APPROACH TO A PATIENT WITH UTI

DR. MD ABDUL HAKIM

FCPS (Medicine)
MD (Nephrology)
 CONTENTS
▪ Introduction
▪ Classification
▪ Epidemiology
▪ Pathogenesis
▪ Risk factor
▪ Etiology
▪ Clinical features
▪ Investigation
▪ Managements
▪ Other related topics
▪ complications
 DEFINITION

• UTI is inflammation of urinary tract due to

infectious agent,comprises of variety of
clinical entities from subclinical
infection,Asymptomatic bacteriuria to
disease like cystitis,prostatitis and
pyelonephritis.
 Classification of UTI

1.According to site :
• Upper urinary tract infection:
- Pyelonephritis, Pyelitis, Ureteritis.
• Lower urinary tract infection
- Cystitis ,Urethritis, prostatitis.

2.Symtoms : Symptomatic
:Asymptomatic
 CONTD…

• According to Recurrence :
• 1. Sporadic: less or equal one UTI in 6 month and
less or equal 2 UTI in a year.
• 2.Recurrent : more than 2 UTI in 6 month or more
than 3 UTI in a Year.
Types: a. Relapse
b. Re-infection.
• According to complicating factors:
-Uncomplicated UTI
- Complicated UTI
Uncomplicated UTI:

• When infection occurs in a patient

without any functional and anatomic
abnormalities or instrumentation of
urinary tract is called UcUTI.
 COMPLICATED UTI

• Complicated UTI are those arising in a

setting of catheterization, instrumentation,
anatomic or functional and urological
abnormalities like stones,obstructions,renal
impairment or diabetic conditions.
• Also occuring in metabolic,structurally &
functionally defective urinary tract.
 RECURRENT UTI

• when patient suffer from UTI for Two or

more times within 6 month or 3 or more
times in a year.
• In women, recurrent UTI is common
• Types
• Relapse
• Reinfection
 RELAPSE 20%

• Despite of treatment Within 2 weeks

patient is reinfected with same
organism and implies failure to
eradicate infection usually in conditions
such as stones,scarred kidneys,
polycystic disease or bacterial
prostatitis.
 RE-INFECTION 80%

• After 2 weeks patient is reinfected

by same or different organism.
• This is not due to failure to
eradicate infection rather
reinvasion of susceptible tract with
new organisms.
 EPIDEMIOLOGY

• Between 1 year and ~50years of age UTI and

recurrent UTI are predominantly disease of
females.
• 50-80% women in general population acquired
at least one UTI during their Lifetime –UcUTI.
• About 20-30% of women who have had one
episode of UTI ll have recurrent episode.
• Approximately 3% of non-pregnant adult
women and 5% of pregnant women have
asymptomatic bacteriuria.
 ETIOLOGY

• Uncomplicated UTI • Complicated UTI :

: • E.coli
• E. coli (70-90%) • Klebsiella
• S.saprophyticus • Pseudomonas
(5-20%)
• Staphylococcus
• Proteus
mirabilis(1-2%) • Citrobacter

• Enterococci(1-2%) • Others.

• Klebsiella spp.(1-
2%)
• Staphylococcus
epidermidis
 PTHOGENESIS

1.Route of infection :
• Ascending route-most common.
• Hamatogenous route
• Lymphatic route.

2.Anatomical abnormalities
3.Uroepithelial adherence
4.Bacterial virulence
 WHY UTI IS COMMON
IN FEMALE?

• Urethra is shorter
• Absence of bactericidal prostatic
secretions
• Sexual intercourse may cause
minor urethral trauma &
transfer bacteria from the
perineum to bladder
• Close proximity of urethra to
anus
• The spectrum of presentation of UTI
▪ Asymptomatic bacteriuria
▪ Symptomatic acute urethritis & cystitis
▪ Acute pyelonephritis
▪ Acute prostatitis
▪ Septicemia
 ASYMPTOMATIC
BACTERIURIA

• This is defined as 10^5 organisms/ml

in the urine of apparently healthy
asymptomatic patient.
• Rx is not indicated in this cases bt
Rx is required in infants ,pregnant
women & those with urinary tract
abnormalities.
 CLINICAL
FEATURES

• Cystitis & urethritis

1. abrupt onset of frequency of micturation &
urgency.
2.dysuria(scalding pain in urethra during
micturation)
3.Strangury( intense desire to pass more urine
after micturation due to spasm of the
inflammed bladder wall)
4.Urine may appear cloudy & have an
unpleasant odur
5.microscopic or visible haematuria
 PROSTATITIS

• Dysuria
• Voiding difficulty
• Perianal or suprapubic pain
• Pain on ejaculation
• prostatic tenderness on examination
 PYELONEPHRITIS

• Fever with chill & rigors

• Dysuria
• Loin pain
• Vomiiting
• Hypotension
• Renal angle tenderness
 DIAGNOSTIC APPROACH

• Evaluation a patient with proper history

taking, meticulous examination and relevant
investigations..
• History taking :
• Fever: High graded associated with
chills&rigors,loin pain,renal angle tenderness
suggestive –pyelonephritis.
• H/O Fever, dysuria,frequency,incontinence –
cystitis,urethritis
• Symptoms of BEP: Frequency, urgency,
nocturia,hesitancy, dribbling urine.
 CONTD-

• H/O DM,Constipation
• H/O Retention of urine.
H/O pregnancy
• H/O Uterine prolapse
• Diaphragm or spermicidal jelly use.
• Early menopause (Atropic Vaginitis)
• Sexual trauma.
• Immunosuppressive agents: Steroids,
cytotoxic drugs.
 EXAMINATIONS

• Pelvic exam:
• Uterine prolapse
• Pelvic mass
• Digital rectal examination (DRE in male)-
BEP

• Neurological exam:
• Diabetic neuropathy
• Multiple sclerosis
• Spina bifida.
 URINALYSIS

• Dipstick urine: positive leucocyte

esterase+nitrite reductase.L.esterase
corresponds to pyuria and nitrite reflects
presence of Enterobacteriaceae which
converts nitrate to nitrite.
• Clean-catch early morning MSU for
microscopy at ×40magnificance(hpf),pyuria
(>10^4 WCC per ml urine) + organisms.wcc
cast suggest strongly pyelonephritis.
 CONTD-

• Culture :
• Sample should be plated on
Laboratory within 2 hrs of collection.
• If not possible, store at 4°C (<48hrs).
• If Sample left at room temperature
>4hrs –thus increases risk of bacterial
overgrowth of contamination.
• Diagnostic interpretation:

ASB in a MSU shows-

• For women 2 consecutive specimens
with isolation of at least 10^5 cfu/ml or
organisms/ml of the same bacterial
species.
• For men a single specimen with isolation
of at least 10^5 cfu/ml or organisms/ml
of a single bacterial species.
 CONTD-

• 10^5 colonies per ml of urine is considered

standard for diagnosis.
• 10^3 to 10^4 colonies accepted as significant
if patient is symptotic.
• Any growth in Suprapubic puncture is
diagnostic.
 RX OF RECURRENT UTI

• Non pharmacological therapy:

• Fluid intake at least 2L/day.

• Regular complete bladder emptying
• Good personal hygiene
• Emptying of bladder before & after coitus
• Double voiding in case of reflux disease
• Cranberry juice
• If vesicoureteric reflux is present practice double
micturation (empty the bladder then attempt
micturaion 10-15 mins later)
 PHARMACOLOGICAL THERAPY
• If an underlying cause cannot be removed,
Suppressive antibiotic therapy can be used to
prevent recurrence & reduce the risk of septicaemia
& renal damage.
• Urine culture should be done at regular intervals & a
regime of 2 or 3 antibiotics in sequence, rotating
every 6 months is often used in an attempt to reduce
the emergence of resistant organism.
• This antibiotics are trimethoprim, nitrofurantion, co-
amoxiclav
• Prophylasix : low dose Nitrofurantoin 50mg at night
followed by cotrimoxazole 480mg or co-amoxiclav
• Prophylasix for one year initially.
 PYELONEPHRITIS

• DEF: Infammation of kidney and renal

pelvis is known as pyelonephritis
 C/F OF
PYELONEPHRITIS

• Classical triad:
1.loin pain
2. fever(with rigor ),which is the main
feature usually high , spiking “picket fence “
pattern & resolve over 72 hour of therapy
3. Tenderness over kidney
• Other : dysuria due to cystitis, vomitting,
hypotension
 D/D OF
PYELONEPHRITIS

• Pyelonephrosis
• Acute appendicitis
• Diverculitis
• Cholecystitis
• Salpingitis
• Ruptured ovarian cyst or
ectopic pregnancy
HOW PYELONEPHRITIS
CAUSE AKI?

Acute pyelonephritis

Papillary necrosis

Fragments of papillary tissue

cause ureteric obstruction

AKI
 MANAGEMENT OF
PYELONEPHRITIS

• I/V rehydration in severe cases

• Antibiotic
• If response to treatment is not prompt-
urine re-culture .
• renal tract USG to exclude urinary tract
obs/ perinephric collection
• If obstruction present drainage by
percutaneous nephrostomy or ureteric stent
 CATHETER ASSCOCIATED
BACTERIURIA

• In case of long term catheterization

(>30days) bacteriuira is common and
associated with multiple antibiotic
resistant flora,fever,catheter obstruction,
stone formation.
• Rx is usually avoided in asymptomatic
patient, as treatment does not reduce
bacteriuria,rather can lead to
antimicrobial resistance.
• Remove the catheter as soon as possible
 URETHRAL
SYNDROME

• Some patients usually female have

symptoms suggestive of cystitis&
urethritis but no bacteria present in
urine culture .
 CAUSES

• Infections with organisms that not cultured

by ordinary method
• Intermittent or low count bacteriuria
• Reactions with toiletries
• Post menopausal atrophic vaginitis
• Symptoms related to sexual intercourse
 STERILE PYURIA

• When neutrophil is present in urine but

urine culture negative is called sterile
pyuria.
• Causes
• Renal TB
• UTI treated early
• UTI with fastidious organisms
• Interstitial nephritis
• Renal stone
• Renal cell carcinoma
 CANDIDURIA

• Appearance of candida in urine, is an

increasingly common complication of
indwelling catheterization.
• Common in: - ICU patient
-Those taking braod spectrum
antibiotic
- DM
Organism:
1. C. albicans
2.C. glabrata
3.other non-albicans
Presentation:
assymptomatic lab find to pyelonephritis &
sepsis
Rx:
in assymptomatic: removal of catheter
Symptomatic pt: Fluconazole(200-400mg/d for
14 days
If resistance then, oral Flucytosine &/or
parentral Amphotericine B.
 PREDISPOSING FACTORS

• DM
• Chronic urinary obstruction
• Analgesic nephropathy
• Sickle cell disease
 COMPLICATIONS UTI

1.Acute complicated UTI:

• Sepsis
• urethral narrowing
• Shock
• Multiple organ system dysfunction
• Acute Renal failure
• Permanent damage of kidney
• Delivery of low birth weight baby in case of a
pregnant woman
2.Acute pyelonephritis:

• Renal corticomedullary abscess

• Perinephric abscess
• Emphysematous pyelonephritis
• Papillary necrosis
• Xanthogranulomatous pyelonephritis
 URINARY INCONTINENCE

• Involuntary loss of urine and comes

to medical attention when sufficiently
severe to cause social or hygiene
problem.
• Occurs in 15% of women and 10% of
men aged over 65 years.
• Types:
• 1. Urge incontinence
- due to detrusor over activity
- results in urgency and frequency.
2. Stress incontinence
- due to pelvic floor muscle weakness
3. Overflow incontinence
 REFERENCE

1.Harrison‘s principles of internal medicine -21st

edition.
2.Davidson principles and practice of medicine, 24th
edition..
3.Kumar and clerk’s clinical medicine, 10th edition.
4.Oxford Handbook of Nephrology and
Hypertension, 2nd edition.
5.Newsletter -6th Issue, feb'2023