INFECTIOUS DISEASES

Topic: Urinary Tract Infections

Lecturer: Dr. Iturralde

DEFINITIONS ETIOLOGY
 Cystitis – infection of the urinary bladder  Pathogens vary by clinical syndrome but are USUALLY ENTERIC GRAM-
 Pyelonephritis – infection of the kidneys NEGATIVE RODS that have migrated to the urinary tract
 Escherichia coli: uncomplicated cystitis, uncomplicated pyelonephritis,
 Uncomplicated – cystitis or pyelonephritis in non-pregnant outpatient
CAUTI
women without anatomic abnormalities or instrumentation
 *worldwide increase in resistance to TMP-SMX and Ciprofloxacin
 Complicated – symptoms of cystitis or pyelonephritis with an anatomic
o This happens primarily because of the left and right use of
predisposition to infection with a foreign body in the urinary tract, or
these antibiotics even if they are not indicated
with factors predisposing to delayed response to therapy
 Uncomplicated Cystitis and Pyelonephritis:
 Recurrent UTI - >2 UTIs in 6 months or >3 UTIs in 1 year
o Staphylococcus saprophyticus, Klebsiella, Proteus,
 Catheter-associated UTI (CAUTI)
Enterococcus, Citrobacter species
 Complicated UTI:
EPIDEMIOLOGY AND RISK FACTORS
o Pseudomonas aeruginosa, Klebsiella, Proteus, Citrobacter,
 Males > Females (neonatal period)
Acinetobacter, Morganella species; Enterococci,
o In <1 year old, UTI is more common among males because
Staphylococcus aureus; yeasts
newborn males usually have a congenital anatomic
abnormality in the urinary tract
NOTE: All the aforementioned organisms enter the urinary tract
 Females > Males (>1 year old to ~50 years old)
when they gain access to the urethra via the anus. Many of them are
o >1 year old to 50 years old, female are more common to have part of the normal flora of the GI tract
UTI due to risk factors (will be discussed later)
Yeasts can also cause UTI. They gain access to the urinary tract via
 Males = Females (after 50 years of age)
hematogenous route
o After 50 years of age, male equals with females to have UTI
because BPH (benign prostatic hyperplasia) is common at this
PATHOGENESIS
age group
 Bacteria establish infection by ascending from the urethra to the
bladder
Uncomplicated cystitis risk factors:
 Interplay of host, pathogen, and environmental factors
 Recent use of diaphragm with spermicide
o This is a form of contraception wherein a device is placed up to  Continuing ascent up the ureter to the kidney is the pathway for most
renal parenchymal infections
the inferior of the cervix in order to prevent the sperm from
entering the cervix
 Frequent sexual intercourse (1.4x-4.8x)
o The relative risk increases on a dose related manner  the
more frequent the sexual intercourse in the previous week =
increased risk of developing UTI
o 1.4x increased risk of having UTI if one sexual intercourse in
the preceding 1 week prior to the infection  it increases to
4.8x or even 5x if there is five episodes of sexual intercourse in
the preceding week prior to the onset of UTI
 History of UTI
 *DM, incontinence, and sexual activity in postmenopausal
o Not urinary incontinence per se but rather the incontinence
brought about by a surgical procedure
 Infection, colonization, and elimination of the organisms depends on
NOTE: These factors are also the risk factors for developing the interplay of the 3 factors: host, organism, environment
pyelonephritis because of the pathogenesis of UTI  the infection from  Host Factors:
the bladder (cystitis) just ascended to the kidneys (pyelonephritis) o Genetics  they have seen a genetic backgrounds, especially
in females, wherein they develop UTI at an early age (<15 yrs.
The first 3 bullets are risk factors during the premenopausal age old) because of the structure in their uroepithelium and it
The last bullet are risk factors during the postmenopausal age provides receptor for the E. coli
o Behavior  use of spermicides
Recurrent UTI o Comorbidities  DM will predispose a person to UTI because
 Premenopausal: frequent sexual intercourse, use of spermicide, new if there will be uncontrolled blood sugar, there will be
sexual partner, maternal history of UTI, first UTI before 15 years of age glucosuria and the presence of glucose on the urine will
o Those in red are those consistent behavioral risk factor for facilitate growth of bacteria in the GUT
recurrent UTI o Tissue-specific receptors  related with the gene expression
o 1st UTI before 15 years of age  there is a genetic background for the receptors which facilitate attachment of the E. coli
that will predispose an individual to UTI before age 15. It has  Organism Factors:
something to do with epithelial lining that will facilitate the o Species  some strains of E. coli will not cause UTI while
attachment of the bacteria others can due to presence of virulence factors
 Postmenopausal: history of premenopausal UTI, cystocoeles, urinary o Virulence Factors  fimbriae and pilus which facilitates
incontinence, residual urine attachment to the uroepithelium of human can cause infection
and colonization of the urinary tract

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 INFECTIOUS DISEASES
Topic: Urinary Tract Infections
Lecturer: Dr. Iturralde
Pathogenesis continued…..
 Environmental Factors:
o Vaginal ecology  the vagina has normal flora, Lactobacillus,
which maintains the acidic pH. Disruption of the normal flora
such as use of antibiotics or feminine wash will predispose the
woman to pathogenic E. coli
o Anatomy  females has increased incidence of UTI than male
because of the proximity of the female urethra to the anus
and NOT because of females having a shorter urethra than
males (According to Dr. Iturralde)
o Urinary retention  the more frequent you urinate = less
chance of UTI = less time for bacteria to grow. It is like flushing
out the bacteria from the GUT
o Medical devices  the use of foley catheters (CAUTI)
CLINICAL SYNDROMES
Asymptomatic Bacteriuria (ASB/ABU)
 Bacteriuria in screening urine culture detected incidentally in a patient
without local or systemic symptoms referable to the urinary tract
Cystitis
 Dysuria, frequency, urgency; nocturia, hesitancy, suprapubic
discomfort, gross hematuria
 Dysuria, frequency & urgency  commonly termed as lower urinary
tract symptoms
Pyelonephritis
 Fever + lower back pain / CV angle tenderness; rigors, nausea, vomiting,
flank and/or loin pain
 Fever is the most distinguishing feature of pyelonephritis
o There is no fever in cystitis (whether complicated or
uncomplicated)
o Fever happens because there is tissue invasion
Prostatitis
 Infection is almost always bacterial; dysuria, frequency, pelvic/perineal
pain; fever and chills, symptoms of bladder outlet obstruction
o Chronic pelvic pain syndrome or chronic prostatitis
o Treatment of prostatitis is usually longer than UTI (can take up
to 4 weeks treatment with antibiotics)
Complicated UTI
 Symptoms of cystitis or pyelonephritis with an anatomic predisposition
to infection, with a foreign body in the urinary tract, or with factors
predisposing to delayed response to therapy
o Examples: presence of stones in the bladder, problem with
function of the bladder, DM, immunocompromised state, renal
transplantation
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DIAGNOSTIC APPROACH
Acute Onset of Dysuria, Frequency and Urgency
 Healthy, nonpregnant female; low risk for multidrug resistance:
Uncomplicated cystitis; no urine culture needed
o If with history or risk factors for STI: uncomplicated cystitis vs
STI
 Male with perineal, pelvic, prostatic pain: Acute prostatitis; do
urinalysis and culture; possible urology consult
 Patient with IFC: CAUTI; change/remove IFC, blood cultures
o IFC for >2 weeks  probably a case of CAUTI
o CAUTI is a complicated UTI
 All other patients: complicated UTI; urinalysis and culture and address
modifiable anatomic/functional abnormalities
o If patient has BPH  address the BPH (e,g, giving Finasteride)
Acute Onset of Back pain, Nausea/Vomiting or Fever
 Otherwise healthy, nonpregnant female: uncomplicated
pyelonephritis; urinalysis and culture
 All other patients: pyelonephritis vs acute prostatitis; urine and blood
cultures
Fever, Altered Mental Status, Leukocytosis
 Elderly, spinal cord injury, immunocompromised, and no alternate
diagnosis: complicated UTI; urine and blood cultures; other etiologies?
No Urinary Symptoms: + Urine culture
 In pregnant patient, renal transplant recipient, or patient undergoing
invasive urological procedure: ASB (Asymptomatic bacteriuria);
screening and treatment warranted
o Treatment is given for the aforementioned patients (pregnant,
renal transplant, invasive urological procedures) with ASB
o If pregnant patient is not treated for their ASB  increased risk
of preterm delivery or low birth weight baby
 In all other patients: ASB; no additional workup/treatment needed
o No treatment needed because studies have shown that there
is very low risk of developing complication or morbidity even if
ASB is not treated  advantage of this is no unnecessary use
of antibiotics
 In patients with IFC: CA-ASB (Catheter associated-ASB); no additional
workup/treatment; remove/change IFC
Recurrent Urinary Symptoms
 Otherwise healthy, non-pregnant female: recurrent cystitis; urine
culture; prophylaxis or patient-initiated management
 Male patient: chronic bacterial prostatitis; urology consult
**Next page is the whole diagram for diagnostic approach to UTI for better
understanding**
 INFECTIOUS DISEASES
Topic: Urinary Tract Infections
Lecturer: Dr. Iturralde

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 INFECTIOUS DISEASES
Topic: Urinary Tract Infections
Lecturer: Dr. Iturralde

TREATMENT
Acute Uncomplicated Cystitis

NOTES:
 Nitrofurantoin 100 mg in the Philippines has a different formulation
o The dosing is not BID (2 times a day) but rather QID (4 times a day), every 6 hours for 5 days
o Nitrofurantoin is very effective for uncomplicated cystitis. It also has poor tissue deposition which is why it is not very effective in cases of pyelonephritis
 TMP-SMX
o Before, it was the 1st line agent in the late 1990’s
o Due to inappropriate use of this drug, antibiotic resistance of bacteria (especially E. coli) to this drug increased
o There has been a decrease on its use due to occurrence of Stevens Johnson Syndrome (manifested as rashes)
 Fluoroquinolones
o Also effective for acute uncomplicated cystitis but as much as possible, if culture reveals that the bacteria that a patient has is susceptible to a specific
drug (e.g. TMP-SMX)  then use it as treatment
o Collateral damage  common in fluoroquinolones wherein it also kills the normal flora
 Beta-lactams
o Its use will be dependent on a country’s local data  check if it is effective or not
 In the Philippines, cephalosporins are still effective

Pyelonephritis Complicated UTI

 Ciprofloxacin  Individualized; culture-guided
 Ceftriaxone o Depending on the result of culture  to know what antibiotic
 *Extended spectrum cephalosporin, carbapenems, B-lactam + B- you will use
lactamase inhibitor o Manage also what makes the condition complicated:
o *Use of these drugs are guided by urine culture  E.g. anatomic abnormality, presence of DM

UTI in Pregnant Women ASB

 Nitrofurantoin, ampicillin, cephalosporin (Asymptomatic or
Symptomatic UTI)
o It is safe to use Cefuroxime (cephalosporin) or Nitrofurantion
or Ampicillin in pregnant patients
 Parenteral B-lactam with or without aminoglycosides
o Although this is a second line drug  avoid using
aminoglycosides in pregnant females because it has effects on
the fetus
o Also, fluoroquinolones is avoided in pregnant patients
 Treatment is discouraged EXCEPT in pregnant women, persons
undergoing urologic surgery, neutropenic, or renal transplant patients
o Pregnant women  not treating ASB leads to low-birth weight
infants and preterm delivery
CAUTI
 Urine cultures are essential to guide treatment
 Prevent!
o Done by minimizing (prolonged) use of IFC

UTI in Men Candiduria

 Fluoroquinolone (Ciprofloxacin/Levofloxacin) or TMP-SMX; 7-14 days  Fluconazole 200-400mg/day for 7-14 days
o Almost always, UTI in men is complicated  Other drugs that can be used: Amphotericin B IV if they do not respond
o Uncircumcised men has increased incidence of UTI because to fluconazole
the E. coli attaches to the prepuce and glans efficiently if the
foreskin is there
o BPH also predisposes men to UTI (Age >50 years old)
o Moxifloxacin may be used but it is given longer because its
levels in the blood is not as high as that of cipro- and
levofloxacin
o Chronic prostatitis: Levofloxacin for 4 weeks

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 INFECTIOUS DISEASES
Topic: Urinary Tract Infections
Lecturer: Dr. Iturralde

PREVENTION OF RECURRENT UTI IN WOMEN

Three strategies:
1. Continuous
2. Post-coital
3. Patient-initiated

Continuous and Post-coital

 Low-dose TMP-SMX, fluoroquinolone, nitrofurantoin

Patient-Initiated
 Supply patient with materials for urine culture and with a course of
antibiotics for self-medication at the first symptoms of infection
 When a patient feels that she has the episode of UTI again, since she is
already familiar with the symptoms, she well send a urine culture and
the physician will prescribe the medication
 Or the physician will already prescribe the antibiotic to the patient so
that anytime that the patient will experience the first symptoms of UTI,
even without doing culture, she may self-medicate
 Note that this is done for Recurrent UTI

PROGNOSIS
 UTI is treatable in general and they do not cause significant morbidity if
they are treated adequately
 Cystitis is a risk factor for recurrent cystitis and pyelonephritis
 ASB does not increase risk of death in elderly and catheterized patients
 Long-term IFC is a well-documented risk factor for bladder cancer in
patients with spinal cord injury
o This happens due to chronic irritation of the uroepithelium 
there will be mutation  become malignant and become
cancer

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