By. Dr. Wondifraw A.

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Introduction
Urinary tract infection is the presence of microbial
pathogens in the urinary tract.

Infections are usually bacterial although

fungi(various species of Candida),viruses and
parasites may cause UTI.

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Introduction Cont.
The urinary tact is normally sterile and sterility is
maintained by
-- The urinary flow rate
-- Rapid bladder emptying
-- Mounting of an active inflammatory response by
WBC and
-- Antimicrobial peptides secreted by the epithelium.

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Epidemiology
 Primarily an infection of females and males affected at the
two extremes of life(neonate, age>50).
 In sexually active women incidence of 0.5-0.7 per year.60%
will have at least one UTI in their lifetime.

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UTIs may involve deep tissue infection or be
confined to the bladder mucosa.
90% of infections in males involve deep tissue
invasion and >70% of infections in women are
superficial infections.

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The most important issue to be addressed when a
UTI is suspected is
the characterization of the clinical syndrome as ASB,
uncomplicated
cystitis, pyelonephritis, prostatitis, or complicated
UTI.
This information will shape the diagnostic and
therapeutic approach.

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UTI Classification
Lower UTI ( Urethritis,Cystitis)
UpperUTI(Pyelonephritis,Pyonephrosis,perinephric
abscess)
 Causes : GNB of GI flora , E.coli(most common),
-Other GNB : Klebsella, proteus less commonly in
uncomplicated UTI but more important with
pseudomonas in complicated ones
- Grampositive:
S.saprophiticus,Enterococi,S.aureus,S,epidermidis

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 UTI
UTI may be symptomatic or asymptomatic, complicated
or uncomplicated.
Asymptomatic UTI is isolation of bacteria in urine in
quantitative amounts consistent with infection but
without localizing GU 0r systemic signs or symptoms.
Complicated UTI refers to UTI in the presence of
structural or functional abnormalities of the urinary tract.
(includes those with UTI following instrumentation)
Enterobacteriace the most common pathogens with E.coli
accounting for most infections.

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Pathogenesis
The ascending route the most common route of
infection(>95%).
Organisms originate from the gut flora, colonize the
vagina& periurethral area and ascend into the bladder.
Bacterial virulence factors and host factors determine
whether infection is sustained.

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Gender a major determinant of incidence.
Uropathogenic E.coli have virulence properties
that mediate key steps: sustained intestinal
carriage, persistence in the vagina and ascension
and invasion of the urinary tract.
Virulence properties include the O antigen,K
antigen,hemolysins, adhesins,etc.

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Risk factors for UTI
 Gender and Sexual Activity
 Anatomic urinary tract abnormality
-stone,obstruction,vesicoretral reflux(in children)
 Urinary tract instrumentation
 Urinary tract obstruction
 Lack of circumcision in males
 Pregnancy
D.M

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UTI: Clinical manifestations
UTIs maybe asymptomatic.
Lower tract UTI symptoms include dysuria,frequency
and urgency,suprapubic pain,gross hematuria.
Upper tract UTI symptoms include flank pain,
fever/chills ,nausea/vomiting and CVA tenderness.
Fever is the main feature distnguishing cystitis from
pylonephritis. The fever of pyelonephritis cxd as high
spiking and resolves over 72hrs of therapy.
If the fever persistes despite the therapy
complications of pylonephritis like intra pranchymal
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absces should be suspected.
Diagnostic work up
o Urine Dipstick Test, Urinalysis, and Urine Culture
 Useful diagnostic tools include the urine dipstick test
and urinalysis, both of which provide point-of-care
information, and the urine culture, which
can retrospectively confirm a prior diagnosis.
 Understanding the parameters of the dipstick test is
important in interpreting its results.

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
Only members of the family Enterobacteriaceae
convert nitrate to nitrite, and enough nitrite must
accumulate in the urine to reach the threshold of
detection.

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If a woman with acute cystitis is forcing fluids
and voiding frequently, the dipstick test for nitrite is less
likely to be positive, even when E. coli is present.
The leukocyte esterase test detects this enzyme in
polymorphonuclear leukocytes in the host’s urine,
whether the cells are intact or lysed. Many reviews have
attempted to describe the diagnostic accuracy of dipstick
testing.

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Either nitrite or leukocyte esterase positivity can be
interpreted as a positive result.
Blood in the urine also may suggest a diagnosis of UTI
A dipstick test negative for both nitrite and leukocyte
esterase in this type of patient should prompt
consideration of other explanations for the patient’s
symptoms and collection of urine for culture.

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A negative dipstick test is not sufficiently sensitive to
rule out bacteriuria in pregnant women, in whom it is
important to detect all episodes of bacteriuria

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Urinalysis:

• Urinary sediment :
• Leukocytes are found in the urine : > 5 WBCs/ high power
field in centrifuged urine or > 10 WBCs/ higher power field
in unspun urine suggests UTI

• Microscopic bacteruria:
single microorganism per oil immersion field of unspun
urine is indicative of a colony growth on culture of more
than 100,000 colonies /ml.

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. Culture of the urine:

A definitive means for diagnosis

• A clean catch , mid stream urine specimen should be

collected

• The growth of more than 100,000 colonies /ml in

the presence of symptoms signifies infection that needs
treatment
Radiologic urologic evaluation: may be help full in
identification of some predisposing conditions such as
urolithiasis, BPH, vesicoureteral reflux

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Dx
Culture of urine collected through suprapubic
aspiration the gold standard for diagnosis.
Quantitative urine culture of clean catch urine
the next best to distinguish between true infection
and contamination.
Morning specimen preferable.
In a young woman with typical symptoms and
pyuria the constellation of symptoms may be
diagnostic of UTI and culture may not need to be
done.
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Dx
Standard definition of a positive urine culture is >
100,000CFU/ml.

Acute uncomplicated pyelonephritis in women:> 1000

CFU/ml of a single uropathogen makes the diagnosis.

UTI in men:>10,000CFU/ml offers a sensitivity and

specificity of >90%.

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UTI : Treatment
Decisions on treatment (duration/specific antibiotic)
depends on:
The sites i.e. lower vs upper urinary tract,
Susceptibility
pattern of organisms,

History of drug allergy,

Pregnancy history,

Uncomplicated or complicated
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1. Acute Uncomplicated lower UIT in women : may be treated with

• Trimethoprim –Sulfamethoxazol : 480 mg 2 tabs PO

BID for 3-5 days

• Norfloxacin 400 PO BID or Ciprofloxacin 500 mg PO BID for

5-7 days

2. Acute uncomplicated pyelonephritis in women :

E. coli, P. mirabilis, S. saprophyticus are the
common causes

• Norfloxacin 400 PO BID or Ciprofloxacin 500 mg PO BID for 7-

14 days or

• Single dose of Ceftriaxon 1gm or Gentamicin 80 mg23

Decision to hospitalize:
Indications for admission to the hospital in acute
pyelonephritis

1. Inability to maintain oral

hydration or take medications

2. Concerns about patient

compliance

3. Uncertainty about the diagnosis

4. Severe illness with high

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UTI :Rx
UTI in men: should always be assumed to mean tissue
invasion of the prostate, kidney or both.
Risk factors include lack of circumcision, anal intercourse
and acquisition from a sexual partner.
Standard treatment is 10-14 days of TMP-SMX or
floroquinolone.
In those with recurrent infection after an appropriate
course of treatment urologic evaluation as well as
extended treatment(4-6wks) required.
Prostatic infection particularly difficult to eradicate.
Nitrofurantoin remains highly active against E. coli and
most non–E. coli isolates.

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3. Complicated UTI in men and women:

E. coli, Proteus, Klebsiella,

Pseudomonas, Serratia, enterococci, staphylococci are the
common etiolog
• Mild to moderate illness, no nausea
or vomiting: outpatient therapy
• Norfloxacin 400 PO BID or
Ciprofloxacin 500 mg PO BID for 10-14 days.

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4.Severe illness or possible urosepsis: hospitalization is required.
• Ceftriaxone 1gm IV daily or BID

• Gentamicine 80 mg IV TID

• Ampicillin 1gm IV QID and then 500 mg IV QID

• IV quinolones such as Ciprofloxacin 200-400 mg IV BID

can also be used if available

Note: IV medication should be changed to PO as soon as the

patient became afebrile and then give PO TMP-SMX or Ciprofloxacin or
Norfloxacin for 10- 21 days

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UTI:Rx
Recurrent UTI in women : Reinfection vs relapse.
Relapse is recurrence with the same organism(with in 2
wks after the therapy.
 Reinfection is recurrence with a different organism
Most recurrences are reinfections.First steps to prevent
reinfections include
i)Voiding after intercourse & changing contraceptive
practice
ii) Estrogen replacement (local or systemic) in
postmenopausal women.
In those with recurrent infection after treatment lasting
<14 days it may indicate presence of a sequestered
focus(relapse). Extended treatment 4-6 wks.

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Urologic consultation and evaluation of the upper urinary tract with
an U/S should be considered if the patient remains febrile or has not
shown signs of demonstrable clinical improvement after 72 hrs of
treatment to r/o the presence of obstruction, renal or perinephric
abscesses, or other complications of pyelonephritis.

UTI in pregnancy: Limited drug choice because of toxicity,

continuing follow-up is a must.
Ampicillin, cephalosporins,Nitrofrantoin, sulphonamides (except near
term and 1st TM) can be used. Avoid floroquinolones.

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THANK YOU!

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