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Urinary Tract Infection
Urinary Tract Infection
Urinary Tract Infection
Dr Robin Smith
• Definition
– Significant bacteriuria in the presence of
symptoms
• Importance
– Common community infection
• 25% of women will suffer at least 1 UTI in lifetime
• 5.5 million GP prescriptions per year
– Most common hospital-acquired infection
• 9% of inpatients have a hospital-acquired infection
• 25% of all hospital-acquired infections are UTIs
Epidemiology: changes with age
• Neonates
– 1 -2%
– Males > females
• 1 yr old
– F:M = 4.5 : 0.5%
• School
– F:M = 1.2 : 0.03%
• Adults
– F:M = 1-3 : 0.1%
• Elderly
– F:M = 20 : 10%
Pathogenesis (1)
• Ascending infection
– Colonisation of urethra
• Women > men
– Bowel carriage of urovirulent strains
• Urovirulent E. coli, Staphylococcus saprophyticus
– Instrumentation
• Catheterisation, cystoscopy
– Stagnation of urine
Pathogenesis (2)
• Haematogenous route
– Affect renal parenchyma
• Staphylococcus aureus bacteraemia / endocarditis
– (Lymphatic route)
Host-parasite interaction:
host defence
• Urinary flow
• Urinary tract mucosa
• Urine itself
– pH and osmolality
– urinary substances
• Systemic immune system
• Surrounding area
– Genital tract / perineal environment
Host-parasite interaction:
microbial virulence
• Bacterial virulence
– adherence
– evade immune system
– invasion
– nutrition and survival
Symptoms
• Young children
– Non-specific: fever, failure to thrive, poor feeding,
vomiting
• Older Children and Adults
– Lower Urinary Tract (cystitis)
• Dysuria, frequency, urgency, suprapubic pain, turbid urine,
proteinuria, haematuria
– Upper urinary tract (pyelonephritis)
• + fever, loin pain, systemic symptoms
• Elderly
– Asymptomatic, incontinence, non-specific: confusion
Diagnosis
• Dipsticks
– protein, leukocyte
esterase, nitrites
• negative predictive
value = 99%
Diagnosis: microscopy
• Microscopy
– >50 WBC / mm3
• NB. sterile pyruria
– RBC, casts, crystals
– Gram stain – not routine
Diagnosis: culture
• Culture
– mainstay of diagnosis
– impossible to sterilise urethra / periurethral
area
• degree of contamination is inevitable
• quantification aims to differentiate infection from
contamination
Diagnosis: culture
• Criteria for laboratory diagnosis of UTI
– 100,000 (105) cfu of a single bacterial species / ml
• False negatives:
– Patient already on antibiotics
– Frequent bladder voiding
– Men
– Slower growing organisms
– Suprapubic and ureteric urine
• False positives:
– Contamination
Diagnosis: culture
• Technique
– Calibrated loop containing 0.001ml urine
– 100 colonies on plate = 105 colonies / ml
Diagnosis: culture
• Sources of error
– Errors in collection
• poor preparation of patient
• previous antibiotics
– Errors in transit
• delayed examination
– cells break down
• lack of refrigeration
– bacteria multiply
– Errors in laboratory
Organisms
• 71% E.coli
• 13% Klebsiella
• 11% Proteus
• 4% Staphylococcus saprophyticus
• 1% others
– (enterococci, pseudomonas, other staphylococci)
Management
• Antibiotic treatment
– Ideally await culture and sensitivity result
• 50% will settle
– Empirical choice for severe or complicated
infection
• cover the most likely pathogens
• local resistance rates
GP urines sent to RFH – 2005
– Duration
• Uncomplicated: 3 days
• Complicated: 7-14 days
• Asymptomatic bacteriuria
– 30% will get pyelonephritis
• Association with prematurity and low birth-
weight infants
• Symptoms
Usual UTI symptoms
+ Renal parenchyma involvement
• loin pain, nausea, vomiting
+/-Bacteraemia
• high fever, rigors, sepsis
• Is this a UTI?
• Are any additional investigations necessary?
Case study 3
• A 75 year old man presents to a urology follow-up clinic
– Prostatic surgery for prostatic enlargement two weeks ago.
– He was sent home with a supra-pubic catheter attached to a bag.
– He is well and able to care for himself competently.
– On examination, he has mild lower abdominal discomfort but no
temperature.
– Urine in the bag appears cloudy, so CSU was sent for culture