Case history 2:

A 50-year-old women went to her physician complaining of tiredness, shaking chills, a pain
in her loin, and a burning sensation on passing urine, which she was doing more frequently
than normal. On examination, she seemed a bit pale and that she had some suprapubic
tenderness. Her urine was tested with a dipstick and showed a positive result for nitrite, pus
cells, and protein. The doctor took a blood and urine sample for confirmation and sent them
to the laboratory. A diagnosis of pyelonephritis was made and she was started on
antibiotics. The following day the laboratory results were available. The full blood count
showed a neutrophilia and a pure culture of Gram – negative bacilli, oxidase negative,
and lactose fermenting was grown from the urine.
1. What is the suspected causative agent? What other causative agents of UTI?

● The commonest infecting agent for urinary tract infections is E. coli

(Uropathogenic E. coli (UPEC) is the major cause of urinary tract infections (UTIs) in
anatomically normal, unobstructed urinary tracts)

N.B.
80% of all UTI are caused by E. coli in the community and about 60% in hospital.

● Other agents causing UTI are: Enterococcus, Proteus, Staph. saprophyticus, Pseudomonas,
and other enteric bacteria.

2. How does the causative agent enter the body and how does it spread within the body?

● The infection is endogenous, the source of the bacteria being the fecal flora.
● Organisms gain entry to the bladder from the perineum and in the presence of
vesico-ureteric reflux may infect the renal parenchyma.
● UTI is more common in females because of the short urethra.
3. What is the virulence factors of the causative agent and the disease pathogenesis?

● UPEC have several adhesins that bind to uroepithelial cells.

● UPEC produce a number of toxins that increase desquamation of uroepithelial cells and
are also cytotoxic.
● UPEC are protected from the innate host defense system by the K1 capsular antigen,
which is antiphagocytic.
● Binding of UPEC to uroepithelial cells stimulates the production of IL-8 and the
recruitment of granulocytes to the renal tract.
● The role of the adaptive immune system in protection is uncertain although IgA and IgG
are produced.
4. What is the media uesd routienly for urine specimen?
• In routine practice urine is cultured on cystine lactose electrolyte-deficient (CLED) medium.
Cystine is a growth factor for some organisms; lactose is to differentiate utilization of lactose
from non-utilization (e.g. Pseudomonas); and the electrolyte deficiency inhibits the swarming of
Proteus, which may obscure bacterial colonies.

• Other media can be used: Blood agar - MacConkey agar

5. What is the best time to collect urine sample?

• MSU (mid-stream urine), In the early morning

6. How the result of culture is interpreted?

(A significant bacteriuria is a single species in numbers greater than 105 organisms per ml of urine.)
• The number of colonies are counted by the following:
• 50 CFU (colony forming unit) or more indicate infection or
• 105 (100,000) or more bacteria/ ml (significant bacteruria)
• 104 -105 (doubtful significant)
• A count of less than 10,000 (104) /ml is always due to contamination (non significant).

Note: most UTI show growth of a single type of organism although some infections can occur
with two species.
7. What is the typical clinical presentation and what complications can occur?
● Infection may be asymptomatic.
● In pregnant women and children asymptomatic infection can have serious consequences.
● Cystitis presents with frequency of micturition, dysuria, and suprapubic pain.
● Pyelonephritis presents with loin pain, fever, rigors, frequency of micturition, and dysuria.
● Neonates have a nonspecific presentation with fever, vomiting, and failure to thrive.
● Elderly patients may have fever, incontinence, and dementia.
● Complications are septicemia, renal scarring, renal abscess, and renal failure.

8. what is the differential diagnosis?

● Differential diagnosis includes musculoskeletal injury, renal vein thrombosis, urolithiasis.

9. How is the disease managed and prevented?

● Asymptomatic bacteriuria in pregnant women or children should be treated.
● Antibiotic use depends upon the local resistance pattern.
● Three days treatment with an appropriate antibiotic is usually sufficient for uncomplicated
cystitis.
● Two weeks treatment with the same antibiotic is required for pyelonephritis.