URINARY

TRACT
INFECTIONS

Contents

Introduction
Terminology
Classification of UTI
Epidemiology
Etiology
Pathogenesis
Risk factors
Clinical presentation
Diagnosis
Treatment
Conclusion

Introduction
Symptomatic
presence of
micro organisms
within the
urinary tract
i.e., kidney,
ureters, bladder
and urethra.

Associated with
inflammation of

 Significant bacteriuria: presence of at

5
least 10 bacteria/ml of urine.
Asymptomatic bacteriuria : bacteriuria
with no
symptoms.
Urethritis: infection of anterior urethral
tract
*dysuria, urgency and frequency of
urination.
Cystitis: infection to urinary bladder

 Acute pyelonephritis: infection of

one/both kidneys; sometimes lower
tract also.
*pyuria, fever, painful
micturition

Chronic pyelonephritis: particular

type of pathology of kidney;
may/may not be due to infection.

UTI - Terminology
Uncomplicated: UTI without underlying renal
or neurologic disease.

Complicated: UTI with underlying structural,

medical or neurologic disease.

Recurrent : > 3 symptomatic UTIs within 12

months following clinical therapy.

Reinfection: recurrent UTI caused by a different

pathogen at any time

Relapse: recurrent UTI caused by same species

causing original UTI within 2 wks after therapy.

fic

i
s
s n
a
o
Cl

i
t
a

UTI

Upper

Lower

Acute pyleonephritis
Chronic pyleonephriitis
Interstitial pyleonephritis
Renal abscess
Perirenal abscess

Cystitis
Prostatitis
Urethritis

Both upper & lower UTI are further divided

into complicated and uncomplicated.

Epidemiology
Seen in all age groups
Infants up to 6 months 2/1000
More common in boys than girls
Women at greater risk than men;
prevalence 40-50% in women and 0.04%
in men.
10% women have recurrent UTI in their
life
7 million new cases of lower UTI / year
1 million hospitalizations / year
Incidence of UTI increases in old age;

Etiology
Acute uncomplicated UTI:
Escherichia coli cause about 80% of
UTI
20% of UTI caused byGram negative enteric bacteria
Klebsiella,
Proteus
Gram positive cocci Streptococcus
faecalis
Staphylococcus

Complicated UTI:
Pseudomonas aeruginosa,
Enterobacter & Serratia
Isolated in hospital acquired
infections and catheter associated
UTI.
Viruses

Rubella, Mumps and HIV

Fungi - Candida, Histoplasma

capsulatum

Pathogenesis
4 routes of bacterial entry to
urinary tract.
1) Ascending infection
2) Blood borne spread
3) Lymphatogenous spread
4) Direct extension from other
organs

 Ascending Infection:
most common route.
organisms ascend through urethra
into bladder.

 Hematogenou
s spread:
Blood borne
spread to
kidneys.
Occurs in
bacteraemia
mostly
S.aureus.

 Lymphatogenous spread:
Men- through rectal and colonic
lymphatic vessels to prostrate and
bladder.
Women- through periuterine
lymphatics to urinary tract.
Direct extension from other
organs:
Pelvic inflammatory diseases
Genito-urinary tract fistulas

 The organism:
E.coli many strains present but only
few cause infection.
Virulence factors:
1. fimbriae
2. resistance to serum bactericidal
activity ; increased amounts of
capsular K antigen activity
3. toxin production
4. production of urease enzyme
(proteus sps)

Vesiculourethral reflux

UTI RISK FACTORS

1. Aging: diabetes mellitus
urine retention
impaired immune system

2. Females: shorter urethra

sexual intercourse
contraceptives
incomplete bladder emptying with
age
3. Males: prostatic hypertrophy
bacterial prostatis
age

UTI-CLINICAL PRESENTATION
Clinical manifestations
depending on site of infection

Clinical manifestations
depending on age of patient

Clinical manifestations
depending on site of infection
Urethritis:
Discomfort in voiding
Dysuria
Urgency
frequency

 Cystitis:
dysuria, urgency and frequent
urination
Pelvic discomfort
Abdominal pain
Pyuria

Hemorrhagic cystitis:
Visible blood in urine.
Irritating voiding symptoms

 Pyleonephritis:
Invasive nature
Suprapubic
tenderness
Fever and chills
White blood cell
casts in urine
Back pain
Nausea and
vomiting
Complications
include sepsis, septic
shock and death.

Clinical manifestations depending on age

Babies and infants:

Failure to thrive
Fever
Apathy
Diarrhoea

Children:
Dysuria, urgency, frequency
Haematuria
Acute abdominal pain
Vomiting

 Adults:
Lower UTI- frequency, urgency,
dysuria,
haematuria
Upper UTI- fever, rigor and lion
pain and symptoms of lower UTI.
Elderly patients:
Mostly asymptomatic
Not diagnostic as the symptoms
are common with age.

UTI- DIAGNOSIS
Microscopic examination of urine
Urinalysis
Urine culture
Imaging techniques CT scan and
MRI

Laboratory examination
Uncontaminated, midstream urine sample
used.

Methods for urine collection:

1. stick on bags
2. catheterization
3. suprapubic aspiration(SPA)

gold standard for urine collection

Laboratory findings
Normal Findings
pH - 4.6 8.0
Appearance- clear
Color pale to
amber yellow
Odor aromatic
Blood none
Leukocyte esterase
none

Abnormal findings
pH Alkaline
( increases)
Appearance cloudy
Color - deep amber
Odor foul smelling
Blood maybe
present

WBC- absent

Leukocyte esterase present

Bacteria- absent

WBC- present
Bacteria- present

Urinalysis :
Presence of pus,
white blood cells, red
blood cells
Bacterial count >
105 /ml significant
bacteriuria
Leukocyte esterase
dipstick test WBC in
urine
Nitrite dipstick test-

Urine culture :
For pyelonephritis
Not a rapid diagnostic
tool
>105 bacteria /ml
Differential leukocyte
count- increased
neutrophils

Urine culture

Diagnostic tests for adults with recurrent UTI

Intravenous pyelography / excretory

urography

 Voiding cystourethrography

Cystoscopy

Manual pelvic and

prostrate
examination

m is
h
t
i os
r
go agn
l
A di
r
o
f

UTI
urinalysis
Urine microscopy and
culture

Adult
female
Lower UTI

Treat
without
further
investigati
on

Further
investigation
pyelonephri
tis
Male
Complicate
Any UTI
d

Ultrasound
cystoscopy

Blood
cultures
CT scan
Check renal

Children
Any UTI

cystoureth
rography

UTI - management
Symptomatic UTI- antibiotic
therapy
Asymptomatic UTI- no treatment
required except in special
situations.
Non- specific therapy:
more water intake.
Maintaining acidity of urine by

Clinical Classification of Urinary Tract Infection

1. Acute uncomplicated cystitis in women

2. Acute uncomplicated pyelonephritis in women
3. Complicated UTI in both sexes
4. Recurrent infections in women
5. Asymptomatic bacteriuria
6. Catheter associated UTI

McBryde C, Redington. Primary Care Case Rev 2001 ;

Acute uncomplicated cystitis in women

Single dose or 3-day course of treatment

Follow-up urine culture 7-14 days later

Cured
(sterile urine)

No investigation

Failure or relapse
(identical pathogens)

Reinfection
(new pathogen)

Ultrasonography urinary tract

KUB radiograph
Treatment for 2 weeks

Catel WR. Clin Drug Invest 1995 ; 9 (suppl 1) : 8-13

Empiric antibiotics can be prescribed using a

first-line agent for a 3-day course without
further evaluation

Women younger than 55

No other comorbidities
Not postmenopausal
Not pregnant
No recent UTI
No vaginitis or cervicitis symptoms
Presence of increased urinary frequency
Presence of dysuria.
Litza, Brill. Prim Care Clin Office Pract 2010, 37: 491507

Antimicrobial therapy for

uncomplicated cystitis

Abbreviations: DS, double strength; TMP-SMX, trimethoprim-sulfamethoxazole.

Lane DR, Takhar SJ. Emerg Med Clin N Am 2011,29: 539552

Clinical Classification of Urinary Tract Infection

1. Acute uncomplicated cystitis in women

2. Acute uncomplicated pyelonephritis in women
3. Complicated UTI in both sexes
4. Recurrent infections in women
5. Asymptomatic bacteriuria
6. Catheter associated UTI

McBryde C, Redington. Primary Care Case Rev 2001 ; 4 :

Pathogenesis
urinary pathogens from the bowel, or in
some cases from the vagina (as a result of
direct inoculation during sexual activity)
colonize the periurethral mucosa
ascend to the bladder and kidney

Acute uncomplicated pyelonephritis in women

Severe illness

Moderate severity

Outpatients and oral

therapy possible

Hospitalization with initial

parenteral therapy

No resolution
in 5 days

Resolution
in 5 days

Urologic evaluation

No resolution
in 5 days

Radiologic evaluation
Treatment 14 days

Oral treatment 14 days or

longer as required

Risk Factor
Risk factors for uncomplicated sporadic
and recurrent cases of cystitis and
pyelonephritis include sexual intercourse,
use of spermicides, previous urinary tract
infection, a new sex partner (within the
past year), and a history of urinary tract
infection in a first-degree female relative

Features of Uncomplicated versus Complicated Cystitis and Pyelonephritis.

Hooton TM. N Engl J Med 2012;366:1028-1037.

Antimicrobial therapy for

uncomplicated pyelonephritis

Abbreviation: IV, intravenous

Lane DR, Takhar SJ. Emerg Med Clin N Am 2011,29:539552

Clinical Classification of Urinary Tract Infection

1. Acute uncomplicated cystitis in women

2. Acute uncomplicated pyelonephritis in women
3. Complicated UTI in both sexes
4. Recurrent infections in women
5. Asymptomatic bacteriuria
6. Catheter associated UTI

McBryde C, Redington. Primary Care Case Rev 2001 ; 4 :

Complicated UTI in both sexes

Hospitalize, urine culture, blood culture
Empiric therapy with parenteral regimen
Significant clinical improvement

Yes
5 Days
Switch to or continue
oral regimen
For total 2 weeks

No

Review antimicrobial susceptibility pattern

Radiologic & urologic evaluation
Correct reversible risk factors

Review treatment plan as appropriate,

treat for total 2 weeks or longers if necessary

Follow-up urine culture after treatment

Clinical Classification of Urinary Tract Infection

1. Acute uncomplicated cystitis in women

2. Acute uncomplicated pyelonephritis in women
3. Complicated UTI in both sexes
4. Recurrent infections in women
5. Asymptomatic bacteriuria
6. Catheter associated UTI

McBryde C, Redington. Primary Care Case Rev 2001 ; 4

Recurrent infections in women

Reccurent UTI in women
Relapse

Conventional antibiotic
therapy 2-6 weeks

Sexually active

Antibiotic therapy :
On demand or
Postcoital or
Longterm prophylaxis

Diagnosis

Reinfection

3 year

2 year

Postmenopausal

Conventional antibiotic
therapy 3-7 days

Estrogen substitution
(oral & topical)
Antibiotic therapy :
On demand or
Longterm prophylaxis

Madersbacher S, et al. Curr Opin Urol 2000 ; 10

Strategies for Nonantimicrobial Prevention of Recurrent Acute

Uncomplicated Cystitis.

Hooton TM. N Engl J Med 2012;366:1028-1037.

Drug regimens for long-term, low-dose prophylaxis of

recurrent urinary tract infection
Drug

Dose*

Nitrofurantoin

50 mg

Trimethoprim

100 mg

Co-trimoxazole

0.24 g

Norfloxacin

200 mg

Ciprofloxacin

125 mg

Cephalexin

125 mg
( useful if renal insufficiency)

Hexamine hippurate

1g

* Treatment is effective if taken each night, alternate nights, three times a week,
or just after intercourse

Clinical Classification of Urinary Tract Infection

1. Acute uncomplicated cystitis in women

2. Acute uncomplicated pyelonephritis in women
3. Complicated UTI in both sexes
4. Recurrent infections in women

5. Asymptomatic bacteriuria
6. Catheter associated UTI

McBryde C, Redington. Primary Care Case Rev 2001 ; 4

Indication for the treatment of patients with

asymptomatic bacteriuria
Definitive

Possible

Not indicated

Pregnancy

Diabetes mellitus

Elderly

Before an invasive
genitourinary
procedure

Short-term
indwelling
catheterization

School girls and

premanopausal women

Intermittent
catheterization

Children with reflux

Long-term
indwelling catheter

Patients with abnormal

urinary tract

Renal transplant

Raz R. Nephrol Dial Transplant 2001 ; 16 (suppl 6) : 1

Clinical Classification of Urinary Tract Infection

1. Acute uncomplicated cystitis in women

2. Acute uncomplicated pyelonephritis in women
3. Complicated UTI in both sexes
4. Recurrent infections in women
5. Asymptomatic bacteriuria

6. Catheter associated UTI

McBryde C, Redington. Primary Care Case Rev 2001 ; 4 : 2

Prevention of bacteriuria: keep the closed catheter system

closed and remove the catheter as soon as possible.

Irrigation of the catheter and bladder with antibacterial

solutions has not curtailed bacteriuria.

Asymptomatic bacteriuria need not be treated as long as

catheter short term or long-term, remains in place.
EXCEPTIONS :
1. For patients who may be at high risk of serious
complications (e.g. granulocytopenic patients, solid
organ transplant patients, and pregnant women)
2. Patients undergoing urologic surgery

Conclusion
Urinary tract infections are the 2nd
most common bacterial infections.
Women are the most infected
subjects in the population.
Development of resistance to
antibiotics by the bacteria result in
problems during the treatment and
lead to relapse or recurrence.
Recent advances such as
development of immunologicals like
intranasal vaccines may result in life