URINARY TRACT

INFECTION
PRESENTED BY : IBRAHIM RUKAYYAH SHITTABEY(MB;BS UNILORIN)
OUTLINE
• INTRODUCTION
• CLASSIFICATION
• AETIOLOGY
• PATHOPHYSIOLOGY
• PRESENTATION
• HISTORY
• EXAMINATION
• INVESTIGATIONS
• DIAGNOSIS
• TREATMENT
• PREVENTION
• COMPLICATIONS
• PROGNOSIS
• CASE STUDY
• CONCLUSION
INTRODUCTION
DEFINATION

• Inflammatory disease of the urinary tract which is secondary

to invasion by microorganisms.
• It can also be defined as significant bacteriuria in the setting of
symptoms of cystitis or pyelonephritis.

EPIDEMIOLOGY

• The incidence of UTI is 50,000 per million persons per year

and accounts for 1–2% of patients in primary care.
• Neonates – commoner in males than females
• ADULTS - Commoner in females than males.
CLASSIFICATION
• Upper and lower UTI – based on anatomic site involved.
• UPPER – e.g Pyelitis or pyelonephritis
• LOWER – e.g Cystitis, urethritis

• Complicated and uncomplicated – based on presence or

absence of anatomic and physiologic defect in the
urinary tract.
• Uncomplicated – UTI in the presence of functionally normal
urinary tracts (with normal renal imaging)
• Complicated - Tracts with stones, or associated diseases such as
diabetes mellitus which themselves cause kidney damage, may
be made worse with infection (complicated UTI).
AETIOLOGY
• Infection is most often due to bacteria from the patient’s own
bowel flora.
• Transfer to the urinary tract is most often via the ascending
transurethral route .But it may also be via
• the bloodstream,
• the lymphatics or
• by direct extension (e.g. from a vesicocolic fistula).
AETIOLOGY
AETIOLOGY
• Other causative agents include
• Viral ex:
Adenovirus
Herpes simplex virus

• Fungal ex:
Candida spp
Torulopsis spp

• Atypical organisms ex:

Ureaplasma urealyticum
Mycoplasma hominis
Gardnerella vaginalis
PATHOGENESIS
RISK FACTORS
• Female anatomy
• Sexual intercourse
• Family history
• Menopause
• Spinal injury
• Use of spermicides, douching
• Washing from back to front
• Indwelling catheter
• Immunosupression: DM
• excessive antibiotic use
• Urinary tract obstruction- kidney stones, enlarged prostate
• Urinary tract abnormality- fistula, bladder diverticulum
•MANAGEMENT
HISTORY
• Biodata: women are more prone
• History of:
• back or side pain
• High fever
• Chills and rigour
• Nausea and vomiting
• Are suggestive of acute pyelonephritis

• History of:
• Lower abdominal pain (suprapubic)
• Frequent urination
• Painful urination )dysuria)
• Haematuria
• Are suggestive of cystitis
HISTORY
• In urethritis painful urination is the usual presentation
• There could be history of urgency, cloudy urine
• Hx of rectal pain in men
• Hx of pelvic pain in women
• Rule out causes by asking for history of risk factors such as:
• Menopause
• Indwelling catheter
• Spinal injury
• Immunosupression e.g DM
• Use of spermicides etc

• Rule out DD, Hx of vaginal discharge suggests vaginitis,cervitis,or PID,

hx of std and multiple sexual partners
• Clerk for history suggestive of complications (septic shock and kidney
damage.) eg hx of reduce urine output
EXAMINATION
• GENERAL
• Patient might be pale, febrile (high grade in acute pyelonephritis)
• Dehydrated
• Symptomatic orthostasis
Irritable*
Excessive crying *
• * neonate

• SYSTEMIC
• Suprapubic tenderness in cases of cystitis
• Renal angle tenderness in acute pyelonephritis
• Rectal examination in males may reveal enlarge prostate
• Vaginal and speculum examination in female may reveal an abnormal pelvic
mass ,cervical motion tenderness suggesitive of PID
INVESTIGATIONS
• GENERAL
• Full blood count: may reveal aneamia or leucocytosis
• e/u/cr to rule out complications
• blood culture: if there is fever, rigors or if there is evidence of septic
shock
SPECIFIC
Always culture urine prior to starting antibiotic therapy for sensitivities.
Urine microscopy should be carried out in all patients suspected of having
renal disease
Microbiology
• URINE Microscopy, culture and sensitivity this is the gold standard
• Specimen:
• Clean-catch midstream urine
• supra pubic aspirate
• Catheter specimen
INVESTIGATIONS

• Microscopy:
• presence of red cells,
• Wbc:
• Or bacteria
* White blood cells. The presence of ≥10 WBCs/mm3 in fresh
unspun mid-stream urine samples is abnormal and indicates an
inflammatory reaction within the urinary tract such as urinary
tract infection (UTI), stones, tubulointerstitial nephritis, papillary
necrosis, tuberculosis and interstitial cystitis.
INVESTIGATIONS
Biochemical tests
URINALYSIS
• Dipsticks – detection of Urinary:
• Nitrite- Most Gram negative organisms reduce nitrates to
nitrites (False-negative results are common)
• Leucocyte / Leukocyte esterase
• Dipstick tests positive for both nitrite and leucocyte esterase
are highly predictive of acute infection (sensitivity of 75% and
specificity of 82%).
• Testing for blood or protein is of no value in the diagnosis of a
UTI as both can be absent in the urine of many people with
bacteriuria.
INVESTIGATIONS
Radiology
• Uncomplicated UTI usually does not require radiological
evaluation unless it is recurrent or affecting males and children
or there are unusually severe symptoms. Patients with
predisposing conditions such as diabetes mellitus or
immunocompromised states benefit from early imaging

• Abdominopelvic uss: to identify anatomical abnormalities eg

obstructions,cysts,or calculi
• Intravenous urography to identify anatomical and physiologic
abnormalities . has largely been replaced by ultrasonography
and CT scanning.
INVESTIGATIONS
• Micturating cystourethrography: to identify and quantitate
vesico ureteric reflux and disturbed bladder emptying (in
children)
• Cystoscopy : in patients with chronic haematuria annd
suspected bladder lesions
• CT is a more sensitive modality for diagnosis and follow-up of
complicated renal tract infection. Contrast enhanced CT allows
different phases of excretion to be studied and can define the
extent of disease and identify significant complications or
obstruction.
• MRI is particularly useful in those with iodinated contrast
allergies, offering an ionizing radiation-free alternative in the
diagnosis of both medical and surgical diseases of the kidney
DIAGNOSIS
• Diagnosis is based on quantitative culture of a clean-catch
midstream specimen of urine and the presence or absence of
pyuria,
• The criteria for the diagnosis of UTI, particularly in
symptomatic women, are shown in the next slide
DIAGNOSIS
TREATMENT
PRINCIPLES
• Patient with upper tract symptoms require 10 days to 2 weeks of
antimicrobial therapy
• Patients with fever , chills and elevated WBC counts require initial
IV therapy
• Patients with hospital acquired pyelonephritis, a history of
recurrence or prior infection with resistant organisms, initial
therapy should include anti pseudomonal spectrum antibiotics – eg
piperacillin, ticarcilllin
• Bacteria should be cleared from urine within 24-48 hours of
therapy, if not antibiotics should be changed based on
susceptability results.
• Patients who have persistent fever or toxicity despite appropriate
therapy should be investigated for perinephric or renal cortical
abscess
TREATMENT
• SINGLE ISOLATED ATTACK
• Use antibiotics for 3-5 days
• Antibiotics for 3–5 days
• amoxicillin (250 mg three times daily),
• nitrofurantoin (50 mg three times daily)
• trimethoprim (200 mg twice daily) or
• an oral cephalosporin.
• The treatment regimen is modified in light of the result of urine culture
and sensitivity testing, and/or the clinical response.
• For resistant organisms the alternative drugs are co-amoxiclav or
ciprofloxacin.
• Single-shot treatment with 3 g of amoxicillin or 1.92 g of co-trimoxazole is
used for patients with bladder symptoms of less than 36 hours’ duration
who have no previous history of UTI.
• A high (2 L daily) fluid intake should be encouraged during treatment and
for some subsequent weeks.
• Urine culture should be repeated 5 days after treatment
TREATMENT
• If the patient is acutely ill with high fever, loin pain and tenderness (acute
pyelonephritis), antibiotics are given intravenously, e.g. aztreonam,
cefuroxime, ciprofloxacin or gentamicin (2–5 mg/kg daily in divided doses),
switching to a further 7 days’ treatment with oral therapy as symptoms
improve.
• Intravenous fluids may be required to achieve a good urine output.
• In patients presenting for the first time with high fever, loin pain and
tenderness, urgent renal ultrasound examination is required to exclude an
obstructed pyonephrosis. If this is present it should be drained by
percutaneous nephrostomy.
TREATMENT
• RECURRENT INFECTION
• A- Relaspse:Infection by the same organism within 7 days of completion of
antibacterial treatment and implies failure to eradicate infection usually in
conditions such as stones,scarred kidneys,polycystic dx,bacterial prostatitis
• B-Reinfection: is when bacteriuria is absent after treatment or at least 14
days,usually longer,followed by recurrence of infection with the same or
different organisms.
• Pre-treatment and post-treatment urine cultures are necessary to confirm
the diagnosis and identify whether recurrent infection is due to relapse or
reinfection.
• Relapse. A search should be made for a cause (e.g. stones or scarred
kidneys), and this should be eradicated.
• Intense or prolonged treatment – intravenous or intramuscular
aminoglycoside for 7 days or oral antibiotics for 4–6 weeks – is required.
TREATMENT
• If this fails, long-term antibiotics are required.
• Reinfection implies that the patient has a predisposition
to periurethral colonization or poor bladder defence
mechanisms.
• Contraceptive practice should be reviewed and the use
of a diaphragm and spermicidal jelly discouraged.
• Atrophic vaginitis should be identified in postmenopausal
women, who should be treated with Intravaginal
oestrogen therapy
• All patients must undertake prophylactic measures.
PREVENTION
• Prophylactic measures especially to be taken in cases of reinfection are as follows;
• A 2 L daily fluid intake
• Voiding at 2–3-hour intervals with double micturition
• Voiding before bedtime and after intercourse
• Avoidance of spermicidal jellies and bubble baths and other chemicals in bath
water
• Avoidance of constipation, which may impair bladder emptying.
• Evidence of impaired bladder emptying on excretion urography/ultrasound
requires urological assessment.
• If UTI continues to recur, treatment for 6–12 months with low-dose prophylaxis
(trimethoprim 100 mg, co-trimoxazole 480 mg, cefalexin 125 mg at night or
macrocrystalline nitrofurantoin) is required; it should be taken last thing at night
when urine flow is low.
• Intravaginal oestrogen therapy has been shown to produce a reduction in the
number of episodes of UTI in postmenopausal women.
• Cranberry juice is said to reduce the risk of symptoms and reinfection by 12–20%
but studies are limited.
SPECIAL MENTIONS
Urinary infections in the presence of an indwelling catheter:
• Bacterial infection is common in the presence of an indwelling
catheter
• So long as the bladder catheter is in situ, antibiotic treatment
is likely to be ineffective and will encourage the development
of resistant organisms.
• Treatment with antibiotics is indicated only if the patient has
symptoms or evidence of infection, and should be
accompanied by replacement of the catheter.
• When changing catheters, a single injection of gentamicin is
recommended
SPECIAL MENTIONS
Bacteriuria in pregnancy
• The urine of all pregnant women must be cultured, as 2–6% have
asymptomatic bacteriuria.
• While asymptomatic bacteriuria in the non-pregnant female seldom
leads to acute pyelonephritis and often does not require treatment,
acute pyelonephritis frequently occurs in pregnancy under these
circumstances.
• Failure to treat may thus result in severe symptomatic pyelonephritis
later in pregnancy, with the possibility of premature labour.
• Asymptomatic bacteriuria, in the presence of previous renal disease,
may predispose to pre-eclamptic toxaemia, anaemia of pregnancy, and
small or premature babies.
• Tetracycline, trimethoprim, sulphonamides and 4-quinolones must be
avoided in pregnancy.
• Amoxicillin and ampicillin, nitrofurantoin and oral cephalosporins may
safely be used in pregnancy.
SPECIAL MENTIONS
• Bacterial prostatitis is a relapsing infection which is difficult to
treat.
• It presents as perineal pain, recurrent epididymo-orchitis and
prostatic tenderness, with pus in expressed prostatic
secretion.
• Treatment is for 4–6 weeks with drugs that penetrate into the
prostate, such as trimethoprim or ciprofloxacin. Long-term
low-dose treatment may be required.
• Prostadynia (prostatic pain in the absence of active infection)
may be a very persistent sequel to bacterial prostatitis.
Amitriptyline and carbamazepine may alleviate the symptoms.
SPECIAL MENTIONS
• Renal carbuncle is an abscess in the renal cortex caused by a
blood-borne Staphylococcus, usually from a boil or carbuncle
of the skin.
• It presents with a high swinging fever, loin pain and
tenderness, and fullness in the loin. The urine shows no
abnormality, as the abscess does not communicate with the
renal pelvis, more often extending into the perirenal tissue.
Staphylococcal septicaemia is common.
• Diagnosis is by ultrasound or CT scanning.
• Treatment involves antibacterial therapy with flucloxacillin
and surgical drainage.
SPECIAL MENTIONS
• Tuberculosis of the urinary tract
• Tuberculosis of the urinary tract presents with frequency, dysuria or
haematuria.
• In males the disease may present with testicular or epididymal
discomfort and thickening.
• Diagnosis depends on constant awareness, especially in patients with
sterile pyuria. Imaging may show cavitating lesions in the renal papillary
areas, commonly with calcification. There may also be evidence of
ureteral obstruction with hydronephrosis.
• Diagnosis of active infection depends on culture of mycobacteria from
early-morning urine samples. Imaging may be normal in diffuse
interstitial renal tuberculosis
• Treatment. The treatment is as for pulmonary tuberculosis
• Renal ultrasonography and/or CT scanning should be carried out 2–3
months after initiation of treatment as ureteric strictures may first
develop in the healing phase
SPECIAL MENTIONS
• Xanthogranulomatous pyelonephritis
• This is an uncommon chronic interstitial infection of the
kidney, most often due to Proteus, in which there is fever,
weight loss, loin pain and a palpable enlarged kidney. It is
usually unilateral and associated with staghorn calculi and
urinary tract infection.
• CT scanning shows up intrarenal abscesses as lucent areas
within the kidney.
• Nephrectomy is the treatment of choice; antibacterial
treatment rarely, if ever, eradicates the infection.
COMPLICATIONS
• Recurrent infections
• Permanent kidney damage
• Increased risk of delivery of low birth weight babies
• Sepsis
PROGNOSIS
• Although simple lower UTI may resolve spontenously, effective
treatment lessens the duration of symptoms and reduces the
incidence of progression to upper UTI.
• Even with effective treatment, however 25% of women with
cystitis will experience recurrence.
• Younger patients have the lowest rates of morbidity
• Nosocomial infections develop in 5% of patients admitted to
the hospital with UTI accounting for 40% of these infections.
From2-4 % of these patients become bacteremic, with a
mortality of 12.5%
CASE STUDY
• A 23 years old woman presents to her doctor complaining of 1
day of increased urinary frequency, dysuria and sensation of
incomplete voiding
• She is otherwise healthy, takes no medications, and is sexually
active, using spermicide-coated condoms for contraception.
• She says she does not have fever, chills, vaginal discharge, or
flank pain
• Sexually active with one partner, no hx/of sexually transmitted
diseases
CASE STUDY
• She looks a little uncomfortable but is afebrile, with a normal
blood pressure
• Her abdominal exam is notable for mild suprapubic
tenderness, no RUQ tenderness, no costovertebral tenderness
• Pelvic exam is deferred
CASE STUDY
• Urinalysis: pyuria (WBC too numerous to count), RBC and
bacteria present
• Urine dipstick positive leukocyte esterase and nitrite
• Urine culture: yielded E. Coli
• Patient receives TMP/SMX for Treatment of UTI

• Repeat culture after treatment

• Advice patient to drink lot of water at least 2L per day
• To void after sexual intercourse
• To avoid use of spermicides
CONCLUSION
• URINARY Tract infection is a common infection, accounting for
over 6 million doctors visits per year in the US, it is thus
imparative on physicians to know its subtle signs and
symptoms to diagnose early and initiate prompt treatment
• There is associated morbidity and economic burden
• It should be treated promptly to avoid complications
• Patient education on prophylactic measures is key in reducing
recurrence.
REFERENCES
• https://ceufast.com/course/uti

• https://emedicine.medscape.com/article/233101-overview#a
1

• https://emedicine.medscape.com/article/231470-overview#a
4
• Urinary tract infections by Magdelena sobieszczyk
• Kumar and Clark
• The Guide Medicine
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