Urinary Tract

Infections
(UTIs)
Effort By: Zeeshan Akbar
 Overview read that

 Any site or structure within the urinary tract can become infected, but the bladder
(cystitis) and kidney (pyelonephritis) are most frequently involved.
 In men, the prostate, epididymis, and testis can also become infected by bacteria
originating from the urinary tract.
 The presence of bacteria or fungi in the urine is termed bacteriuria or funguria,
respectively.
 However, the detection of bacteria or fungi in the urine does not always imply
infection or a clinically significant condition.
 Bacteria in the urine without signs and symptoms of infection is termed
asymptomatic bacteriuria.
 Urinary tract infections (UTIs) are classified as either uncomplicated or
complicated.
 This distinction is important since management strategies often differ between
these two groups.
 Uncomplicated UTIs include acute cystitis and pyelonephritis in otherwise healthy
individuals.
 These patients have the lowest risk of complications or treatment failure.
 Complicated infections can be acute or chronic and occur in a diverse mix of
patients with metabolic, functional, or structural abnormalities of the urinary
tract or kidneys.
 Metabolic factors include diabetes mellitus, renal failure, and kidney
transplantation.
 Examples of functional abnormalities are neurogenic bladder and vesicoureteral
reflux. Structural abnormalities result from stones, tumors, strictures, or foreign
objects such as catheters, stents, and other forms of instrumentation.
 Recurrent infection in a patient with a previous UTI can be due to either a relapse
or reinfection.
 Relapses are caused by the same microorganism as in the preceding infection and
usually occur within 2 to 4 weeks after treatment has ended.
 Reinfections typically occur after a greater length of time and may be due to a new
strain or species.
 Patients who never improve or who immediately relapse following completion of
treatment have persistent infection.
 Urosepsis is a serious condition in which the bacterial species found within the
urinary tract is also recovered from the patient's blood in conjunction with the
clinical picture of sepsis.
 Patients who develop urosepsis are usually physically debilitated or have an
underlying immunodeficiency.
 Etiology make list of microbes
names

 Enteric bacteria are the most common organisms causing urinary tract infections.
 This is due to the anatomic proximity of bowel flora to the urethra, particularly in
women.
 More important is the pathogenicity specific to the urinary tract that certain species
of enteric organisms have acquired.
 Such organisms are called uropathogens for their ability to cause infection even in
the healthy host.
 The most prevalent causative agent is Escherichia coli among all patient groups in
both upper and lower tract infections.
 Uropathogenic E. coli (UPEC) may possess one or more virulence factors that
allow for colonization and persistence within the urinary tract. The number of
factors expressed may correlate with the severity of infection.7
 A key virulence factor is the presence of bacterial structures named adhesins,
which mediate bacterial attachment to urinary epithelium.
 UPEC strains with the greatest capacity for attachment to uroepithelial receptors
succeed more frequently in establishing infection.
 Close attachment to epithelial cells improves the chances for cellular invasion and
results in higher exposure to cytotoxic or inflammatory compounds released by
UPEC strains.
 Strong affinity for urinary tract epithelium also correlates with bacterial persistence
within the vagina and periurethral area in women.
 Subsequently, the same strain can be responsible for recurrent UTI in women if
therapy is not effective against UPEC strains harbored outside the urinary tract.4
 The most pathogenic strains of E. coli are those that have filamentous adhe- sins
termed p-pili or p-fimbriae.
 E. coli with p-pili are responsible for almost all cases of bacteremic pyelonephritis
in previously healthy patients.
 Other UPEC virulence factors include diminished susceptibility to phagocytosis,
iron extraction from host sources, and adaptations to the nutrient-poor environment
of the urine.
 In uncomplicated UTI in women, Staphylococcus saprophyticus is the next most
common causative organism.
 S. saprophyticus is a coagulase-negative staphylococcus that does not originate
from the bowel.
 This organism causes cystitis and pyelonephritis clinically similar to E. coli.
 Risk factors for UTI due to S. saprophyticus include use of spermicide-coated
condoms, young age, previous UTI, and multiple sexual partners.
 Other bacteria known to cause UTIs in a small but significant number of patients
are Klebsiella spp. and Proteus mirabilis.
 These enteric organisms are often difficult to eradicate from the urinary tract,
particularly when the kidney is involved.
 Both organisms are capable of possessing various adhesins and other
uropathogenic virulence factors.
 Proteus mirabilis often produces urease, which mediates the conversion of urea to
ammonia.
 This raises urinary pH, which can then initiate the formation of urinary stones or
encrustations on catheters.
 Stones can become a continuous nidus for infection and a cause of treatment
failure by obstructing urine flow or by harboring organisms.
 In complicated UTIs, a broader spectrum of microbial species is encountered.
 A greater variety of organisms can cause infection because the required degree of
microbial virulence is lower in patients with structural or functional abnormalities of
the urinary tract.
 Many of these patients have received multiple courses of antimicrobial therapy and
have become colonized with microorganisms that are intrinsically resistant or have
acquired resistance to standard treatment regimens.
 Also, recovery of more than one organism from culture is not uncommon.
 Although E. coli is most frequently identified as the causative agent in complicated
UTI, other organisms such as Candida spp., Pseudomonas aeruginosa,
enterococci, Enterobacter spp., and other gram-negative aerobic bacilli are
common pathogens in this patient population.
 Fungal UTIs are common among hospitalized patients, particularly those with
diabetes mellitus, urinary catheterization, malignancy, recent broad-spectrum
antibacterial therapy, and kidney transplantation.
 In addition to Staphylococcus aureus and Candida spp., Mycobacterium
tuberculosis and Salmonella spp. can infect the urinary tract via dissemination from
the bloodstream.
 Pseudomonal UTI may be acquired via the bloodstream or the urethra.
 Asymptomatic bacteriuria and funguria are usually due to a variety of relatively
nonvirulent bacteria or fungi.
 Patients with functional or structural defects often harbor organisms intermittently
or chronically.
 These nonpathogenic strains do not effectively invade or attach to uroepithelium,
so a full immune response with subsequent clinical symptoms does not develop.
 The presence of these nonpathogenic organisms may actually protect against
infection by more virulent bacteria.
 Risk Factors

 Multiple risk factors can predispose an individual to the development of a UTI.

 Among healthy young women, the most common risk factor is sexual activity, with
the highest risk occurring within 48 hours of intercourse.
 This increased risk is possibly due to the facilitated movement of organisms from
the vaginal introitus into the urethra.
 Also, the use of either a diaphragm with spermicide or a spermicide-coated
condom results in a two- to three-fold increased risk of acquiring a UTI.
 The spermicide, usually nonoxnol-9, appears to alter vaginal flora such that urinary
pathogens can colonize the vaginal introitus more easily.
 Lower estrogen levels in postmenopausal women and recent antibiotic use can
also alter vaginal flora and predispose to bacteriuria and UTI.
 Additional risk factors are associated with the development of pyelonephritis.
 Pregnancy-induced changes, such as decreased peristalsis and dilation of the
ureters, allow bacteria easier access to the kidneys during the later stages of
pregnancy.
 Decreased neutrophil function, renal microangiopathy, neurogenic bladder, and
glucosuria, which are often associated with diabetes, may contribute to the greater
frequency of upper tract involvement in these patients.
 Obstruction of the ureters by stones, strictures, or tumors also increases
susceptibility to pyelonephritis. Fifteen percent of all stones are infectious and can
be a cause of recurrent UTIs.
 Risk Factors for Developing Bacteriuria
and Urinary Tract Infections
only table
Age Group Risk Factor
Children Congenital anomalies such as
vesicoureteral reflux, male sex

Healthy Young or Middle-aged Sexual activity, diaphragm or condom

women use with spermicide, history of UTI in
childhood, prior adult UTI, prior
administration of antibiotics
Healthy Young or Middle-aged men Instrumentation of urinary tract, lack of
circumcision, anal intercourse
 Risk Factors for Developing Bacteriuria
and Urinary Tract Infections

Age Group Risk Factor

Elderly Uterine prolapse and low estrogen
level in women, prostatic hypertrophy,
decreased antimicrobial activity of
prostatic secretions in men, diabetes,
functional debility (bedridden), bowel
incontinence
All ages Catheterization, other instrumentation,
neurogenic bladder, nephrolithiasis,
obstructive tumors and strictures,
certain blood groups, renal failure,
kidney transplantation
 complete krna ha

Pathophysiology
 Organisms enter the urinary tract primarily via an ascending route from the
urethra.
 Less commonly, organisms from the blood infect one or both kidneys and then
descend into the bladder with the flow of urine.
 The organisms infecting via the ascending route originate almost exclusively
from the bowel.
 These organisms spread to the perineum and, in women, colonize the vaginal
introitus and vagina.
 Once the vaginal introitus and periurethral area are colonized, bacteria can
readily gain entry into the urethra and bladder.
 Since vaginal colonization with potential urinary pathogens is an important
intermediate step in pathogenesis, changes in vaginal flora or pH that
promote colonization of urinary pathogens dramatically increase the risk of
developing a UTI.
 In healthy adult men, UTIs are very uncommon due to the greater distance
organisms must travel from the perineum to urethra.
 Also, the longer urethra in males further discourages entry into the bladder.
 After bacteria (or fungi) reach the bladder, the balance between host
defenses and bacterial virulence will determine whether the bacteria will be
able to survive, replicate efficiently, and invade the bladder mucosa.
 Most bacteria introduced into the bladder of healthy individuals are normally
cleared by host defenses within 2 to 3 days.
 However, if patients have high postvoid residuals, alterations in urine flow
from stones or strictures an abnormal narrowing of a bodily passage (as from
inflammation, cancer, or the formation of scar tissue), or prolonged urethral
catheterization, bacteriuria may never spontaneously resolve.
 Chronic or intermittent bacteriuria may remain asymptomatic if the organisms
are not able to adhere to and invade the bladder mucosa.
 The presence of these nonpathogenic strains within the bladder may protect
these high-risk individuals from infection by discouraging subsequent
colonization with more uropathogenic organisms.
 UPEC strains, however, readily attach to and invade bladder
epithelial cells, where the organisms may replicate intracellularly
or become quiescent (quiescence is the state of not dividing).
 The infected host cells may then respond by undergoing
exfoliation or apoptosis such that the intracellular bacteria are
mechanically removed with urination.
 Persistence of viable microbes harbored within epithelial cells
may be a source of relapsing UTIs.
 Mucosal attachment and invasion also triggers a host immune
response.
 The mucosal cells release chemokines that attract neutrophils to
the affected tissues.
 Recruited neutrophils cross the mucosa and are released into
the urine (pyuria) to phagocytose infecting organisms.
 With the onset of this local inflammatory response, the patient
may experience symptoms of infection.
 Systemic responses such as fever or leukocytosis rarely
occur with uncomplicated cystitis.
 Spontaneous resolution of infection may occur in 70% of
previously healthy females within 30 days.
 Pyelonephritis results when bacteria ascend the ureters and infect one or both
kidneys.
 The entire kidney is rarely involved; instead, patchy areas of necrosis and scarring
are found adjacent to normal tissue.
 Local inflammation occurs with neutrophil recruitment, but in pyelonephritis,
the host also experiences a systemic response resulting in leukocytosis,
cytokine release, and immunoglobulin M (IgM) and immunoglobulin G
(IgG) elevations.
 A significant number of patients will be bacteremic, and urosepsis may
develop in those with comorbidities.
 Full recovery and sterilization of the kidney tissue may take as long as 6
to 10 weeks, even in previously healthy patients.
 For both cystitis and pyelonephritis, neutrophil response is crucial to the successful
clearance of organisms from the urinary tract.
 Genetically based variations in host response that result in suboptimal neutrophil
recruitment, activation, and phagocytosis of uropathogens may predispose some
seemingly healthy individuals to UTIs or frequent reinfections.
 Acquisition of a UTI from the descending route appears to account for only 3% of all
UTIs.
 Bacteremia or fungemia from a non-urinary tract source rarely results in clinically
significant kidney infection.
 The exception is for organisms with a special affinity for kidney tissue such as S.
aureus or Candida spp.
 Complete ureteral obstruction or preexisting renal injury substantially increases the risk
of kidney infection in the presence of bacteremia.
 Once the kidney is infected, bacteria or fungi can enter the urine stream and proceed to
the bladder, where bacteriuria may then be detected.
 Host Defenses
complete krna ha

 The host defenses that deter bacteria from colonizing the urinary tract are primarily
mechanical and not immunologic.
 Urination washes out microorganisms that have entered the urethra and bladder.
Since normal postvoid bladder residuals are only 0.09 to 2.4 mL, the vast majority
of colonizing organisms are physically removed with each void.
 The peristaltic action of the ureters and the one-way vesicoureteral valve at the
junction with the bladder dissuades (detachment/ separation) pathogens from
ascending from the bladder to the kidneys.
 Other host defenses discourage replication or attachment of microorganisms.
 Tamm-Horsfall protein, low-molecular-weight sugars, secretory immunoglobulin A
(IgA), and uromucoid (a phosphatidylinositol-linked membrane protein.) can act as
false ligands for bacterial attachment, leaving fewer bacteria to attach to the
mucosa.
 In men, prostatic secretions contain compounds with antibacterial properties.
 The pH and osmolarity of urine can alter bacterial growth in that both very dilute
urine and concentrated urine with low pH can inhibit growth.
 Tamm-Horsfall glycoprotein (THP) is the most abundant urine protein, with
multiple roles in renal physiology and bladder protection. THP protects against
bacterial UTI by blocking bacterial adherence to the bladder epithelium, but its role
in defense against fungal pathogens is not yet described.
 Tamm-Horsfall (TH) glycoprotein is a major protein of normal urine and is the
primary component of waxy nephron casts. Tamm-Horsfall protein is of renal origin
and has been localized in the thick ascending limb of the loop of Henle and in the
distal convoluted tubule.
 Tamm–Horsfall protein is made in the thick ascending limb of the loop of Henle and
released to the urine by proteolytic cleavage. It is believed to play a key role
in prevention of stone formation.
 Waxy or pre-waxy casts are closely related to impaired renal function.
 Waxy casts can be found in people with advanced kidney disease and long-term
(chronic) kidney failure .
 Individuals with abnormal urine dynamics are at greater risk of UTI.
 For example, patients with neurogenic bladder have higher postvoid residual urine
volumes and so are less efficient at removing bacteria with urination.
 Also, the dilated ureters of women in the later stages of pregnancy cannot prevent
organisms from reaching the kidneys.
 In healthy people, therefore, an uncomplicated UTI results when the virulence of the
pathogen is sufficient to overcome normal host defenses.
 Conversely, a complicated UTI often results from the inadequacy of host defenses to
prevent even low-virulence organisms from establishing infection.
 The immune system has no significant role in preventing UTIs but is activated only after
bladder mucosa or kidney tissue has been invaded.
 Therefore, immunocompromised patients do not have a greater incidence of UTIs but
are at higher risk of severe forms of infection and treatment failure when they do occur.
 Clinical Presentation
Signs and Symptoms
in clinical presentation learn only symptoms of
 Acute Uncomplicated Cystitis

 The vast majority of patients diagnosed with acute

uncomplicated cystitis are young to middle-aged women.
 The majority of women will experience the typical symptoms
of pain or burning on urination (dysuria), frequent voiding of
small amounts of urine (frequency), and needing to urinate
immediately (urgency).
 Suprapubic [above the pubis] tenderness or low back pain
may be reported in some individuals.
 Few patients experience systemic symptoms such as fever or
chills, even though 20% to 30% will have “silent” involvement
of the kidney.
 On gross visual examination, the urine may look cloudy or
blood-tinged [hematuria].
 On urinalysis, nearly all patients will have pyuria and 40% will
have hematuria.
 Making the diagnosis of acute cystitis is relatively
straightforward in patients with typical symptoms and pyuria,
especially if the patient reports sexual activity within the
previous 24 to 48 hours.
 However, only 65% of women presenting for medical care
with symptoms possibly referable to the urinary tract actually
have a UTI.
 Infections of the vagina such as candidiasis, bacterial
vaginosis, and trichomoniasis need to be ruled out.
 Sexually transmitted infections such as chlamydial urethritis
also can mimic bacterial cystitis.
 Patients with cystitis associated with sexual activity with a
new partner should be screened for sexually transmitted
diseases, since coinfection is not uncommon.
 The presence of the characteristic symptoms of dysuria, frequency, and urgency, in
addition to a positive dipstick or microscopic urinalysis for pyuria, is usually
sufficient to make the diagnosis of uncomplicated cystitis in otherwise healthy
patients.
 These patients usually can be started on antimicrobial treatment without further
workup.
 To assist in making the diagnosis, individuals with unclear symptoms or a negative
urinalysis should have a urine sample collected for culture and sensitivity testing.
 Due to the possibility of atypical or resistant organisms, a urine culture is also
indicated for patients who recently received antimicrobial therapy.
 A microscopic urinalysis should be performed in any symptomatic patient when the
less sensitive dipstick result is negative for pyuria.
 Dipstick urinalysis
Dipstick urinalysis: Urinalysis (UA) is
used as a screening
and/or diagnostic tool to detect
substances or cellular material in the
urine associated with metabolic
disorders, renal dysfunction or urinary
tract infections (UTI).
 Older women, children (particularly infants), men of all ages, diabetics, and
patients with early relapse of UTI are at risk for complicated or upper tract UTI and
should have a more extensive history and physical examination performed.
 Also, these patients often have a broader range of possible pathogens and should
have a urine culture performed.
 Many women with acute uncomplicated cystitis experience recurrent infections, the
majority of which are reinfections with the same bacteria.
 A more extensive history and physical examination, along with a microscopic
urinalysis and urine culture, is indicated at least once for these patients.
 If no complicating factors are uncovered, invasive diagnostic procedures rarely
uncover abnormalities.
 Acute Uncomplicated Pyelonephritis

 Acute uncomplicated pyelonephritis can range from a relatively benign to a

relatively severe, destructive infection of the kidney.
 At presentation, some patients complain merely of mild fever or flank pain, while
others experience a full range of symptoms such as fever, chills, nausea, vomiting,
flank pain, costovertebral angle tenderness, weakness, malaise, or headache.
 Symptoms of cystitis may not always precede the development of pyelonephritis.
 Notably, patients at either age extreme may present with mild, nonspecific
symptoms in the face of significant kidney involvement.
 The initial workup of the patient with presumptive pyelonephritis includes a
complete blood count, urinalysis, urine Gram stain, and urine culture.
 Blood cultures should also be obtained in patients with severe symptoms because
20% to 30% of patients are bacteremic (Bacteremia is the presence of bacteria in
your blood.).
 A uropathogen will be identified from blood culture in 10% of patients with no
growth or mixed organisms on urine culture.
 Most individuals will have a leukocytosis (high white blood cell count) with
increased band cells (often termed a left shift).
 Band cells are an immature form of neutrophils, which are the most commonly
produced white blood cell. They are essential for fighting disease. That's why your
body produces them in excess during an infection. A normal band cell count is 10%
or less.
 On urinalysis, substantial pyuria is almost always present, and hematuria,
proteinuria, and white blood cell casts may also be seen.
 Urine bacterial counts of 105 colony-forming units (CFU) or more per mL are
detected in 80% to 95% of patients.
 A higher cutoff of 104 CFU per mL is generally recommended for the diagnosis of
acute pyelonephritis, because low bacterial counts are infrequently associated with
pyelonephritis compared to cystitis.
 For symptomatic patients with lower bacterial counts, urinary tract obstruction or a
perinephric abscess should be considered.
 The Gram stain may be useful in directing initial treatment, while culture and
antimicrobial susceptibilities are essential for the redirection of therapy in patients
who are unresponsive to or intolerant of initial treatment.
 The decision to hospitalize the patient is primarily based on the severity of
symptoms.
 Patients with persistent nausea and vomiting cannot take oral
antimicrobials and will therefore require parenteral therapy.
 Adjunctive care, such as intravenous fluid replacement or parenteral pain
medications, may also necessitate hospitalization.
 Patients who are deemed to be at high risk for noncompliance or who
might fail to return for follow-up should also be hospitalized.
 Most hospitalized patients improve significantly within 72 hours of starting
treatment and can be discharged home within 3 to 4 days.
 Culture results are available by this time and an appropriate oral home regimen
can be selected.
 For both inpatients and outpatients, failure to improve on effective antimicrobials
after 72 hours, or an early relapse, warrants further diagnostic testing to rule out a
renal abscess or obstruction.
 Approximately 12% of outpatients treated for pyelonephritis with standard
regimens will return to medical care for persistent symptoms.
 Complicated Urinary Tract Infections
complete

 Complicated UTIs occur in a diverse mix of patients who have an increased risk of
either acquiring a UTI or experiencing a severe or persistent UTI.
 This category includes patients with mild lower tract disease as well as those with
significant kidney infection and urosepsis.
 The clinical presentation may include the hallmark symptoms of dysuria,
frequency, and urgency.
 However, vaguer symptoms of fatigue, headache, temperature instability, and
irritability may be the only clues.
 Immunocompromised persons may not exhibit the usual symptoms due to their
dampened inflammatory response to infection.
 An important example of this is the debilitated elderly patient, who may have UTI-
associated bacteremia in the absence of fever or leukocytosis.
 Men with prostatic enlargement and UTI may complain only of obstructive
symptoms, but further questioning can reveal symptoms referable to a UTI.
 Therefore, the clinician must hold a greater degree of suspicion for possible UTI in
these individuals, since treatment delays may lead to more serious infections.
 In the patient suspected of having urinary abnormalities, an extensive workup may be
indicated to delineate the extent of the abnormality and to determine whether it is
correctable.
 Without amelioration [the act of making something better; improvement] of the
underlying problem, relapses or reinfections are to be expected.
 Some infections may never be cured without corrective action, as in the presence of
kidney stones or urinary stents.
 For patients with known or suspected complicated UTIs, a urinalysis, urine culture,
blood count, and serum creatinine should be performed.
 For those who are sicker or are immunocompromised, blood culture and imaging
studies of the upper tract may be indicated to determine the extent and severity of
infection.
 Diabetics in particular have an increased risk of perinephric abscess or
emphysematous pyelonephritis.
 Pyuria is expected but is less specific, since the primary urinary abnormality may be
responsible for the presence of white blood cells.
 An appropriately obtained urine culture is crucial to effective treatment, since a
multitude of non-uropathogens with varied antimicrobial susceptibilities can infect the
urinary tract in individuals with hampered host defenses.
 Colony counts are usually 105 CFU or more per mL.
 Negative culture results may necessitate further testing for fastidious organisms.
 It may be reasonable to wait for culture and sensitivity results before initiating
treatment in the stable patient with lower tract infection.
 Because persistence and relapse of infections are common, a repeat urine culture
1 or 2 weeks after therapy may be helpful.
 Hospitalization is indicated for patients who cannot take oral medications, need
other intravenous therapy, or have probable kidney involvement or possible
urosepsis.
 The diagnosis of urosepsis is made when bacteremia originating from a urinary
source is associated with fever, tachycardia, hypotension, and general
decompensation.
 Urosepsis occurs most frequently in debilitated elderly patients,
immunocompromised persons, and those with chronic urinary obstruction.
 Nosocomial and Catheter-
Associated Urinary Tract Infection
complete
 The majority of nosocomial UTIs are associated with indwelling (inside your body)
urinary catheters.
 This catheter drains urine from your bladder into a bag outside your body.
Common reasons to have an indwelling catheter are urinary incontinence
(leakage), urinary retention (not being able to urinate), surgery that made this
catheter necessary, or another health problem.
 Other confounding factors in nosocomial UTI include the severity of the underlying
illness causing hospitalization; antimicrobial therapy for other infections, which
increases the risk for resistant or unusual organisms; multiple medications being
administered, which may interact with UTI treatment; and possibly the inability of
the patient to describe symptoms of UTI due to altered mental status.
 Confounding occurs when a competing cause of illness is associated with one or
more of the factors being examined under the study hypothesis.
 Management of catheter-associated UTI varies considerably depending on
whether catheterization is short term or chronic.
 Even with good insertion and maintenance techniques, the incidence of bacteriuria
among catheterized patients increases with time at a rate of 3% to 10% per day of
catheterization.
 Thus, a large percentage of patients will be bacteriuric after a week and virtually all
will be bacteriuric after a month of catheterization.
 The organisms are believed to gain entry via the space between the catheter and
the urethral mucosa.
 The biofilm that develops on catheters may allow organisms within it to elude (to
not be caught by someone) leukocytes and antimicrobials.
 Patients with long-term catheters often have polymicrobial bacteriuria.
 Differentiating between infection and colonization can be difficult because
bacteriuria is present in almost all patients with prolonged catheterization.
 Among hospitalized patients, symptoms may not be clearly associated with the
urinary tract, since they may have other reasons for lower abdominal discomfort,
leukocytosis, and fevers.
 Also, the usual symptoms of dysuria, hesitancy, and urgency are not seen in
catheterized patients.
 Difficulty starting or maintaining a urine stream is called urinary hesitancy.
 Often the only symptoms manifested are confusion or fever.
 In spinal cord-injured patients, symptoms may include fever, diaphoresis,
abdominal pain, or increased muscle spasticity.
 Overall, only 30% to 50% of infected patients undergoing short-term
catheterization will experience symptoms.
 For patients who have symptoms, a urinalysis and culture of urine and blood
should be obtained.
 Screening for bacteriuria in asymptomatic individuals is generally discouraged
because antimicrobial treatment in this situation can lead to recolonization with
more resistant strains.
 Antimicrobial treatment of catheter-associated UTI has relatively high failure and
relapse rates.
 Catheter-associated urinary tract infections (CAUTIs) represent the most common
type of nosocomial infection and are a major health concern due to the
complications and frequent recurrence. These infections are often caused
by Escherichia coli and Proteus mirabilis.
 Removing the catheter increases cure rates, but for patients who require chronic
catheterization, replacement with a new catheter does not always improve the
odds/chances for success.
 Recurrence rates in patients chronically catheterized may be improved with
suprapubic bladder catheterization, because bacterial colonization on the
abdominal wall is less than in the periurethral area/ being the tissues surrounding
the urethra..
Suprapubic catheters provide an alternate method
to drain the urinary bladder. These are commonly
utilized to manage bladder dysfunction and urinary
retention not amenable/preventable to urethral
catheterization.
 Diagnosis
important and complete
 Diagnostic tests are used when the clinical presentation or physical examination
does not yield a clear diagnosis.
 The most frequently used tests are dipstick urinalysis, urine microscopy with or
without Gram stain, and quantitative urine culture with antimicrobial susceptibility.
 Such tests help to determine whether the patient's symptoms are consistent with
UTI and to identify the infecting organism.
 Other diagnostic procedures include localization tests such as bilateral ureteral
catheterization, bladder washout techniques, and antibody-coated bacteria assays.
 These procedures are used to differentiate upper tract infections from lower tract
ones, but they are rarely necessary in the management of most patients.
 Ultrasound and computed tomography (CT) studies may help to identify renal
abscesses or structural abnormalities of the kidneys.
 Intravenous pyelograms are performed less frequently but may also help to assess
possible structural defects and urine flow patterns.
 Collecting the urine specimen correctly is important to ensure the accuracy of the
results for both urinalysis and urine culture.
 In non-catheterized patients, urine is collected in a sterile container midway
through urination.
 Using a midstream voided urine sample is preferred, although some data show
that contamination rates are similar without this precaution.
 Although rarely done in routine cases, specimens obtained via urethral
catheterization or suprapubic bladder aspiration have the lowest risk of
contamination.
 Urinalysis
 A complete urinalysis consists of biochemical dipstick testing of fresh urine and a
microscopic examination of the urine sediment.
 Urine dipsticks have multiple reagent pads that undergo color changes when
dipped in the urine sample.
 The pad colors are then compared to a standardized color reference.
 Most dipsticks can determine pH and can give a quantitative value for red blood
cells, protein, nitrites, and leukocyte esterase.
 Leukocyte esterase, an enzyme produced by activated leukocytes, is used as a
marker for the presence of leukocytes in the urine sample.
 The dipstick urinalysis is often the only diagnostic test used by the office- or clinic-
based practitioner to confirm the clinical diagnosis of uncomplicated cystitis.
 On microscopic examination of the urine sediment, the number of leukocytes,
erythrocytes, bacteria, fungi, and other solid elements can be quantified.
 The most important aspects of the urinalysis in diagnosing urinary tract infections
are pH and the presence of nitrites, blood (hematuria), bacteria (bacteriuria), fungi
(funguria), and particularly leukocytes (pyuria) or white blood cell casts.
 A high pH may indicate the presence of urea-splitting organisms such as Proteus
spp.
 The conversion of nitrates in urine to nitrites has been associated with the
presence of enteric bacteria.
 In patients who are not menstruating, the presence of hematuria can localize the
problem to the urinary tract.
 Finding microorganisms on urinalysis may assist in making the diagnosis of UTI
but may also represent contamination from organisms residing in the distal urethra
or periurethral area.
 The leukocyte count is of primary importance when determining the significance of
bacteriuria and confirming UTI as the cause of dysuria.
 Pyuria usually is defined as eight leukocytes or more per mm3, which correlates to
two to five leukocytes per high-power field.
 However, most patients with UTIs have 20 or more leukocytes per mm3.
 Pyuria in the absence of bacteriuria or a positive urine culture can occur in patients
with vaginal infections or urethritis due to Chlamydia or other fastidious organisms.
 Urine Culture
 Several culture techniques are available, but the biplate method is used most
commonly.
 With the biplate method, a selective medium on one side of the culture dish is used to
isolate possible gram-negative urinary pathogens, while the other side usually contains
nonselective culture medium.
 Use of the selective culture medium often allows for more rapid identification of
potential uropathogens.
 The microorganism colony count is determined using the nonselective side of the plate.
 The number of colonies can be correlated to the number of organisms or CFU per mL
in the original urine sample.
 Using the standard inoculum size, this method can detect bacterial concentrations of
103 CFU or more per mL.
 Antibacterial susceptibility testing is then performed on the predominant organisms
recovered from the biplate.
 BluEcoli™ Urine Biplate is a urine culture media, consisting of Blood Agar on one
side and BluEcoli™ Agar on the other side, which is used for the isolation of
urinary pathogens and for the identification of E. coli.
 Features and Benefits:
• A revolutionary agar bi-plate for screening urine specimens for E. coli, which
causes about 85% of all urinary tract infections (UTI).
• Blood Agar (side 1) is recommended as a primary plating medium when culturing
urine specimens. All common bacteria and yeasts will grow on this medium.
• BluEcoli™ (side 2) is a urine culture medium used for the selective culture and
isolation of urinary pathogens and for the identification of E. coli which turns blue
within 24 hours by using chromogenic substrates. No further testing is needed!
• Inoculate both sides of the biplate with the urine specimen. If the infecting
organism is E. coli, the colonies on the chromogenic side of the biplate will turn
blue.
• The blue color of E. coli is confirmatory! No further confirmation or indole testing is
required. Save time and money by not using an expensive identification system. All
other Gram-negative bacteria will appear as they would on a MacConkey plate
(pink for lactose fermentors and clear for non-fermentors).
• With the BluEcoli™ Urine Biplate, you can select a colony from the blood agar side
of the biplate for susceptibility testing.
• Helpful in spotting mixed infections.
 Traditionally, a single-species microorganism count of 105 CFU or more per mL from a midstream
urine specimen was considered indicative of infection.
 Multiple studies have shown, however, that as few as 102 CFU per mL in a symptomatic patient
with pyuria represents true infection.
 Up to half of all young women with true uncomplicated cystitis will have bacterial counts of 102 to
104 CFU per mL.
 According to the Infectious Diseases Society of America guidelines, a midstream urine culture of
103 CFU or more per mL of a single uropathogen is indicative of cystitis in patients with pyuria and
symptoms consistent with lower tract infection.
 However, for unspeciated coagulase- negative staphylococci, 105 CFU per mL is used as a cutoff
due to the potential for contamination by these organisms.
 In a symptomatic patient with pyuria, a midstream urine culture with less than 102 CFU per mL can
be seen in patients with chlamydial urethritis, infections due to other fastidious organisms, early
infection, partially treated infection, and candidal or bacterial vaginitis.
 In symptomatic women without pyuria, 105 CFU or more per mL is still required for the diagnosis of
UTI. However, any sample with 102 CFU or more per mL obtained by suprapubic bladder aspiration
or urethral catheterization is considered significant.
 For patients without risk factors for complicated UTI, any urine culture result with mixed organisms
or with a nonuropathogen is probably due to contamination.
 Urine cultures are not routinely done for presumed cases of uncomplicated lower
UTI, because the causative agent is reliably E. coli and occasionally S.
saprophyticus.
 The finding of typical clinical symptoms in patients with pyuria or hematuria is
usually sufficient to make the diagnosis and start empiric treatment.
 However, with unclear symptoms, complicated cases, treatment failure, or
pyelonephritis, a urine culture should be done to confirm the diagnosis and to
ensure effective treatment.
 Also, patients with urinary tract symptoms who do not demonstrate pyuria by
urinalysis should have a urine culture performed.
 A urine Gram stain may be useful to guide initial treatment for complicated UTIs.
 Treatment
Pharmacotherapy
 The ability to eradicate bacteria from the urinary tract is directly
related to the sensitivity of the organism and the achievable
concentration of the antimicrobial agent in the urine.
 The therapeutic management of UTIs is best accomplished by first
categorizing the type of infection: acute uncomplicated cystitis,
symptomatic abacteriuria, asymptomatic bacteriuria, complicated
UTIs, recurrent infections, or prostatitis.
 Acute Uncomplicated Cystitis
nii krnaaa
 These infections are predominantly caused by E. coli, and antimicrobial
therapy should be directed against this organism initially.
 Because the causative organisms and their susceptibilities are generally
known, a cost-effective approach to management is recommended that
includes a urinalysis and initiation of empiric therapy without a urine culture.
 Short-course therapy (3-day therapy) with trimethoprim–sulfamethoxazole
or a fluoroquinolone (e.g., ciprofloxacin or levofloxacin, but not
moxifloxacin) is superior to single-dose therapy for uncomplicated infection.
 Fluoroquinolones should be reserved for patients with suspected or possible
pyelonephritis due to the collateral damage risk.
 Instead, a 3-day course of trimethoprim–sulfamethoxazole, a 5-day course
of nitrofurantoin, or a one-time dose of Fosfomycin should be considered as
first-line therapy.
 In areas where there is more than 20% resistance of E. coli to trimethoprim–
sulfamethoxazole, nitrofurantoin or Fosfomycin should be utilized.
 Nitrofurantoin is an antibiotic medication that is used for the treatment of
uncomplicated lower urinary tract infections. It is effective against most
gram-positive and gram-negative organisms. Nitrofurantoin's primary use
has remained in treating and prophylaxis of urinary tract infections.
 Fosfomycin was safe and significantly more efficacious in treating
uncomplicated UTI versus ciprofloxacin.
 Amoxicillin or ampicillin is not recommended because of the high
incidence of resistant E. coli.
 Follow-up urine cultures are not necessary in patients who respond.
 Complicated Urinary Tract Infections
ACUTE PYELONEPHRITIS
 The presentation of high-grade fever (>38.3°C [100.9°F]) and severe flank pain
should be treated as acute pyelonephritis, and aggressive management is
warranted.
 Severely ill patients with pyelonephritis should be hospitalized and IV drugs
administered initially. Milder cases may be managed with oral antibiotics in an
outpatient setting.
 At the time of presentation, a Gram stain of the urine should be performed,
along with urinalysis, culture, and sensitivities.
 In the mild to moderately symptomatic patient for whom oral therapy is
considered, an effective agent should be administered for 7 to 14 days,
depending on the agent used.
 Fluoroquinolones (ciprofloxacin or levofloxacin) orally for 7 to 10 days are the
first-line choice in mild to moderate pyelonephritis.
 Other options include trimethoprim–sulfamethoxazole for 14 days.
 If a Gram stain reveals gram-positive cocci, Streptococcus faecalis should be
considered and treatment directed against this pathogen (ampicillin).
 In the seriously ill patient, the traditional initial therapy is an IV
fluoroquinolone, an aminoglycoside with or without ampicillin, or an
extended-spectrum cephalosporin with or without an aminoglycoside.
 If the patient has been hospitalized in the last 6 months, has a urinary
catheter, or is in a nursing home, the possibility of P. aeruginosa and
enterococci infection, as well as multiple-resistant organisms, should be
considered.
 In this setting, ceftazidime, ticarcillin–clavulanic acid, piperacillin,
aztreonam, meropenem, or imipenem, in combination with an
aminoglycoside, is recommended.
 If the patient responds to initial combination therapy, the aminoglycoside
may be discontinued after 3 days.
 Follow-up urine cultures should be obtained 2 weeks after the completion
of therapy to ensure a satisfactory response and to detect possible relapse.
 Recurrent Infections

 Recurrent episodes of UTI (reinfections and relapses) account for a

significant portion of all UTIs. These patients are most commonly women
and can be divided into two groups: those with fewer than two or three
episodes per year and those who develop more frequent infections.
 In patients with infrequent infections (i.e., fewer than three infections per
year), each episode should be treated as a separately occurring infection.
Short-course therapy should be used in symptomatic female patients with
lower tract infection.
 In patients who have frequent symptomatic infections, long-term
prophylactic antimicrobial therapy may be instituted.
 Therapy is generally given for 6 months, with urine cultures followed
periodically.
 In women who experience symptomatic reinfections in association with
sexual activity, voiding after intercourse may help prevent infection.
 Also, self-administered, single-dose prophylactic therapy with trimethoprim–
sulfamethoxazole taken after intercourse significantly reduces the
incidence of recurrent infection in these patients.
 Women who relapse after short-course therapy should receive a 2-week
course of therapy.
 In patients who relapse after 2 weeks, therapy should be continued for
another 2 to 4 weeks.
 If relapse occurs after 6 weeks of treatment, urologic examination should
be performed, and therapy for 6 months or even longer may be
considered.
 Urinary Tract Infection in Pregnancy

 In patients with significant bacteriuria, symptomatic or asymptomatic

treatment is recommended to avoid possible complications during the
pregnancy.
 Therapy should consist of an agent with a relatively low adverse-effect
potential (cephalexin, amoxicillin, or amoxicillin/clavulanate) administered
for 7 days.
 Tetracyclines should be avoided because of teratogenic effects and
sulfonamides should not be administered during the third trimester because
of the possible development of kernicterus and hyperbilirubinemia.
 Also, the fluoroquinolones should not be given because of their potential to
inhibit cartilage and bone development in the newborn
 Catheterized Patients

 When bacteriuria occurs in the asymptomatic, short-term catheterized

patient (<30 days), the use of systemic antibiotic therapy should be
withheld (Stop) and the catheter removed as soon as possible.
 If the patient becomes symptomatic, the catheter should again be
removed, and treatment as described for complicated infections should
be started.
 The use of prophylactic systemic antibiotics in patients with short-term
catheterization reduces the incidence of infection over the first 4 to 7 days.
 In long-term catheterized patients, however, antibiotics only postpone the
development of bacteriuria and lead to emergence of resistant organisms.
GLOSSARY complete
 Perineum: The area of the body between the anus and the
vulva in females, and between the anus and the scrotum in
males.
 Introitus: Vaginal introitus: The vaginal opening is called the
introitus of the vagina. The Latin word "introitus" comes from
"intro", into, within + "ire", to go = to go into. In anatomy, an
introitus is thus an entrance, one that goes into a canal or
hollow organ such as the vagina.
 Periurethral: relating to, occurring in, or being the tissues
surrounding the urethra.
 Post-void residual volume (PVR) is the amount of urine
retained in the bladder after a voluntary void and functions as
a diagnostic tool.
 Exfoliation: the shedding of surface components.
 Urinalysis is a test that determines the content of the urine.
 Pyuria (pi-YER-ree-UH) is a condition in which you have high
levels of white blood cells (leukocytes) or pus in your urine
(pee).
 Chlamydial urethritis in men is an infection of the urethra
caused by the sexually transmitted disease (STD) chlamydia.
The urethra carries urine from the bladder, through the penis,
and to the outside of the body. This condition often causes
swelling and inflammation of the urethra, accompanied by
penile discharge.
 The term dysuria is used to describe painful urination, which
often signifies an infection of the lower urinary tract. The
discomfort is usually described by the patient as burning,
stinging, or itching.
Urosepsis is when a urinary tract infection (UTI)
leads to sepsis. Sepsis occurs when your body has a
life-threatening response to an infection. It's a
medical emergency that requires prompt treatment
because it can lead to tissue damage, organ failure
or death. Many different conditions can cause sepsis.
Flank pain is a sensation of discomfort, distress,
or agony in the part of the body below the rib and
above the ilium, generally beginning posteriorly or
in the midaxillary line and resulting from the
stimulation of specialized nerve endings upon
distention of the ureter or renal capsule.
Agony, a terminal state of the body before death.
Suffering of intense degree, relating to physical or
mental suffering.
Flank Pain
Sudden-onset flank pain may be caused
by a serious problem with the blood
vessels.
While uncommon, these issues are
serious and require immediate medical
care. Examples of vascular emergencies
include aortic dissection and acute
aortic aneurysm.
Costovertebral angle tenderness (CVAT)
is a widely used physical examination to
differentiate renal pathology, such as
pyelonephritis and ureteral stones. However,
limited studies have reported
its diagnostic accuracy despite the common
use of CVAT particularly in the emergency
department (ED) setting.
Trichomoniasis is a common sexually transmitted
infection caused by a parasite.
In women, trichomoniasis can cause a foul-smelling
vaginal discharge, genital itching and painful
urination.
Trichomoniasis is caused by a one-celled protozoan,
a type of tiny parasite called Trichomonas vaginalis.
The parasite passes between people during genital
contact, including vaginal, oral or anal sex. The
infection can be passed between men and women,
women, and sometimes men.
Diaphoresis is the medical definition
of excessive sweating due to an underlying
health condition or a medication.
Perinephric abscess refers to
the accumulation of infected material and
consequent necrosis of tissues within the
perinephric space, surrounding the kidneys. It
can result from complications of pyelonephritis
or it can be due to spread of infection from
other body organs through the bloodstream.
Emphysematous can be defined as a
disorder affecting the alveoli (tiny air
sacs) of the lungs. The transfer of
oxygen and carbon dioxide in the lungs
takes place in the walls of the alveoli. In
emphysema, the alveoli become
abnormally inflated, damaging their walls
and making it harder to breathe.
EMPHYSEMATOUS pyelonephritis (EPN)
has been defined as a necrotizing infection of
the renal parenchyma and its surrounding
areas that results in the presence of gas in the
renal parenchyma, collecting system, or
perinephric tissue.
Kernicterus, or bilirubin encephalopathy, is
bilirubin-induced neurological damage, which
is most commonly seen in infants. It occurs
when the unconjugated bilirubin (indirect
bilirubin) levels cross 25 mg/dL in the blood
from any event leading to decreased
elimination and increased production of
bilirubin
Bilirubin encephalopathy is a rare
neurological condition that occurs in
some newborns with severe jaundice.
Kernicterus is a condition where very
high bilirubin levels in the blood are
deposited in the brain tissue causing
irreversible damage to the brain.