Urinary Tract Infection and

focus on its Management

Dr. Santosh Ramesh Achwani
Access Clinic, DIP – 2, Dubai
Monday, 2nd of May, 2021, 9:30 PM
Online Live Webinar
 Index
1. Definition
2. Classification
3. Etiology
4. Risk Factors
5. Pathogenesis
6. Symptomatology
7. Diagnosis
8. Treatment (Empirical & Specific)
9. Spectrum of Levofloxacin
10. Life-style modifications and home remedies for UTI
11. Complications
12. Prevention
13. Summary
 1. Definition of UTI
Infection of
1. Urinary stream (>105 CFU/ml, Isolatable & Cultured)
2. S/s of excretory organ that is
associated with it

- Kidneys (Pyelonephritis)
- Ureters (Uretritis)

- Bladder (Cystitis)**MC
- Prostate (Prostatitis)
- Urethra (Urethritis)  Orchitis
Epididymitis
- Balanitis
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- Balanoposthitis (Fungal)
 2. Classification of UTI
1. Anatomical Classification: (Location)
Upper UTI: Pyelonephritis, Ureter-itis
Lower UTI: Cystitis, Urethr-itis

2. Clinical Classification:
A. Simple UTI: Uncomplicated infection in health patients (1. No underlying structural or functional
abnormality of UT, 2. Non pregnant patients, 3. Pts with no significant comorbidities)
B. Complicated UTI: Child, Pregnant patient or Any of 3 (1. Underlying structural or functional
abnormality of UT + obstruction to urine flow, 2. Comorbidity that increases risk of acquiring
infection or resistance to treatment: DMT2, CKD, Ca Chemotherapy, IMC, IMS therapy, HIV, AIDS,
3. Recent instrumentation or Sx)
C. Recurrent UTI: Multiple symptomatic infections with asymptomatic periods

Terms:
1. Asymptomatic Bacteriuria: MC: Elderly, Bacteriuria > 105 CFU/ml of urine
2. Symptomatic Abacteruria: S/s UTI, but bacterial
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load < 105 CFU/ml (MC: Dysuria)
3. Count < 105 CFU/ml, but still infection +: Concurrent abx + tt, rapid urine flow, low urine pH
3. Etiology of UTI

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3. Etiology of UTI

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 4. Risk Factors

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(Blocking the flow of urine)
 4. Risk Factors
1. Category 1
- Manoeuvres that help bacteria get easily attached onto urinary tract epithelium
2. Category 2:
- Things that allows more time for bacterial proliferation (E.g.: Dehydration,
Constipation in children, BPH, Urethral stricture, Holding urine for long times, wet damp
nappies in neonates)
- Acts that introduce and implant bacteria into uro-epithelium (E.g.: Kidney stones,
Anatomical abnormalities, Intra – abdominal growth causing kinking of ureters)
3. Category 3:
- Manoeuvres that favour urinary retention & promoting bacterial growth and help in
infection ascension further along the urothelium
4. Category 4:
- Weakened defence mechanisms (DMT2, Ca, Chemotherapy)
5. Miscellaneous: Infection spreading from other areas (Unclean genital area: Anus 
Vagina), Non accidental Injuries in children, Post menopausal women with thinner + drier
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vulval tissue (increases the risk of irritation or abrasions that encourage infection)
 5. Pathogenesis of UTI
- Kidney damage

- Infection into kidney parenchyma /

surrounding tissues etc.

- Extension of pathogens towards the kidneys

and to other nearby
- Penetration into the organ tissue

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- Accumulation of bacterial load in urine
 6. Symptomatology
Adult: (Classical S/s) Babies: (Special S/s)
- Dysuria - Lethargy
- Frequency - Poor feeding
- Urgency - Fever or Hypothermia
- Nocturia - Vomiting +/- Diarrhea
- Discharge - Strong smelling urine (Odour)
- Dyspareunia - Irritable + Cranky child
- Suprapubic pain - Crying inconsolably
Elderly: (Non Classical S/s)
± Back pain - Crying when peeing
- Malaise
± Hematuria
- Weakness, tiredness
± Cloudy urine
- Nausea +/- Vomiting +/- Dizziness
± Enuresis
± Fever or hypothermia
± Confusion
± hypotension
10 ± urine retention
 6. Symptomatology
Symptomatology: Helps in **Only gives idea + purpose of description **Non-reliable
− Localizing the organ infected
− Urgency of need of treatment

Upper UTI: Higher: More Systemic S/s: Kidneys (Pyelonephritis), Ureters (Uretritis)
High Grade Fever, Chills, Myalgia, Arthralgia, Loin (Flank) pain, Nausea, Vomiting, Blood Stream
related changes (Elevated: Pulse, WBCs, CRP, Low: BP) **Urgency of t/t **Hospitalizn

Lower UTI: Lower: Local S/s: Dysuria, Urgency, Dyspareunia, Frequency, Hesitancy, incomplete
urination, Hematuria, Cloudy urine, Supra-pubic pain **Non-urgent: OPD care

- Bladder (Cystitis): Low back pain, Pelvic pressure, Lower abdominal discomfort, Hematuria,
Urgency, Supra-pubic pain, Frequency
- Prostate (Prostatitis): Recurrent Dysuria, A/c urinary retention, Severe deep pelvic pain,
unable to sit
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- Urethra (Urethritis): Dysuria, Cloudy urine, pain at base of penis, Pyuria, discharge
 7. Diagnosis
Urine Testing: 1: Clean Catch, 2: Morning 1st Urine sample, 3: Mid-stream

1. ***Urine R/M (e/o Infection: Pus cells, RBCs)

2. ***Urine Dipstick (e/o Infection +: Nitrates +, Leucocyte Esterase +)
3. ***Urine C/S  To obtain MIC Values and antibiotic susceptibility for treatment
4. UGT Imaging Techniques  for evaluating details of Complicated & Recurrent UTI (Further
evaluation and management)

**If STD is suspected then a urethral swab should precede urine sample.

Specimen:

5. Clean voided specimen (CVS)

6. Minicath for menstruating females
7. Perineal bag / Suprapubic tap: babies
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8. Straight cath male (8 to 10 French catheter): only if unable to void
Diagnosis of Infection (Urine-analysis):
- Turbid Urine
- Leucocyte esterase +
- Nitrites +
- WBCs +
- Bacteria +

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Diagnosis of Infection (Urine-analysis):
- Turbid Urine
- Leucocyte esterase +
- Nitrites +
- WBCs +
- Bacteria +
 Diagnosis of UTIs
Laboratory Findings

• Pyuria: WBC > 10 WBC/mm3

• it only signifies the presence of inflammation
• Sterile pyuria is associated with urinary tuberculosis, chlamydial,
and fungal infections
• Hematuria, non-specific, may indicate other disorders such as
calculi or tumor
• Proteinuria is found in the presence of infection
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 8. Treatment of UTIs
 Main treatment: Antibiotics + Home remedies + Symptomatic treatment
 Choice of antibiotics: May differ from country to country according to local health protocol
 Simple UTI: 5-7 days course,
 Complicated/Severe UTI: Hospital admission + IV antibiotics,
 Recurrent UTI:
 Generally: MC Drugs used for UTIs include:

1. Ampicillin, Amoxy-Clavulanate
2. Trimethoprim/sulfamethoxazole (TMP-SMX)
3. Nitrofurantoin
4. Cephalexin
5. Ceftriaxone
6. Quinolones***
7 Fosfomycin (New, Resistant bacteria, Single dose therapy)

 Increasing rates of antibiotic resistance + high recurrence rates  leads us to use simpler
forms of antibiotics first and then step up therapy
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is unsuccessful, also to avoid the development
of resistance in UTI causing bacteria.
9. Levofloxacin Broad Spectrum Coverage

Aerobic Gram-Positive Aerobic Gram-Negative Anaerobic Other

bacteria bacteria bacteria
Bacillus anthracis Eikenella corrodes Pepto streptococcus Chlamydophila pneumoniae

Staphylococcus aureus methicillin- Haemophilus influenzae Chlamydophila psittaci

susceptible
Staphylococcus saprophyticus Haemophilus para-influenzae Chlamydia trachomatis

Streptococci, group C and G Klebsiella oxytoca Legionella pneumophila

Streptococcus agalactiae Moraxella catarrhalis Mycoplasma pneumoniae

Streptococcus pneumoniae Pasteurella multocida Mycoplasma hominis

Streptococcus pyogenes Proteus vulgaris Ureaplasma urealyticum

Providencia rettgeri
Levofloxacin is a good choice for empiric treatment of acute Pyelonephritis

Levofloxacin shows proven efficacy compared with Ciprofloxacin and Lomefloxacin.1

Clinical response rates among microbiologically evaluable patients1

100%
Clinical Cure rate (% )

80%
92%
88%
60% 80%

40%

20%

0% Adapted from ref 1

Levofloxacin Ciprofloxacin Lomefloxacin 400
250 mg OD* 500 mg BD* mg OD*

Two randomized, multicenter trials to evaluate Levofloxacin compared with Ciprofloxacin and Lomefloxacin for efficacy and safety in treating acute pyelonephritis. We enrolled a
total of 186 patients with bacteriologically proved infection. Of these, 89 patients in both trials combined received Levofloxacin 250 mg once daily; 58 received Ciprofloxacin 500
mg twice daily in the first trial (double- blind); and 39 received Lomefloxacin 400 mg once daily in the second trial (open-label). Microbiologic response of patients evaluable for
microbiologic efficacy was the primary efficacy variable, and clinical response of microbiologically evaluable patients was the secondary efficacy variable in both studies.1

The once-daily oral administration, proven efficacy, and good tolerability make Levofloxacin an excellent choice
for empiric treatment of acute pyelonephritis.1

Levofloxacin should be administered 500 mg once daily for 7-10 days. 2

1. Richard GA, Klimberg IN, Fowler CL, et al. Levofloxacin versus ciprofloxacin versus lomefloxacin in acute pyelonephritis. Urology. 1998;52(1):51-55. 2. Levofloxacin 500 mg Summary of Product Characteristics. Abbott. Last revision date 14 Oct 2016.
Levofloxacin is a good choice for empiric treatment of acute Pyelonephritis
vs. Ciprofloxacin & Lomefloxacin with less adverse events
The once-daily oral administration, proven efficacy, and good tolerability make Levofloxacin an excellent choice for
empiric treatment of acute pyelonephritis. 1

8%

8%
Adverse events

6%

4%
5%
2%

0%
2% Adapted from ref 1
Levofloxacin 250 Ciprofloxacin Lomefloxacin
mg OD* 500 mg BD* 400 mg OD

Two randomized, multicenter trials to evaluate Levofloxacin compared with Ciprofloxacin and Lomefloxacin for efficacy and safety in treating acute pyelonephritis. We enrolled a
total of 186 patients with bacteriologically proved infection. Of these, 89 patients in both trials combined received Levofloxacin 250 mg once daily; 58 received Ciprofloxacin 500
mg twice daily in the first trial (double-blind); and 39 received Lomefloxacin 400 mg once daily in the second trial (open-label). Microbiologic response of patients evaluable for
microbiologic efficacy was the primary efficacy variable, and clinical response of microbiologically evaluable patients was the secondary efficacy variable in both studies.1

Levofloxacin should be administered 500 mg once daily for 7-10 days. 2

1. Richard GA, Klimberg IN, Fowler CL, Callery-D’Amico S, Kim SS. Levofloxacin versus ciprofloxacin versus lomefloxacin in acute pyelonephritis. Urology. 1998;52(1):51-55. 2.
Levofloxacin 500 mg Summary of Product Characteristics. Abbott. Last revision date 14 Oct 2016.
Levofloxacin shows higher urinary excretion rate compared with Ciprofloxacin
Urinary excretion of Levofloxacin and Ciprofloxacin1
90%
80%

Urinary Excretion (%) 84%

70%
60%
50%
40%
30% 43%
20%
10%
Adapted from ref 1
0%
Levofloxacin Ciprofloxacin

EAU* guidelines for empiric therapy of c-UTI** Advise the use of fluoroquinolones with
mainly renal excretion when empiric therapy is necessary 1

*EAU: The European Association of Urology

**c-UTI: Complicated urinary tract infection

1. McGregor JC, Allen GP, Bearden DT. Levofloxacin in the treatment of complicated urinary tract infections and acute
pyelonephritis. Ther Clin Risk Manag. 2008;4(5):843-853.
Levofloxacin is recommended for Urological Infections according to…

American Academy of Family Physicians1

Levofloxacin is recommended as First-line treatment for Chronic Bacterial Prostatitis.1

Fluoroquinolones, such as Levofloxacin, are considered drugs of choice for treatment of

chronic bacterial prostatitis, because of their favourable pharmacokinetic properties, their
generally good safety profile, and antibacterial activity against Gram-negative pathogens,
including P. aeruginosa. In addition, Levofloxacin is active against Gram-positive and atypical
pathogens, such as C. trachomatis and genital mycoplasmas.2

BJUI The quinolones (e.g. Levofloxacin) are considered the antibiotics of choice
BJU* because of their favorable pharmacokinetic properties for treatment of
Interntional chronic bacterial prostatitis (CBP).3
*British Journal of Urology

1.Sharp VJ, Takacs EB, Powell CR. Prostatitis: diagnosis and treatment. Am Fam Physician. 2010;82(4):397-406.
2.Grabe (Chair) M, Bartoletti R, Bjerklund Johansen TE, et al. Guidelines on Urological Infections. European Association of Urology. 2015;1-86. Available at: https://uroweb.org/wp-
content/uploads/19-Urological-infections_LR2. pdf Accessed on April, 2018.
3.Rees J, Abrahams M, Doble A, Cooper A; Prostatitis Expert Reference Group (PERG). Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic
pain syndrome: a consensus guideline. BJU Int. 2015;116(4):509-525.
Levofloxacin is recommended for Urological Infections according to…

EAU Guidelines

Levofloxacin once daily for 7-10 days is recommended in mild

and moderate uncomplicated pyelonephritis. 1

1. Grabe (Chair) M, Bartoletti R, Bjerklund Johansen TE, et al. Guidelines on Urological Infections. European Association of Urology. 2015;1-86. Available at: https://uroweb.org/wp-
content/uploads/19-Urological-infections_LR2. pdf Accessed on April, 2018.
 Levofloxacin Dosing

Infection of urinary tract, including your kidneys or bladder

o Pyelonephritis:
One tablet of Levofloxacin 500 mg once a day for 7 - 10 days 1

o Complicated urinary tract infections:

One tablet of Levofloxacin 500 mg once a day for 7 – 14 days 1

o Chronic bacterial prostatitis:

One tablet of Levofloxacin 500 mg once a day for 28 days treatment 1
1. Levofloxacin 500 mg Summary of Product Characteristics. Abbott.Last revision date 14 Oct 2016.
 Life Style Modification and
Home remedies
Life Style modifications recommended:

• Drink plenty of water: Water helps to dilute urine and flush out bacteria.

• Avoid drinks that may irritate the bladder: (tend to aggravate s/s)

• Coffee, Alcohol, Carbonated drinks
• Drinks containing citrus juices, Caffeine

• Use a heating pad: Apply a warm, heating pad to abdomen to minimize

bladder pressure or discomfort.

• Topical Estrogen therapy: markedly reduces the incidence of recurrent UTIs in post-
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menopausal women with atrophic vaginitis or atrophic urethritis
 Complications of UTI

• Recurrent: >=2 UTIs in 6m OR >=4 UTIs in 1 year

• Permanent kidney damage: AKI. CKD (MCC: Pyelonephritis, untreated UTI)
• Increased risk in pregnant women: Pre term Labor  LBW / Premature baby
• Urethral stricture: Men > women, d/t: Recurrent urethritis and instrumentation
(gonococcal urethritis)
• Urosepsis: Infection spreading from urine  blood  Other organs of body via blood

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 Prevention of UTIs
• Stay hydrated: Drink plenty of water (MOA): Dilute your urine + excrete non concentrated
urine more frequent  timely excretion of waste products + bacteria prevents building of bacterial
load and crystals.
• Drink cranberry juice: Studies inconclusive, drinking juice does more good than harm anyways
• Tissue Wipers: Wipe from front to back: helps prevent bacteria in the anal region from
spreading to the vagina and urethra (especially females)
• Wear cotton underwear and loose-fitting pants: Avoid synthetic clothes (absorbs sweat)
• Empty bladder after intercourse: To flush away the bacteria entering urethra from vault after
intercourse.
• Avoid potentially irritating products: Using deodorant sprays or other artificial products (E.g.:
douches, powders, in the genital area can irritate the urethra)
• Change birth control method: Diaphragms, spermicide-treated condoms, can all contribute to
bacterial growth
• Go to the toilet as soon as you feel the urge to urinate, rather than holding on
26 • Treat vaginal infections quickly (Thrush, Trichomonas)
• Avoiding Constipation / Diarrhea
 Summary (Take Home Message)
 Refer infant < 3 months with UTI
 T/t children >=3 months with simple medications using Amoxicillin/
Augmentin, send C/S + consider request for USG
 T/t all non-pregnant women with UTI: Nitrofurantoin
 T/t asymptomatic bacteruria in pregnant women
 Rule out STI (Urethritis, Prostatitis) in male patients
 Do not give prophylaxis for adult with catheter and do not treat
asymptomatic bacteruria

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