Urinary Tract Infections

Renal 2 Module
Jolyne Drummelsmith
 Learning Objectives
1. Compare and contrast symptoms of lower urinary tract infection (cystitis) and
upper urinary tract infection (pyelonephritis).
2. Outline the epidemiology and pathogenesis of urinary tract infections.
3. Describe and differentiate the microbes (bacteria, fungi, viruses, helminthes) that
can cause urinary tract infections.
4. Diagnose urinary infections given the results of urinalysis and quantitative urine
culture.
5. Determine the specific causative organism of UTI given a patient vignette.
6. Explain strategies to prevent urinary tract infections/complications.

Practice questions posted on Canvas.

More questions presented in the UTI therapy workshop
 Definition of Urinary Tract Infection (UTI)
• The normal urinary tract is sterile, except for the distal urethra.
• DEFINITION: Ascending invasion of the bladder, kidneys, or
prostate gland by a microbe that multiplies and causes
inflammation, leading to signs and symptoms that may include
dysuria, increased urinary frequency, back pain, fever, pyuria,
and bacteriuria.
• Excluded are infections largely confined to the urethra, which
are likely to be sexually transmitted infections.
 Importance of Urinary Tract Infections

• Common bacterial infection: most otherwise healthy women

experience several infections in their lifetimes
• A common cause of healthcare-associated infection in US,
usually associated with catheterization (CAUTI)
Infection control
• Can be a source of sepsis (urosepsis) Sepsis

• Asymptomatic bacteriuria in pregnancy can lead to premature

delivery and low birth weight babies
Anatomy
Anatomic Considerations

Note proximity of
anal, vaginal,
and urethral
orifices
 Epidemiology

• Most patients are females in the reproductive age group

• Most female patients are sexually active, sometimes pregnant
• Male patients are mostly over 50 years old and have enlarged
prostate glands
• Catheterization of the bladder is a strong risk factor, leading to
many healthcare-associated infections
 Clinical Features in Symptomatic Bacteriuria

Lower UTI (cystitis) Upper UTI (pyelonephritis)

• Dysuria (burning pain) • Fever, chills, and sweats, nausea, vomiting
• Frequency • Flank pain (CVA tenderness) or abdominal
• Urgency discomfort/pain
• Bladder fullness/ pressure • May have S/S of dehydration and
hypotension, sicker than in cystitis
• Abdominal/suprapubic discomfort or pain
Bacteriuria
Hematuria (50%) Pyuria
WBC casts sometimes present
Bacteriuria
Pyuria
May be confused with other serious disease
Ascending from cystitis OR hematogenous
Easily confused with urethritis (STIs) spread

7
 Clinical Features of Prostatitis
• Less common than cystitis and pyelonephritis
• Fever, pelvic pain, back pain, and urinary retention are present
• Tender prostate on rectal examination
• Escherichia coli and Staphylococcus aureus are common
• Some have abscesses, some chronic cases have no symptoms
or signs on physical exam
• May occur after cystoscopy
 Pathogenesis
• Retrograde ascension of microbes up urethra to bladder or further to
kidneys via ureters. Rarely hematogenous spread to kidney.
• Ascension is aided by
1) mechanical effects of intercourse,
2) obstruction in urinary tract (as by stone or pregnancy) or
3) reflux of urine.
• Indwelling catheters are high risk because they tend to acquire biofilms.
• Spermicides kill some of the normal vaginal flora, allowing more
colonization by pathogens
 Microbes Causing Urinary Infections
• Escherichia coli
• Proteus mirabilis, Proteus vulgaris
• Klebsiella pneumoniae
• Pseudomonas aeruginosa
F2, D2 modules
• Staphylococcus saprophyticus
• Enterococcus faecalis
• Staphylococcus aureus (less common)

• Candida albicans

• Adenoviruses
• BK virus

• Schistosoma haematobium
 Escherichia coli

• Leading cause of nosocomial and

community-acquired UTIs

• Nitrite (+) MacConkey agar

• Normal GI tract flora

– Colon  vagina and urethra 
ascending UTI
– Some are uropathogenic , UPEC

11
 E. coli virulence factors helpful in urinary tract
(fimbriae)

• O, H and K antigens
• Specific binding to uroepithelial cells:
• Type 1 fimbriae bind mannose-containing receptors (mannose-sensitive
pili) – initial adhesion, establishment of cystitis
•Tamm Horsfall Protein, aka uromodulin
•most abundant protein in normal urine
•blocks attachment of Type 1 fimbriae to epithelium
• P fimbriae – bind P blood group antigen – important in acute
pyelonephritis
•Hemolysin HlyA – linked to inflammatory response Mucosal Immunology,
basic bacteriology
 Staphylococcus
• Nitrite (-)
• Pyuria, hematuria
• Urease (+)
• S. saprophyticus
– Causes 15-20% of UTIs in young, sexually active females (2nd to E. coli)
– Adheres very well to uroepithelial cells
– “Honeymoon cystitis”
• S. aureus
– Less common cause
– Prostatitis, kidney abscess, hematogenous spread (e.g. endocarditis)
13
 Enterococcus faecalis

• Nitrite (-)
• Less common cause, but look for in
patients with BPH, institutionalized
patients

14
 Proteus (esp. P. mirabilis)…

• Swarming motility, Nitrite (+), Urease (+)

• Source is human colon
• Infection more common in certain patients:
– Hospitalized or catheterized
– Institutionalized elderly
• Urease: raises pH
– May cause ammonia odor
– May cause kidney stones (staghorn  magnesium
ammonium phosphate aka struvite)
Urease (-) Urease (+)
15
Associated w/catheterization

16
 Viral UTIs
Adenoviruses BK Virus
Family Adenoviridae Polyomaviridae
Nucleic Acid Linear dsDNA Circular dsDNA

• Immunocompromised • Immunocompromised
Patients at Risk
• Bone marrow transplant recipients • Renal/bone marrow transplant recipients

• Acute hemorrhagic cystitis* in • Most people have had, usually

children, esp. boys (serotypes 11 asymptomatic  viral persistence in
Clinical Disease and 21) kidneys
• Cystitis, hemorrhagic cystitis*, ureteral
stenosis when immunosuppressed

Respiratory droplets, feces, fomites,

Transmission close contact, poorly sanitized Respiratory droplets
swimming pools

* Painful hematuria and passage of clots in urine 17

 Schistosoma hematobium
• Flukes (flat and fleshy) aka trematodes
• Geography
– Nile (Egypt), Jordan, Cyprus and Portugal, Asia
• Acquired in contaminated water
– Snails are the intermediate host, liberate a larval form
(cercariae) into the water
• Larvae invade human skin  bloodstream  lungs 
move against the blood flow in the portal veins to the
vesical, prostatic and uterine plexuses by way of the
inferior rectal veins  eggs deposited in bladder wall 
urine Terminal
• Symptoms: hematuria and dysuria Fund2, GI2
spine
18
 Diagnosis: Urine Specimens
• Specimen types:
– Midstream clean-catch urine
– Random urine
– Suprapubic aspiration (sterile but invasive)
– Catheter – unless patient is already catheterized,
this can cause an infection – only if absolutely
necessary!!
• Use a sterile collection container
19
Pathology Rapid Urine Dipstick Screening

Most relevant tests for UTI include:

1) pH
2) Leukocyte esterase test
3) Nitrate → nitrite test (first void best, may be false negative)
** Follow up with full urinalysis including microscopy, culture if needed 20
 Quantitative Urine Culture
Volume of uncentrifuged urine specimen
plated on plates of sheep blood agar &
1st streak MacConkey agar
1 µL = 0.001 mL = 10-3 mL

2nd streak

- Suspected pyelonephritis, treatment failure, recurring cystitis, complicated

21
cases
 Urine Culture Results
1. Count the number of colonies (CFU = colony forming units) growing on the
blood agar plate after 18-24 hrs of incubation
2. Multiply the CFU by the dilution factor (dilution factor = reciprocal of the dilution)
if 1 mL used, this is 1/1000 of 1 mL, so dilution of 10-3 = 103 dilution factor
Example:
76 colonies/1mL = 76 CFU/mL x 103 mL/mL= 76,000 CFU/mL = 7.6 x 104 CFU/mL

Significant if:
suprapubic aspirate; ≥1 CFU/mL
clean-catch urine: cystitis; ≥103 CFU/mL
pyelonephritis; ≥104 CFU/mL
asymptomatic; ≥105 CFU/mL…important in some
patient populations esp. pregnant women
22
 Preventing UTI and Complications
• Uncertain benefits: cranberry juice, good hydration, post-
coital voiding, prophylactic antibiotics, advising abstinence
• Asymptomatic bacteriuria during pregnancy – treat to avoid
pyelonephritis, hypertension, and low birth weight and/or
preterm delivery
• Urine culture before instrumentation to prevent urosepsis
• Catheter care: sterile insertion, changes on schedule or as
needed
 Practice - Highly Recommended
• Any chance you have to do urine dipstick, Gram stain, streak a
plate…take it!