DOI: https://doi.org/10.

53350/pjmhs221610810
ORIGINAL ARTICLE

Urinary Tract Infections: Epidemiology, Mechanisms of Infection, and

Treatment
MUHAMMAD SHAHZAD1, EHTESHAM MALIK KHAN2, OMAR QUDDUS KHAN3, UMER BIN TARIQ4, AROOJ SABAHAT5
1
MBBS, FCPS(Urology). Assistant Professor Urology, Ayub Medical Teaching Institute, Abbottabad.
2
MBBS, FCPS Gen surgery, Senior Medical officer, Benazir Bhutto Shaheed Teaching Hospital Abbottabad.
3
MBBS, FCPS(Urology). Assistant Prof Urology Frontier Medical College, Abbottabad.
4
MBBS, Nawaz Sharif Medical College, Gujrat.
5
MBBS, Ayub Medical College, Abbottabad.
Correspondence to: Omar Quddus Khan, Email: Okhan7614@gmail.com, Cell: 03114838211

ABSTRACT
Purpose: The main purpose of this study was to determine the mechanism of infection and the response of preferred antibiotic
treatment during this study.
Study: This study was conducted from February to March 2022. The approval for this randomized study was taken by the
Ethical Committee of the concerned hospital. Written informed consent was signed by all participants. Total of 110 participants
who reported problems with UTIs were part of this study. Levofloxacin 750 mg per day for five days and ciprofloxacin 500 mg
twice per day for ten days were given to patients for treatment.
Results: The total number of patients was 110, 65 (59.09%) males and 45 (40.90%) females having a mean age of 28 ± 5,
urinary tract abnormalities were observed in 28 (25.45%) patients including obstruction in 16 (14.54%) patients, stone in 8
(7.27%)cases, the neurogenic bladder was in 4 (3.63%) patients and poly-microbial etiology was in 25 (22.72%) and
catheterized patients was 35 (31.81%) in which chronic catheter cases were 15 (13.63%), intermittent catheter cases were 20
(18.18%), and Complicated UTIs was found in 22 (20.02%). 55 patients were treated with levofloxacin 51 (46.36%) reported a
positive response and 51 (46.36%) were not cured with a p-value of 0.05. 55 patients were treated with ciprofloxacin of which 48
(43.63%) patients were cured and 7 (6.36%) were not cured with a p-value of 0.05. The number of patients treated with
levofloxacin had a higher cured percentage 46.36% than those treated with Ciprofloxacin.
Conclusion: Eventually, this study demonstrated that UTIs of all the microorganisms detected during the study can be cured
with levofloxacin and ciprofloxacin. While ciprofloxacin was slightly less effective in a few cases than levofloxacin.
Keywords: Urinary tract infection (UTIs), Ciprofloxacin, levofloxacin, infection treatment

INTRODUCTION METHODOLOGY
Worldwide urinary tract infections (UTIs) have been affecting more This study was conducted from February to March 2022. The
than 150 million people each year.1 Clinically, it's divided into approval for this randomized study was taken by the Ethical
uncomplicated and complicated UTIs. As uncomplicated UTIs have Committee of the concerned hospital. Written informed consent
no structural or neurological damage and the affected individuals was signed by all participants. Total of 110 participants who
seem healthy.2-3 While it's discrimination based on lower and upper reported problems with UTIs were part of this study. Levofloxacin
UTIs problems of cystitis and pyelonephritis.4 Cystitis has a potent 750 mg per day for five days and ciprofloxacin 500 mg twice per
association with many risk factors like female gender, sexual day for ten days were given to patients for treatment.
activity, vaginal infection, and other diseases including diabetes Inclusion Criteria: Patients of age 20 to 35 years were part of the
and obesity along the genetic factors.5 Although complicated UTIs study. Patients diagnosed with Acute pyelonephritis (AP) and UTIs
can be defined with risk factors associated with or cause urinary with 105 colony forming units. CFUs were included. Moreover,
tract obstruction, urinary retention because of neurological people have a history of
disorder, renal failure, transplantation, and other factors foreign  Fever, nausea, vomiting, dysuria
bodies, calculi, etc.6 The bacteria (gram positive and gram
negative) and certain fungi might be causative agents for UTIs. 7
 Flank pain or cost vertebral angle tenderness
Most patients are treated with antibiotics that lead to changes in  Patients reported complicated factor neurogenic bladder,
normal microflora of the vagina and gastrointestinal tract as well as partial obstruction, and distorted urethral structure
in the production of multidrug-resistant microorganisms.8 Although, Exclusion criteria
women are suspected to develop UTIs because of the shorter  People had a history of surgery
urethra while older adults are at higher risk of cystitis due to  Chronic pyelonephritis
alteration of bladder abnormalities. Commonly, pregnant women
are at great risk to suffer from urinary tract infections, untreated  People with complete obstruction were also excluded from
asymptomatic bacteriuria increases the chances of premature this study
delivery, pyelonephritis, and fetal mortality.9 Oral amoxicillin is Mechanism of pathogenesis associated with catheter urinary
used to treat the asymptomatic and symptomatic bacteriuria in tract infection: Urinary tract infections associated with catheter
pregnant women probably for ten days or recommend conciliated by Proteus mirabilis that based on the appearance of
nitrofurantoin for 7 days.10 Moreover, for UTIs treatment Pilli (mannose- resistant Proteus like) for its attachment to develop
trimethoprim, is prior to use except for women who show the biofilm in the bladder and on the surface of the catheter.
resistance while following the local guidelines. Escherichia coli is Ensuing the urease formation that leads to the development of
more frequently found in female patients than in males diagnosed calcium crystals and starts the precipitation of magnesium
with urinary tract infections. Morganella morganii is commonly ammonium phosphate in urine because of hydrolysis of CO2 and
observed in patients who undergo Urological ammonia, this process increases the pH. The attached bacteria on
devices.11 Pseudomonas aeruginosa, Staphylococci, Candida the catheter use crystal and produced the crystalline biofilm; it acts
species, and many other organisms isolated from infected as a safeguard to protect from the host immune system and from
people.12 antibiotics. On the other hand, it causes trouble with urine drainage
In this study we have focused on epidemiology, mechanism and reflux problem. It leads to developing pyelonephritis, shock as
of action of catheter-associated infection as well as treated the well as septicemia. Although, bacteria toxins production starts
participants with antibiotics. damaging the tissues and bacteria spreads to the kidneys.
Bacterial toxins induced the pores and enter the cell membranes to

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 M. Shahzad, E. M. Khan, O. Q. Khan et al

destabilize the host cell and destroy tissues. Catheter implantation Similarly, in 20 intermittent catheter cases, Pseudomonas
causes inflammation of the bladder and releases fibrinogen that aeruginosa was isolated from 6 (30.00%) cases, E.coil isolated
begins to accumulate. Enterococcus faecalis uses the fibrinogen from 4 (20.00%) cases, Enterococcus species in 3 (15.00%)
as food and make a biofilm that protects bacteria from the host Coagulase-negative staphylococcus in 3 (15.00%) cases, and
immune system. Providencia species in 4 (20.00%) cases.
Statistical Analysis was performed using statistic software 8.1. Complicated UTI cases includes Pseudomonas
The data was presented in the number of percentages and a p- aeruginosa 3 (13.63%) cases, E.coil were diagnosed 7 (31.81%)
value less than 0.05 shows significant results and a p-value higher patients, Enterococcus species in 3 (13.63%) patients, Coagulase-
than 0.05 shows a non-significant response. negative staphylococcus in 4 (18.18%) patients, and Providencia
species in 5 (22.72%) cases.
RESULTS
The total number of patients was 110, 65 (59.09%) males and 45 DISCUSSION
(40.90%) females having a mean age of 28 ± 5, urinary tract Among the common bacterial infections UTIs is one of them,
abnormalities were observed in 28 (25.45%) patients including ensuing the billion dollars expenses in health care department
obstruction in 16 (14.54%) patients, stone in 8 (7.27%)cases, the every years.13 Currently, for UTIs infections, recommended
neurogenic bladder was in 4 (3.63%) patients and poly-microbial medication for treatment is antibiotics such as trimethoprim-
etiology was in 25 (22.72%) and catheterized patients was 35 sulfamethoxazole, ciprofloxacin, and ampicillin. However, antibiotic
(31.81%) in which chronic catheter cases were 15 (13.63%), resistance development is another important and growing factor
intermittent catheter cases were 20 (18.18%), and Complicated that brings a 25% change in the management of UTI treatment. 14
UTIs was found in 22 (20.02%). Data of all the patients were given Worldwide antibiotic resistance is a substantial threat to the safety
in table 1. of patients. The development of infection because of antibiotic
Table 2. Represents 55 patients were treated with resistance can lead to more damage to patients’ health. 15
levofloxacin, 51 (46.36%) reported a positive response, and 51 In this study variety of infecting organisms were isolated
(46.36%) were not cured with a p-value of 0.05. 55 patients were from different patients in which Escherichia coli was the most
treated with ciprofloxacin of which 48 (43.63%) patients were cured common organism found in complicated UTIs
and 7 (6.36%) were not cured with a p-value of 0.05. The number cases. Pseudomonas aeruginosa was the second most micro-
of patients treated with levofloxacin had a higher cured percentage organism detected in 6 cases out of 20 cases of intermittent
46.36% than those treated with Ciprofloxacin. catheters while the third most was Enterococcus species found in
Table. 3. Represents the microbial-related data where 15 5 cases of chronic catheter factor. In females after menopause
cases of chronic catheter isolated with different microbes in which estrogen levels begin to decline that bringing chemical and
Pseudomonas aeruginosa was found in 3 (20 %), E.coli isolated structural alterations like decreasing the urinary flow, enhancing
from 3 (20 %) cases, Enterococcus species in 5 (33.33 %), the residual volume, and raising vaginal pH high causing loss of
Coagulase-negative staphylococcus in 4 (26.66%) cases, and lactobacilli in the vagina which enhanced the chances to develop
Providencia species in 1 (6.66%). urinary tract infection. 16 In the cross-sectional study of UTIs in
adult females demonstrated that 14% was prevalent in bacteriuria,
Table 1: General Characteristic of Study and Eschericha coli 34.5% was the main organism detected to
Characteristic Number of patients 110 (%) lead the infection, antibiotic was used to treat both situations. 18 A
Gender clinical study demonstrated that the administration of levofloxacin
Male 65 (59.09%) for five days is more effective than ciprofloxacin for the treatment
Female 45 (40.90%)
of AP. Moreover, they concluded that short-term therapy is more
Age (Mean+ S.D) years 28 ± 5
effective than long-term therapy 17 In this study we use
Urinary Tract abnormalities 28 (25.45%)
Obstruction 16 (14.54%)
levofloxacin and ciprofloxacin both to treat the different organisms.
Stone 8 (7.27%) Ciprofloxacin was slightly more effective than levofloxacin.
Neurogenic bladder 4 (3.63%) Moreover, we studied the mechanism of action of infection which
Poly microbial 25 (22.72%) needs more research and studies to explain
Catheterized 35 (31.81%)
Chronic catheter cases 15 (13.63%) CONCLUSION
Intermittent catheter cases 20 (18.18%) This study concluded that the cauterized cases were higher in
Complicated UTI 22 (20.02%) number that cases the infection in patients. Urinary infection
because of all the microorganisms detected during study can be
Tables 2: Patients response with levofloxacin and ciprofloxacin
cured with levofloxacin and ciprofloxacin.
Treatment Number of Number of patients P-value
patients cured not cured
Levofloxacin 51 (46.36%) 4 (3.63%) 0.05 REFERENCES
Ciprofloxacin 48 (43.63%) 7 (6.36%) 0.05 1. Flores-Mireles, A. L., Walker, J. N., Caparon, M., & Hultgren, S. J.
(2015). Urinary tract infections: epidemiology, mechanisms of
Table 3: Isolated organisms with complicated urinary tract infections infection and treatment options. Nature reviews microbiology, 13(5),
Organism Chronic Intermittent Complicated UTI 269-284.
isolated catheter cases catheter cases cases n=22 2. Hooton, T. M. Uncomplicated urinary tract infection. New Engl. J.
n=15 n=20 Med. 366, 1028–1037 (2012)
3. Nielubowicz, G. R. & Mobley, H. L. Host-pathogen interactions in
Pseudomonas 3 (20 %) 6 (30.00%) 3 (13.63%)
urinary tract infection. Nature Rev. Urol. 7, 430–441 (2010).
aeruginosa
4. Hannan, T. J. et al. Host-pathogen checkpoints and population
Escherichia 3 (20 %) 4 (20.00%) 7 (31.81%)
bottlenecks in persistent and intracellular uropathogenic Escherichia
coli
coli bladder infection. FEMS Microbiol. Rev. 36, 616–648 (2012).
Enterococcus 5 (33.33 %) 3 (15.00%) 3 (13.63%) 5. Foxman, B. Urinary tract infection syndromes: occurrence,
species recurrence, bacteriology, risk factors, and disease burden. Infect. Dis.
Coagulase- 4 (26.66%) 3 (15.00%) 4 (18.18%) Clin. North Am. 28, 1–13 (2014).
negative 6. Wagenlehner, F. M., Sobel, J. D., Newell, P., Armstrong, J., Huang,
staphylococcu X., Stone, G. G., ... & Gasink, L. B. (2016). Ceftazidime-avibactam
Providencia 1 (6.66%) 4 (20.00%) 5 (22.72%) versus doripenem for the treatment of complicated urinary tract
species infections, including acute pyelonephritis: RECAPTURE, a phase 3

P J M H S Vol. 16, No. 10, October, 2022 811

Urinary Tract Infections: Epidemiology, Mechanisms of Infection, and Treatment

randomized trial program. Clinical Infectious Diseases, 63(6), 754- 13. Sihra, N., Goodman, A., Zakri, R., Sahai, A., & Malde, S. (2018).
762. Nonantibiotic prevention and management of recurrent urinary tract
7. Pappas, P. G., Kauffman, C. A., Andes, D. R., Clancy, C. J., Marr, K. infection. Nature Reviews Urology, 15(12), 750-776.
A., Ostrosky-Zeichner, L., ... & Sobel, J. D. (2016). Clinical practice 14. Llor, C. & Bjerrum, L. Antimicrobial resistance: risk associated with
guideline for the management of candidiasis: 2016 update by the antibiotic overuse and initiatives to reduce the problem. Ther. Adv.
Infectious Diseases Society of America. Clinical Infectious Diseases, Drug Safety 5, 229–241 (2014).
62(4), e1-e50. 15. Flower, A., Wang, L. Q., Lewith, G., Liu, J. P. & Li, Q. Chinese herbal
8. Kauffman, C. A. (2014). Diagnosis and management of fungal urinary medicine for treating recurrent urinary tract infections in women.
tract infection. Infectious Disease Clinics, 28(1), 61-74. Cochrane Database Syst Rev. 6, CD01044 (2015).
9. Hooton, T. M., Gupta, K., & Calderwood, S. B. (2020). Recurrent 16. Luthje, P., Hirschberg, A. L. & Brauner, A. Estrogenic action on innate
simple cystitis in women. UpToDate. Waltham, MA: UpToDate Inc. defense mechanisms in the urinary tract. Maturitas 77, 32–36 (2014).
10. Witteman, L., van Wietmarschen, H. A., & van der Werf, E. T. (2021). 17. Ren, H., Li, X., Ni, Z. H., Niu, J. Y., Cao, B., Xu, J., ... & Chen, N.
Complementary Medicine and Self-Care Strategies in Women with (2017). Treatment of complicated urinary tract infection and acute
(Recurrent) Urinary Tract and Vaginal Infections: A Cross-Sectional pyelonephritis by short-course intravenous levofloxacin (750 mg/day)
Study on Use and Perceived Effectiveness in The Netherlands. or conventional intravenous/oral levofloxacin (500 mg/day):
Antibiotics, 10(3), 250. prospective, open-label, randomized, controlled, multicenter, non-
11. Katouli, M. (2010). Population structure of gut Escherichia coli and its inferiority clinical trial. International urology and nephrology, 49(3),
role in the development of extra-intestinal infections. Iranian journal of 499-507.
microbiology, 2(2), 59. 18. Prakasam, K. A., Kumar, K. D., & Vijayan, M. (2012). A cross
12. Kline, K. A., & Lewis, A. L. (2017). Gram‐positive uropathogens, sectional study on distribution of urinary tract infection and their
polymicrobial urinary tract infection, and the emerging microbiota of antibiotic utilisation pattern in Kerala. Int J Res Pharm Biomed Sci,
the urinary tract. Urinary Tract Infections: Molecular Pathogenesis 3(3), 1125-30.
and Clinical Management, 459-502.

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