Urinary tract infections

Definitions
• Asymptomatic[subclinical infection] and symptomatic [disease]
• Lower urinary tract and upper urinary tract
• Asymptomatic bacteriuria, urethritis, cystitis, pyelonephritis
• Uncomplicated UTI[non pregnant OPD, no instrumentation, no anatomic
abnormalities]
• Complicated UTI
• Relapse- recurrence within 2 weeks
• Reinfection- after 2 weeks
• Recurrent UTI
• CAUTI[Catheter associated UTI]
Epidemiology
• Predominantly a disease of females
• Except- infancy; elderly
• 50-80% females have atleast one episode in their lifetime
• 20-30% have recurrent episodes
Etiological agents
• E. Coli [75-90%]
• Staphylococcus saprophyticus
• Klebsiella
• Proteus
• Pseudomonas
• Enterococcus
• Citrobacter
• Acentobacter
Pathophysiology
• Urine as a culture medium
• Ascending infection- urethra to bladder and above
• Introduction of bacteria into bladder doesn't always lead to
symptomatic infection
• Interplay of host, pathogen, and environmental factors
• Hematogenous spread rare[<2%]
Risk factors for UTI
• Bladder outflow obstruction- BPH, prostate malignancy, Urethral
stricture
• Anatomical abnormalities- VUR, Uterine prolapse
• Neurological problems-
• Foreign bodies- stone disease, catheter, stent, nephrostomy
• Loss of host defences- diabetes, postmenopausal
Clinical features

Lower urinary tract[ cystitis, urethritis] Upper urinary tract[pyelonephritis]

• Dysuria • Prominent systemic symptoms
• Frequency • Fever- chills, rigors; picket fence
• Urgency pattern
• Strangury • Pain
• Suprapubic discomfort during or after • Tenderness, guarding.
voiding
• Vomiting, hypotension,
• Cloudy urine
• Microscopic or macroscopic hematuria
• Only 30% patients with
pyelonephritis have associated
• Systemic symptoms absent lower urinary tract symptoms
Differential diagnosis

Lower UTI Upper UTI

• STD- chlamydia • Acute appendicitis
• Reactive arthritis • Cholecystitis
• Urethral syndrome • Ruptured ovarian cyst
• Ectopic pregnancy
• Diveticulitis
• Perinephric abscess
Investigations
• Diagnosis is clinical and microbiological
• Significant pus cells
• Dipstick and automatic microscopy
• Investigations in Upper UTI, Complicated UTI, Recurrent UTI
• Threshold for symptomatic UTI- females 10 CFU/ml males 10 3
CFU/ml
• Threshold for CAUTI- 10 3 CFU/ml
• Threshold for ASB- 10 5 CFU/ml
Treatment
• Cystitis- quinolones, co-trimoxazole, nitrofurantoin- duration 3 days
• Pyelonephritis- quinolones, cephalosporins-duration 7-14 days
• Culture and sensitivity
Asymptomatic bacteriuria[ASB]
• Clinical and microbiological criteria
• Absence of signs and symptoms
• 10 5 CFU/ml
• Treat if
Pregnancy
Persons undergoing urologic surgery
Renal transplant
Neutropenic patients
Infancy
Urinary tract abnormalities
UTI in pregnancy
• Safety of drugs
• Treat ASB
Recurrent UTI
• PERSISTENT
• RECURRENT
• Prophylactic treatment- nitrofurantoin, cotrimoxazole, quinolone for 6
months
Catheter related bacteriuria[CAUTI]
• Asymptomatic
• Symptomatic
• 10 3 CFU/ml
• Avoid treatment in asymptomatic
Acute pyelonephritis
• TRIAD
Fever
Tenderness
Loin pain
• Can cause AKI
• Emphysematous pyelonephritis
• Xanthogranulomatous pyelonephritis