Urinar y Tract

Infections
Dr. Sameh Ahmad Muhamad abdelghany
Lecturer Of Clinical Pharmacology
Mansura Faculty of medicine
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OBJECTIVES
 Describe pathogenesis & clinical
characteristics of Urinary tract infections
 Identify most likely etiologic organism(s)
 Review appropriate drug therapy
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CONTENTS

INTRODUCTION

Classification

RISK FACTORS
Infections
Diagnosis

Treatment
INTRODUCTION
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INTRODUCTION
 Urinary tract infection is one of the most
common bacterial infection managed in
general medical practice
 Accounts for 1‐3% of consultations
 Up to 50% of women will have a UTI at
some point in their life
 UTI uncommon in men except over the
age of 60 when urinary tract obstruction
due to prostatic hypertrophy may occur
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INTRODUCTION
 Symptomatic presence of
micro-organisms within
the urinary tract i.e.,
kidney, ureters, bladder
and urethra.
 Associated with
inflammation of urinary
tract.
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INTRODUCTION
 Significant bacteriuria:
o presence of at least 105 bacteria/ml of
urine.
 Asymptomatic bacteriuria :
o bacteriuria with no symptoms.
 Urethritis: infection of anterior urethral
tract.
 Cystitis: infection to urinary bladder
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UTI - Terminology
 Acute pyelonephritis:
o infection of one/both kidneys.

 Chronic pyelonephritis:
o particular type of pathology of kidney;
may/may not be due to infection.
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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
CLASSIFICATION
 Classification Of UTI
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A. Upper UTI:
 Acute pyleonephritis
 Chronic pyleonephriitis
 Interstitial pyleonephritis
 Renal abscess
 Perirenal abscess.
B. Lower UTI:
 Cystitis
 Prostatitis
 Urethritis

 Both upper & lower UTI are further divided into

complicated and uncomplicated.
 Epidemiology
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 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; 10% of
men and 20% of women are infected.
 Etiology
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Acute uncomplicated UTI:

 Escherichia coli : cause about 80% of
UTI
 20% of UTI caused by Gram
negative enteric bacteria – Klebsiella,
Proteus
 Gram positive cocci : Streptococcus
faecalis , Staphylococcus
saprophyticus
 Etiology
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 Complicated UTI:
 Pseudomonas aeruginosa, Enterobacter &
Serratia
 Isolated in hospital acquired infections
and catheter associated UTI.
 Viruses : Rubella, Mumps and HIV
 Fungi : Candida, Histoplasma capsulatum
 Protozoa : T. vaginalis, S. haematobium
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RISK FACTORS
 Risk Factors
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1. Aging:
 diabetes mellitus
 urine retention
 impaired immune system
2. Females:
 shorter urethra
 incomplete bladder emptying with age
3. Males:
 prostatic hypertrophy
 bacterial prostatitis
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Host Factors Predisposing to

Infection
1. Extra-renal obstruction
 Posterior urethral valves
 Urethral strictures
2. Renal calculi
3. Incomplete bladder emptying
4. Neurogenic bladder
5. Immunocompromised individuals (e.g.
DM, transplant recipients)
DIAGNOSIS
 UTI-CLINICAL
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PRESENTATION
 Clinical manifestations depends on
i. site of infection
ii. age of patient.
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I. Clinical manifestations
depending on site of infection

 Urethritis:
 Discomfort in voiding
 Dysuria
 Urgency
 frequency
I. Clinical manifestations
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depending on site of infection

 Cystitis:
 dysuria, urgency and
frequent urination
 Pelvic discomfort
 Abdominal pain
 Pyuria
 Hemorrhagic cystitis:
 Visible blood in urine.
 Irritating voiding symptoms
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I. Clinical manifestations
depending on site of infection
 Pyleonephritis:
 Invasive nature
 Suprapubic tenderness
 Fever and chills
 White blood cell casts in urine
 Loin pain
 Nausea and vomiting
 Complications :
 sepsis, septic shock and death.
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SYMPTOMS OF PYELONEPHRITIS
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COMMON SYMPTOMS OF UTI

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II. Clinical manifestations depending

on age
 Babies and infants:
 Failure to thrive
 Fever
 Apathy
 Diarrhea
 Children:
 Dysuria, urgency, frequency
 Hematuria
 Acute abdominal pain
 Vomiting
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II. Clinical manifestations depending

on age
 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.
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Investigations

 Microscopic examination of urine

 Urinalysis
 Urine culture
 Imaging techniques: CT scan and
MRI
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Laboratory examination

 Uncontaminated, midstream urine

sample used.
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Laboratory findings
Normal Findings Abnormal findings

 pH 4.6 – 8.0 Alkaline (increases)

 Appearance Clear cloudy

 Color pale to amber yellow deep amber

 Odor aromatic foul smelling

 Blood none maybe present
 WBC absent present
 Bacteria absent present
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Microscopic examination of urine

Multiple white cells seen in

the urine of a person with
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Urinalysis

 Presence of pus, white blood cells,

red blood cells
 Bacterial count > 105 /ml – significant
bacteriuria
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Urine culture
 For pyelonephritis
 Not a rapid diagnostic tool
 >105 bacteria /ml
 Differential leukocyte count
(increased neutrophils)
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Diagnostic tests for adults with

recurrent UTI
 Intravenous pyelography / excretory
urography
TREATMENT
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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 fluids
like cranberry juice or use of ascorbic
acid.
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Anti-microbial therapy

 Goals of therapy:
 Elimination of infection
 Relief of acute symptoms
 Prevention of recurrence
and long term
complications
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Anti-microbial therapy
 Principles of anti microbial therapy :
o Levels of antibiotic in urine but not in
blood
o Blood levels of antibiotic –important in
pyelonephritis
o Penicillins and cephalosporins –drugs of
choice for UTI with renal failure.
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Anti-microbial therapy
 Treatment duration:
 Single dose therapy
 3 day course
 7 day course
 10 – 14 day course
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Anti-microbial therapy
 Single dose therapy:
 Trimethoprim- sulfamethaxole
 Amoxicillin- clavulnate 500mg
 Amoxcillin 3gm
 Ciprofloxacin 500mg
 Norfloxacin 400mg
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Anti-microbial therapy
 3 day therapy:
 Efficacy same as 7 day therapy with
less adverse effects
 Drugs used include
o quinolines
o TMP-SMZ
o betalactam antibiotics
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Anti-microbial therapy
 7 day therapy:
 Used less for uncomplicated UTI
 Useful in :
a. recurrent cases
b. pregnancy
c. UTI with other risk factors
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Anti-microbial therapy
 14 day therapy:
 For complicated UTI
 High risk of mortality and morbidity
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Pathogen specific treatment

Pathogen Treatment options
Escherichia coli Ceftriaxone
Pseudomonas
Gentamycin
aeroginosa
Klebsiella sps
Enterobacter sps Ceftadizine
Proteus sps

Enterococcus sps Ampicillin

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Infection specific treatment

 Lower UTI:
 3day therapy preferred
o Trimethoprim
o Nitrofurantoin
o Ciprofloxacin -Norfloxacin
o Co-amoxiclav
o Amoxicillin
o Cephalexin
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Infection specific treatment

 Acute pyelonephritis
 Paranteral antibiotics
o Cefuroxime – 750mg i.v. Q8h
o Gentamycin - 80-120g i.v. Q12h
o Ciprofloxacin – 200mg i.v. Q12h
 10-14 days treatment
 Ceftazimide, imipenam, ciprofloxacin
for hospital acquired pyelonephritis
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Infection specific treatment

 Asymptomatic bacteriuria
 Children :
o treatment same as symptomatic
bacteriuria
 Adults :
o treatment required in cases of
a) pregnancy
b) patient with obstructive structural
abnormalities
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Infection specific treatment

 Bacteriuria in pregnancy
 To prevent risk of pyelonephritis
 7 day course with following antibiotics
o Cephalaxin
o Nitrofurantoin
o Amoxicillin
 Therapy continued at regular intervals of
pregnancy.
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Infection specific treatment

 Relapsing UTI
 7-10 day course
 If fails – 2week course / 6week course
 Structural abnormalities corrected by
surgery
 6week course:
i. children
ii. adults with continuous symptoms
iii. high risk of renal damage
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Prophylaxis for UTI

 Single dose of trimethoprim 100mg
/ nitrofurantion 50mg
 Long term low dose prophylaxis
(beneficial)
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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.
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thanks
Fo r W at ching