URINARY TRACT

INFECTIONS
Dr. Shweta Naik
Assistant professor
Areas covered
 Definition
 Anatomy & Normal flora of URT
 Host defense mechanisms
 Predisposing factors
 Pathogenesis
 Classification
 Clinical presentation
 Lab diagnosis
 Etiology
Definition
URINARY TRACT INFECTION-
-Disease caused by microbial invasion of the urinary tract that
extends from renal cortex of kidney to urethral meatus.
- Multiplication of the organism in the urinary tract and presence
of more than a 105 CFU/ml in a midstream sample of urine .

PYURIA - Presence of pus cells in urine which often

accompanies UTI
Anatomy of the urinary tract
Lower UTI Upper UTI

Site Urethra, Kidney, Ureter

Bladder

Symptoms Local Local and

manifestations, systemic
dysuria, manifestation
urgency, s(fever, abd
frequency pain)

Route of Ascending Ascending/

spread Descending
Occurrence More common Less common
Normal flora
 Normally renal tissue, ureters and proximal urethra - sterile
 But several species of bacteria colonise the distal urethra .
 Lactobacillli
 Diptheroids
 Coagulase negative staphylococci
 Anaerobes
 Enterobacteriaceae/Candida may cause UTI
Normal host defense mechanisms
 Flushing action of urine- complete evacuation of urine from the bladder.

 Low PH of urine

 High urine osmolality

 Urinary inhibition of bacterial adherence

 Constant dilution of residual urine in bladder

 Local antibody, lysozyme and complement

Normal host defense mechanisms
 Presence of vesico-urethral valve which prevents reflux of
urine.

 Presence of mucosal IgA

 Tamm Horsfall protein: antiadherence glycoprotein

 Presence of zinc and spermine in the male urine.

 Long urethra in men.

Predisposing factors
 Prevalence : 10% of humans

 Why females are more predisposed to UTI?

 Short urethra
 Proximity of the anus to urethra
 Sexual exposure—” honeymoon pyelitis”.

 Age : Incidence increases with age

 Older males: Prostate enlargement stasis of urineUTI
 Females: 10-20%, reinfection
 Pregnancy
 Anatomical change  stasis, Hormonal changes Increased UTI
Predisposing factors
 Structural and functional abnormality
 Urethral stricture, renal stones, spinal cord injury
 Vesicoureteral reflux
 Catheter in situ
 Foreign bodies
 Urethral catheter or ureteric stent
 Loss of host defences
 Atrophic urethritis and vaginitis in post-menopausal women
 Diabetes mellitus
Etiology
Bacteria E.coli, Klebsiella, Proteus, Pseudomonas
S. aureus, S.saprophyticus, S. agalactiae,
Enterococcus

Fungus Candida albicans, Candida tropicalis

Trichosporon asahii

Virus Adeno, BK virus

Parasites Schistosoma heamotobium

Trichmonas Vaginilis

Atypical Mycobacterium tuberculois

microbes Mycoplasma, Ureaplasma ureolyticum, Chlamydiae
Pathogenesis
There are two routes by which
bacteria reach the urinary tract
：

1.Ascending infection

2. Descending /Hematogenous
infection
 Ascending infection:
• It is the most common infection pathway

• Bacteria from gastrointestinal tract exist around the urethra and

periurethral tissues (the anus is proximate to the urethra in females).

• These bacteria can gain access to urethra and invade bladder, ascend
to the renal pelvis via the ureter with subsequent invasion of renal
medulla.

• In this kind of infection pathway, the main bacteria is gram-

negative bacilli from gastrointestinal tract. Escherichia coli (E. coli)
accounts for 60% to 80% bacteria in the UTI
•
Hematogenous infection
• This pathway accounts for 5% cases of UTI.

• Hematogenous infection occurs most often in debilitated

patients who either have chronic illness or are receiving
immunosuppressive therapy

• The major cause of hematogenous infection is Staphylococcus

(S aureus). It can often be seen in patients with bacteremia or
sepsis caused by staphylococcus

• Salmonella, M.tuberculosis, Listeria

Clinical Manifestations of UTI

 Lower tract infection : urethritis and cystitis

 Upper tract infection : acute pyelonephritis, prostatitis, and

intrarenal and perinephric abscesses

 Immunological sequela: Post-streptococcal

glomerulonephritis
Clinical features of UTI
 Fever (with/without chills and rigors)
 Frequency of micturation
 Dysuria (pain during micturition)
 Urgency (intense desire to pass more urine after micturition,
due to spasm of the inflamed bladder wall )
 Hematuria (Microscopic or visual)
 Suprapubic pain during and after voiding
 Loin pain radiating to iliac fossa and suprapubic area with
tenderness and guarding present (Acute pyelonephritis)
 Urine is cloudy with an unpleasant odor
Lower UTI
 Asymptomatic bacteriuria:
Bacteriuria without symptoms of a UTI
Common in females
 Clinically significant in Pregnant Women

 Symptomatic bacteriuria: Bacteriuria

accompanying symptoms of a urinary tract infection
(i.e. frequency, urgency, dysuria)
Lower UTI
 Cystitis
 Localized symptoms: Dysuria, frequency, urgency, suprapubic
tenderness
 Urine: cloudy, bad odour, hematuria
 No systemic manifestation
 Acute urethral syndrome
 Sexually active females
 Localized symptoms: Dysuria, frequency, urgency, suprapubic
tenderness
 Bacterial count may be low
 Pyuria present
Upper UTI
Pyelonephritis
 Systemic infectious symptoms: frank rigor, fever, headache,
nausea, vomiting.
 Back and loin pain, with exquisite tenderness on percussion
of the costovertebral angle
 Increased WBC in the blood and urine routine examination
Hospital acquired infection
 Catheter associated UTI
 Most common HAI
 Presence of indwelling catheter
 Pseudomonas, Acinetobacter
Lab Diagnosis: Collection of sample
 MALES- Clean catch midstream sample of urine

 Periurethral area is cleaned with soap and water. Prepuce is

retracted. First portion of urine is discarded, then subsequent
urine is collected directly in a sterile container.
Lab Diagnosis: Collection of sample
 FEMALES- Clean catch midstream sample of urine

 Genitalia is washed thoroughly with soap and water, labia are

retracted, the first part of urine is flushed out by voiding and
the urine is collected in a wide mouth sterile container.
Catheterized patient
 Clean catheter tube Y junction with spirit & aspirate
 urine not to be collected from collection bags
Suprapubic Aspiration
 In young children
 the patient is asked to lie on his back and a sterile needle and
syringe is inserted after taking aseptic precautions, urine is
aspirated and transferred to a sterile tube.
Transportation & preservation
 It is absolutely essential for culture purposes that urine be
processed within 1 hour of collection and should be stored in
the refrigerator at 4 degree C for 24 hours.
 If delay is still anticipated, urine should be collected in a
mixture containing sodium format, glycerine and borax.
Processing of urine
 Gross appearance of urine

 Microscopy of urine - wet mount, Gram stain

 Screening tests – greiss nitratre test, catalase, leucocyte

esterase test

 Dipslide method

 Culture methods -
 Quantitative culture method: pour plate method
 Semi quantitative culture: standard loop method
Gross appearance of urine
GROSS EXAMINATION-
 Colour
 Odour
 PH
 Presence of any reducing substances
Microscopy of urine
 WET MOUNT
Leukocyte and bacteria will be present on examination of
uncentrifuged urine in most patients.

 GRAM STAIN
At least 1 organism/ oil immersion field (examine 20 fields)
Screening test
1) NITRATE REDUCTION TEST –detection of nitrate
reducing bacteria in urine
2) GLUCOSE TEST PAPER –based upon utilization of
glucose by bacteria causing infection
3) TTC test –based on the production of a pink precipitate by
the respiratory activity of growing bacteria
4) CATALASE TEST – Presence of catase as shown by
frothing on addition of hydrogen peroxide
5) LEUCOCYTE ESTERASE TEST - to detect number of
segmented neutrophils
Dip Slides
 Dip slides are slides containing MacConckeys Agar and agar
on the other slide.
 The dipslide is charged by asking the patient to void his
midstream sample of urine directly on the dipslide
OR
 The dipslide is immersed in a urine container containing
midstream sample of urine collected by the clean-catch
technique
Culture Methods
How to evaluate the results of the urine culture ?
 The number of bacterial colony-forming units (CFUs) in the
urine culture
 The species of bacteria grew in the urine
 The number of bacterial species in the urine
Culture media
 CLED agar – commonly used

 5 % sheep blood agar

 MacConkey Agar for Gram – ve organisms

 Urochrome agar

 Minimum incubation period – 24 hrs

Urine culture

•Growth

•Identification

•AST
Kass concept of significant bacteriuria
 Normal urine is sterile
 May get contaminated while voiding by
normal urethral flora
 Bacterial count of flora would be lower
than that caused by infection

 Quantitative culture
PRIMARY SECONDAR
Y

TERTIARY QUARTERNARY
Interpretation
 ≥105 CFUs/ml : significantly positive for bacteriuria

 104~105 CFUs/ml : clinical correlation required

 ＜ 104 CFUs/ml : possibly bacterial contamination

 Low counts significant in

 Pt on antibiotics/diuretics
 Infection with S.aureus
 Pyelonephritis, acute urethral syndrome
 Sample taken by suprapubic aspiration
 Symptomatic, catheterized patient,>103 cfu/ml
Special investigations
Usually done for complicated UTI with Calculi, obstruction, and
incomplete emptying
 Intravenous urography (IVU)
 USG
 CT scan, Contrast CT
 Micturating cysto-urethrogram (MCUG)
 Cystoscopy
 Nuclear imaging
Treatment of UTI
 Remove primary cause (such as obstruction, neurogenic
bladder, calculi, etc should be identified and corrected if
possible)
 Perform diagnostic test
 Lower UTI – short course

Upper UTI – long course

 Sensitivity testing done in repeated infections
 Knowledge of local resistance patterns
 Beta lactams
 Quinolones
 Nitrofurantoin
 Aminoglycosides : in serious cases

 Cotrimoxazole (TMP-SMX)

 Penicillins and cephalosporins, Nitrofurantoin are

safe to use in pregnancy
 Higher antibiotics carbapenems/fosfomycin for
CAUTI
Etiology – E.coli
 Uropathogenic E.coli (UPEC):70-75%
 UPEC serotypes O1,O2,O4,O6,O7 & O75
 Virulence factors
 Cytotoxins : CNF 1-Cytotoxic Necrotizing
Factor-1 & SAT: Secreted autotransporter toxin
 Hemolysins
 Fimbriae :P fimbriae
 Capsular K antigen-specific
Etiology – Tribe Proteae
 Genera :Proteus, Morganella, Providencia
 Gram negative, noncapsulated,
pleomorphic lactose nonfermenters
 Positive for phenlyalanine deaminase
(PPA) test
Etiology –Proteus
 MC: Proteus mirabilis, Proteus vulgaris
 Mostly :Saprophytes/Commensals
 Infections produced:
 UTI/Wound & soft tissues/septicemia
 Nosocomial outbreaks
 Struvite stones in bladder
 Urease enzyme : Urea ammonia
 Damage to urinary epithelium+ alkaline urine
deposition of phosphate Renal calculi
Etiology –Lab diagnosis: Proteus
 Gram staining :
Pleomorphic GNCB
 Culture:
 swarming on blood agar
 fishy,seminal odour
 NLF
 ID & AST
Etiology – Proteus
 Biochemical
reactions
 H2S production
 Urease test –
strong pos.
 PPA test -Pos
Etiology – Proteae
 O (somatic) and H (Flagellar)antigen

 Somatic antigen of certain non motile strains

(called X strains) cross react with the alkali-stable
antigen of some Rickettsia species

 Weil Felix reaction used to detect heterophile

antibodies from sera of patients suffering from
rickettsial infections

 OX2,OX19,OXK used
Etiology – Proteae
 opportunistic pathogens- nosocomial
infection
 UTI, Pylonephritis, abscess, infection of
wound, infantile diarrhoea
Case 1
 Young male patient complaints of burning
micturation. Urine R/M was normal and
urine culture shows few colonies of E.coli
 Discuss

Ans: Insignificant Bacteriuria

Case 2
 28 weeks pregnant and asymptomatic
young female, came for routine check up.
Urine R/M showed plenty of pus cells and
bacteria.
 Advice investigations and approach to lab
diagnosis and Rx
Ans : Asymptomatic Bacteriuria, Urine C/S
ABS-Nitrofurantoin, Penicillins,
1st generation cephalosporins
Case 3
 75 yr old catheterized patient with BEP
presents with fever and chills
 How do you collect the sample
 Any specific history required for this age
group.

Ans: Aseptically from Y junction of catheter.

DM
NON-FERMENTERS CAUSING
UTI
 Healthcare-associated UTI.
 Important are

1) Pseudomonas
2) Acinetobacter
ENTEROCOCCAL INFECTIONS
 Most common gram-positive cocci
to causing UTI
 Family Enterococcaceae
Virulence Factors
 Resistance to several antibiotics
 Aggregation substances or pheromones:
They help in clumping of adjacent cells to
facilitate plasmid exchange (transfers drug
resistance) ™
 Extracellular surface protein (ESP): It helps
in adhesion to bladder mucosa ™
 Common group D lipoteichoic acid antigen:
It induces cytokine release such as tumor
necrosis factor α (TNF-α).
Clinical Manifestation
 E. faecalis and E. faecium are the two
species that are clinically important.
 E. faecalis is the most common species
isolated from the clinical specimens
 E. faecium is more drug resistant than E.
faecalis.
Major healthcare-associated
pathogens
 UTI (cystitis)
 Chronic prostatitis
 Endocarditis in intravenous drug
abusers
 Intra-abdominal infections
 Surgical site infections following intra-
abdominal surgeries
 Neonatal infections: Sepsis, bacteremia,
meningitis, and pneumonia
Laboratory Diagnosis
 Specimens for culture: Urine, blood ,
exudate, peritoneal fluid
Identification:
 Gram-positive oval cocci arranged in pairs
 Blood agar: It produces non-hemolytic
translucent colonies ™
 MacConkey agar: It produces minute
magenta pink colonies ™
 Bile esculin hydrolysis test is positive
 Growth in 6.5% NaCl, 40% bile, pH 9.6,
45oC and 10oC ™
 Arabinose fermentation
 VITEK and MALDI-TOF.
 UTI: Ampicillin, nitrofurantoin or
fosfomycin
Intrinsic resistance
 Aminoglycosides (monotherapy),
clindamycin, cephalosporins,
cotrimoxazole, vancomycin (for E.
gallinarum and E. casseliflavus)
streptogramins (for E. faecalis)
Other gram positive cocci causing
UTI
 ™Staphylococcus aureus
 ™Staphylococcus saprophyticus
 ™Streptococcus agalactiae
Other bacterial infections of UTI
 Renal Tuberculosis: 10–15% of all
extrapulmonary tuberculosis;75% of
patients have chest X-ray suggesting
previous or concomitant pulmonary
tuberculosis
Other bacterial infections of UTI
 Post-streptococcal Glomerulonephritis
(PSGN)
 Perinephric and Renal Abscesses