergoing
urologic surgery
Treatment:
CAUTI

•7- to 14-day course of antibiotics is recommended

•avoid insertion of unnecessary catheters and to remove catheters
once they are no longer necessary - best strategy for prevention of
CAUTI
Treatment:
Candiduria
•Removal of the urethral catheter - resolution of candiduria in more than one-
third of asymptomatic cases.
•Therapy is recommended for patients who have symptomatic cystitis or
pyelonephritis and for those who are at high risk for disseminated disease.
•Fluconazole
✦first-line regimen for Candida infections of the urinary tract
✦200–400 mg/d for 7–14 days
✦reaches high levels in urine
Clinical Practice Guideline
ASB
1. When is asymptomatic bacteriuria diagnosed?
•based on results of urine culture specimens that are collected aseptically and with
no evidence of contamination.

•asymptomatic women
✦ 2 consecutive voided urine specimens with isolation of the same bacterial strain
in quantitative counts ≥ 100,000 cfu/mL.
•men
✦ 1 clean-catch voided urine specimen with one bacterial species isolated in a
quantitative count ≥ 100,000 cfu/mL identifies bacteriuria.
•both men and women -
✦ 1 catheterized urine specimen with one bacterial species isolated in a
quantitative count ≥ 100 cfu/mL identifies bacteriuria.
Clinical Practice Guideline
ASB
2. Screening indications
• Patients who will undergo genitourinary manipulation or instrumentation
• All pregnant women

3. Periodic screening and treatment is not recommended in the following:

• Patients with diabetes mellitus
• Elderly patients
• Patients with indwelling catheters
• Solid organ transplant patients
• People living with HIV
• Spinal cord injury patients
• Patients with urologic abnormalities
Clinical Practice Guideline
ASB
4. What is the optimal screening test for asymptomatic
bacteriuria?
• Screening by urine culture is recommended
• In the absence of facilities for urine culture
✦ significant pyuria (>10 wbc/hpf) or
✦a positive gram stain of unspun urine (>2 microorganisms/oif) in 2
consecutive midstream urine samples
• Urine culture and sensitivity testing are not necessary - urinalysis is
negative for pyuria or urine gram stain is negative for organisms.
• Pyuria accompanying asymptomatic bacteriuria - not an indication for
antimicrobial treatment
Clinical Practice Guideline
ASB
Clinical Practice Guideline
Recurrent UTI in Women
1. How is recurrent UTI (rUTI) diagnosed?
• Healthy non pregnant women with no known urinary tract abnormalities
✦ 3 or more episodes of uncomplicated cystitis documented by urine
culture during 12 month period or
✦2 or more episodes in a 6 month period
• rUTI may either be:
✦ Relapse: initial organism persists and reemerges despite adequate
treatment occurring 1-2 weeks after treatment cessation
✦ Reinfection: caused by different bacteria or by previously isolated
bacteria after a negative intervening culture or an adequate period
(more than 2 weeks) between infections
 Clinical Practice Guideline
Recurrent UTI in Women
2. Among those with recurrent UTI, who would benefit from further diagnostic
evaluation?

•Routine screening for urologic abnormalities is not recommended for the general patient
population.
•Screening for urologic abnormalities is recommended in the following situations:
✦ No response to appropriate antimicrobial therapy or rapid relapse after such therapy
✦ Gross hematuria during a UTI episode or persistent microscopic hematuria
✦ Obstructive symptoms
✦ Clinical impression of persistent infection
✦ Infection with urea-splitting bacteria (Proteus, Morganella, Providencia)
✦ History of pyelonephritis
✦ History of or symptoms suggestive of urolithiasis
✦ History of childhood UTI
✦ Elevated serum creatinine
Clinical Practice Guideline
Recurrent UTI in Women
3. What diagnostic work-ups are indicated in women with rUTI
• Radiologic or imaging studies and cystoscopy are not routinely 

indicated in patients with recurrent UTI.
• Renal ultrasound or CT scan/stonogram may be done to screen for urologic
abnormalities

2.4. When is prophylaxis for recurrent UTI indicated?

•recommended in women whose frequency of recurrence 

is not acceptable to the patient in terms of level of discomfort or
interference with activities of daily living.
•withheld according to patient preference if the frequency of recurrence is
tolerable to the patient.
Clinical Practice Guideline
Recurrent UTI in Women
• The following factors should guide the physician in determining the patient’s
risk-benefit profile and in deciding which prophylactic strategies will be used:
• ! Frequency and pattern of recurrences
• ! Patient’s lifestyle, compliance and willingness to commit to a specific
regimen
• ! Plans for a pregnancy
• ! Antimicrobial resistance and susceptibility pattern of the organisms
causing the patient’s previous UTIs
• ! Risk of adverse events and drug allergies
• Antibiotic prophylaxis should be limited to women with recurrent UTI in whom
non-antimicrobial strategies have not been effective and who prefer
prophylactic antimicrobial therapy.
Clinical Practice Guideline
Recurrent UTI in Women
5. How effective are non-antimicrobial strategies in preventing rUTI?
• Cranberry juice and cranberry products are not recommended for the prevention of
urinary tract infections
• Application of intravaginal estriol cream
✦once each night for 2 weeks followed by twice-weekly applications for at least 8
months OR
✦use of an estradiol releasing silicone vaginal ring for 3 months is recommended for
the prevention of recurrent UTI in post- menopausal women
• Low-dose oral estrogen is not recommended for the prevention of recurrent UTI.
• Immunoprophylaxis, using immune-active E. coli fractions is 

recommended for the prevention of recurrent UTI (OD per orem for 3 months)
• A longer/extended dosing regimen
✦OD for 3 months, rest for 3 months, 10 days per month for 3 months, and rest for 3
months
Clinical Practice Guideline
Recurrent UTI in Women
6. How effective are antibiotic prophylactic regimens in preventing
rUTI?
•Prophylaxis is recommended in women whose frequency of recurrence is
not acceptable to the patient in terms of level of discomfort or interference
with activities of daily living.
•Continuous prophylaxis - daily intake of a low-dose of antibiotic for 6-12
months
•Post-coital prophylaxis- intake of a single dose of antibiotic immediately
after sexual intercourse
•Intermittent prophylaxis - self-treatment with a single antibiotic dose based
on patient’s perceived need.
Clinical Practice Guideline
Recurrent UTI in Women
Clinical Practice Guideline
Complicated UTI
1. When is complicated urinary tract infection suspected or diagnosed?
•Complicated UTI (cUTI) is significant bacteriuria plus clinical symptoms which
occurs in the setting of
★ functional or anatomic abnormalities of the urinary tract or kidneys, or
★the presence of an underlying disease that interferes with host defense
mechanisms, or
★any condition that increases the risk of acquiring [persistent] infection and/
or treatment failure
•cut-off for significant bacteriuria in complicated UTI has been set at
100,000 CFU/mL.
• in catheterized patients, low-level bacteriuria or counts < 100,000 CFU/mL
maybe significant.
Clinical Practice Guideline
Complicated UTI
2. In patients with suspected complicated UTI, what diagnostic
tests should be done to assist the physician in managing the
infection effectively?
•urine sample for gram stain, and culture and sensitivity testing
must always be obtained before the initiation of any treatment.
✦Additional ancillary diagnostic tests will depend on the nature
of the complicated UTI
•Imaging of the urinary tract is warranted whenever anatomic or
structural abnormalities are suspected as contributing to a UTI.
•CT-scan is generally preferred over KUB ultrasound
Clinical Practice Guideline
Complicated UTI
3. Do patients with complicated UTI need to be hospitalized?

Require hospitalization:
• marked debility and signs of sepsis,
• uncertainty in diagnosis,
• concern about adherence to treatment,
• unable to maintain oral hydration or take oral medications
• mild to moderate illness (symptoms of fever and lower or upper UTI
without urosepsis, circulatory failure and/or organ dysfunction or
failure)

 Clinical Practice Guideline
Complicated UTI
4. What antibiotics are recommended for empiric therapy of complicated UTI?
•mild to moderate illness
✦oral fluoroquinolones or amoxicillin/clavulanic acid may be used if there
are no risk factors for infection with antibiotic resistant organisms
•severely ill patients
✦broad-spectrum parenteral antibiotics
➡expected pathogens,
➡Results of the urine gram stain,
➡The current susceptibility patterns of microorganisms in the area,
➡Risk factors for the acquisition of drug-resistant organism
Clinical Practice Guideline
Complicated UTI

5. How long should antibiotics be given in complicated

UTI?
• at least 7-14 days of therapy is recommended



Clinical Practice Guideline
Complicated UTI
Clinical Practice Guideline
Complicated UTI
6. When an oral regimen is not available or if continuation of an
intravenously-administered antibiotic is necessary, outpatient parenteral
antibiotic therapy (OPAT) can be an option.


OPAT Criteria:
•An indication for parenteral antibiotic therapy (i.e. presence of an infection that
warrants antibiotic use) in the absence of an oral or alternate routes of delivery
•No other clinical indication for hospitalization
•Consent of the patient and/or caregiver to participate (including an understanding
of the benefits, risks, and economic considerations involved)

Outpatient environment safe and adequate to support care
Clinical Practice Guideline
UTI in Diabetics
1. How should UTI in diabetic patients be managed?
• require pre-treatment urine gram stain and culture and a post-treatment urine
culture.
• At least 7-14 days of oral or parenteral antibiotics may be used.
• present with signs of sepsis should be hospitalized.
• Blood culture is indicated for severely ill patients before starting therapy.
• Failure to respond to empiric therapy within 48 to 72 hours - warrants a plain
abdominal radiograph of the KUB, a renal ultrasound, or a CT-scan.

2. Should diabetic patients be screened and treated for asymptomatic

bacteriuria?
• Screening and treatment for asymptomatic bacteriuria among diabetic patients are
not recommended
Clinical Practice Guideline
CAUTI
1. When is catheter-associated urinary tract infection (CA-UTI)
suspected or diagnosed?
• Fever and/or other signs or symptoms compatible with UTI are
present with no other identified source of infection;
• At least 103 colony forming units (cfu)/mL of at least 1 bacterial
species are present in a single catheter urine specimen or in a
midstream voided urine specimen;
• In a patient with an indwelling urethral, suprapubic or condom
catheter, or which has been removed within the previous 48 hours.
Clinical Practice Guideline
CAUTI
2. Should patients with indwelling urethral, indwelling suprapubic, or
intermittent catheterization be screened and treated for asymptomatic
bacteriuria?
•Screening and treatment of catheter-associated asymptomatic bacteriuria
(CA-ASB) are not routinely recommended.
•Screening and treatment of CA-ASB are recommended only for pregnant
patients and those who will undergo urologic procedures

3. In patients with suspected CA-UTI, what diagnostic tests should be

done to assist the physician in managing the infection effectively?
• obtain urine gram stain and cultures BEFORE starting empiric antibiotic
coverage for CA-UTI.
Clinical Practice Guideline
CAUTI
Clinical Practice Guideline
CAUTI
 Clinical Practice Guideline
Renal Abscess
1.1.When should renal abscess be suspected in patients presenting with upper
UTI?
•Renal abscess should be strongly considered in diabetic patients presenting with
hypotension and renal impairment.
•It can also be considered for patients suspected to have upper UTI who remain
febrile and hypotensive 72 hours after initial IV antibiotic administration.

2.2. What are the diagnostic tests to be done in patients suspected of having renal
abscess?
• CT scan is preferred over ultrasound because of the former’s higher sensitivity.
• Urine and blood cultures should be requested for patients suspected of having renal
abscess.
• abscess aspirate, if drainage has been performed, should be sent for culture studies.
 Clinical Practice Guideline
Renal Abscess
3. In patients diagnosed with renal abscess, when is surgical intervention warranted?
•lesions less than 5 cm in diameter, antibiotics can be given alone and should be continued for
4-10 weeks until the abscess has completely regressed as evidenced by CT scan. Drainage
need not be done.
•Percutaneous drainage should be considered for renal and perirenal abscesses with sizes >5
cm.
•Open drainage should be considered for those with multiloculated abscesses and for those
patients in whom percutaneous drainage is unsuccessful. Antibiotics should be given for a
minimum of four weeks after drainage.

4. What empiric antibiotics should be started on those suspected to have renal abscess?
•activity against gram-negative organisms (Escherichia coli, Klebsiella sp., and Proteus mirabilis)
•Vancomycin can be added for coverage of Staphylococcus aureus if there is another source of
infection where S. aureus is suspected
Clinical Practice Guideline
Urinary Candidiasis
1. If antimicrobial therapy is deemed necessary for a patient with candiduria, what
antifungal agents are effective for treatment?
• Fluconazole 400 mg loading dose, and then 200 mg/day for 7–14 days; route of administration
depends on patient status and oral tolerability.
•certain clinical situations such as prior azole use, refractory infection or suspicion of drug
resistance to fluconazole (e.g., patients with suspected C. glabrata infection), IV amphotericin
B deoxycholate (AmBd) at a dose of 0.3–1.0 mg/kg per day can be given.
•undergo urologic procedures and in whom candiduria was found to be present
★fluconazole 200–400 mg (3–6 mg/kg) daily or
★AmBd 0.3–0.6 mg/kg daily for several days before and after the procedure

2. What is the value of bladder irrigation in the management of urinary candidiasis?

•Bladder irrigation with amphotericin B can be used as an adjunct therapy
•continuous irrigation of amphotericin B at a concentration of 50 mg per liter of sterile water for
a period of five days
Clinical Practice Guideline
Urinary Candidiasis
End