URINARY TRACT INFECTION
Syakib Bakri, Hasyim Kasim, Haerani Rasyid
*Division of Nephrology, Department of Internal Medicine
Faculty of Medicine, Hasanuddin University
Urinary Tract Infections (UTI)
Frequent clinical problem
Any site in the urinary tract may be involved : the urethra, prostate,
bladder, ureter, kidney and perinephric space.
Bacterial infection is most common, but fungi, chlamydia, viruses
and parasites may be responsible in some patients
Women >>> Men
Terminology of Urinary Tract Infections (1)
Bacteriuria : Presence of bacteria in the urine.
Asymptomatic bacteriuria : 105 CFU/ml urine with or without pyuria, in a patient
without symptoms of UTI.
Cystitis : inflammation of the bladder
Bacterial cystitis
Abacterial cystitis (urethral syndrome)
Acute pyelonephritis: acute bacterial infection of the kidney characterized by
chills and fever (often high) and flank pain (usually unilateral), as well as
tenderness.
Chronic pyelonephritis : Radiological diagnosis where there is evidence of focal
scarring of the kidneys with associated calyceal abnormality indicating renal
damage due to a combination of reccurent infection with obstruction of the
pelviocalyceal system (chronic obstructive nephropathy) or vesicoureteral
reflux (reflux nephropathy).
Ribeiro RM, et al. Int Urogynecol 2002;13:19
Terminology of Urinary Tract Infections (2)
Reinfection : An infection with a different strain of microorganism or a different
serological type after (end of therapy) eradication of previous infection.
Most likely represent infections of the bladder, occur weeks to months after
treatment of the previous infection, response well to therapy,
usually associated with a normal urinary tract
Relapse : A consecutive urinary infection caused by the same strain or serotype of
bacteria, usually represent infection of the kidney or prostat, often recur
within 1 6 weeks after antimicrobials have been discontinued, some cases
represent persistent infection, anatomic abnormalities or renal insuficiency
are more common with relapsing or persistent infection, a long course of
antimicrobials or surgery may be required if the urine is to be permanently
sterilized
Ribeiro RM, et al. Int Urogynecol J 2002;13:
Terminology of Urinary Tract Infections (3)
Persistence : the continued presence of the microorganisms isolated at the beginning
of the treatment, owing to resistance to antimicrobial therapy, inadequate
drug dosage, or a urological abnormality. These unresolved infections may
be also in consequence of the patients non-compliance in taking medication,
mixed infections with two different bacterial strains with mutually exclusive
susceptibilities, or renal insufficiency (leading to an inadequate drug
concentration in the urine).
Recurrent UTI: patients with at least two infections within 6 months or three or
more during a single year, in which the initial episode is resolved and
is followed by another infection.
Ribeiro RM, et al. Int Urogynecol J 2002;13:
Diagnosis Urinary Tract Infection
1. Symptoms :
Lower UTI :
Frequency, dysuria, suprapubic pain
Upper UTI :
Fever, flank pain, and chills as well as symptoms similar to bladder
infection
2. Urinalysis
The presence of 10 WBC / mm3 fresh un-spun midstream urine
The presence of 10 WBC / high-power field sediment midstream
urine
3. Culture
4. Radiological evaluation
Ultrosound
Plain abdominal radiography
Intravenous urography
CT scanning
Criteria for diagnosis of significant bacteriuria
Symptomatic women :
102 coliform organisms/ml urine plus pyuria, or
105 of any pathogenic organism/ml urine, or
Any growth of a pathogenic organism from urine obtained by
suprapubic aspiration
Symptomatic men :
103 pathogenic organism/ml urine
Asymptomatic patients :
105 pathogenic organism/ml urine in two consecutive samples
Classification of Urinary Tract Infection (1)
I. Lower urinary tract infection ( Cystitis )
Frequency, dysuria, suprapubic pain
II. Upper urinary tract infection ( Pyelonephritis )
Fever, flank pain, and chills as well as symptoms
similar to bladder infection
Classification of Urinary Tract Infection (2)
I. Uncomplicated urinary tract infection
Occurs in individuals with structurally and functionally normal genitourinary
tracts
Most common bacterial infection that occurs in women, but is uncommon in
men
May involve the bladder or the kidneys and may be symptomatic or
asymptomatic
II. Complicated urinary tract infection
As acute or chronic parenchymal infection associated with a functional or
structural urinary tract abnormality
e.g. : Neurogenic bladder, urinary tract obstruction, immunocompromized
patients, diabetes mellitus, polycystic kidney disease, renal transplant
recipient.
Bacterial etiology of urinary tract infection
E. coli : 70-95% (uncomplicated UTI), 21-54% (complicated)
S. Saprophyticus : 5-20% (uncomplicated), 1-4% (complicated)
Enterococci : 1-2% (uncomplicated), 1-23% (complicated)
Proteus mirabilis : 1-2% (uncomplicated ), 1-10% (complicated)
Klebsiella spp : 1-2% (uncomplicated), 2-17% (complicated)
Pseudomonas aeruginosa : <1% (uncomplicated), 2-19% (complicated)
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
McBryde C, Redington. Primary Care Case Rev 2001 ;
Acute uncomplicated cystitis in women
Single dose or 3-day course of treatment
(trimethoprim sulfamethoxasole, quinolone, amoxycillin)
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) :
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
McBryde C, Redington. Primary Care Case Rev 2001 ;
Acute uncomplicated pyelonephritis in women
Severe illness
Moderate severity
Outpatients and oral
therapy possible
(trimethoprim
sulfamethoxasole,
quinolone, amoxycillin)
Hospitalization with initial
parenteral therapy
(trimethoprimsulfametaxazol,
ceftriaxone, quinolone,
gentamicin
with/without ampicilin
Urologic evaluation
No resolution
in 5 days
Resolution
in 5 days
No resolution
in 5 days
Radiologic evaluation
Treatment 14 days
Oral treatment 14 days or
longer as required
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
McBryde C, Redington. Primary Care Case Rev 2001 ;
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
McBryde C, Redington. Primary Care Case Rev 2001 ;
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
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
McBryde C, Redington. Primary Care Case Rev 2001 ;
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
Indication for imaging studies in
patients with Urinary Tract Infections
Infections in a newborn
Reccurent infection occuring in childhood
Two or more infections in adult females
One infection in adult males
Elevated creatinine level
History of urinary calculi
Neurologic bladder dysfunction
Persistent hematuria
Previous genitourinary surgery
Prolonged fever after initiation of antibiotic therapy
Relapsing infection
Urea-splitting organisms
Unusual causative organism
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