UTI If, when and how to treat pus cells in urine

A urinary tract infection (UTI) is an infection involving the kidneys, ureters, bladder, or urethra Lower tract infection (urethritis and cystitis) Upper tract infection (pyelonephritis, prostatis)

 Urinary tract infection is second only to respiratory infection as the most common type of infection. These infections are much more common in girls and women than in boys and men younger than 50 years of age. The reason for this is not well understood, but anatomic differences between the genders (a shorter urethra in women) might be partially responsible.

 An infection occurs when bacteria get into the urine and begin to grow. The infection usually starts at the opening of the urethra where the urine leaves the body and moves upward into the urinary tract. E.coli:80%, Proteus & Klebsiella & occasionally Entereobacter.

 The following people are at increased risk of urinary tract infection : Gender and sexual activity: Female urethra appears to be particularly prone to colonization with colonic gram negative bacilli coz of its proximity to the anus, its short length (4cm) & its termination beneath the labia. Sexual intercourse causes the introduction of bacteria into the bladder and is temporarily associated with the onset of cystitis

Pregnancy
During pregnancy, there are several factors that boost the risk of UTIs, especially a kidney infection. Hormones cause changes in the urinary tract, and the uterus may put pressure on the ureters or bladder or both -- making it more difficult for urine to pass from the kidneys to the bladder and out. About 20-30% of pregnant women with asymptomatic bacteriuria subsequently develop pyelonephritis. Untreated UTIs can contribute to preterm labor

Obstruction
Any impediment to the free flow of urine- tumor, stricture, stone or prostatic hypertrophy- results in hydronephrosis and greatly increased frequency of UTI. May lead to rapid destruction of renal tissue so it is important to identify and repair obstructive lesions. On the other hand, when an obstruction is minor and is not progressive or associated with infection, great caution should be exercised in attempting surgical correction. The introduction of infection in such cases may be more damaging then an uncorrected minor obstruction that does not significantly impair renal function.

Neurogenic bladder dysfunction

Interference with bladder enervation (spinal cord injury, tabes dorsalis, multiple sclerosis and other disease) may be associated with UTI. The infection may be initiated by the use of catheters for bladder drainage and is favoured by the prolonged stasis of urine in the bladder. An additional factor often operative in these cases is bone demineralization due to immobilization causing hypercalciuria, calculus formation, and obstructive uropathy

Catheter-Associated
Infection occurs when bacteria reach the bladder by one of two routes: by migrating through the column of urine in the catheter lumen or by moving up the mucus sheath outside the catheter/ Most catheter-associated infection cause minimal symptoms and often resolve after withdrawal.

Diabetes
People with diabetes are more vulnerable to UTIs for several reasons. First, their immune systems tend to be weaker. Second, high blood sugar can spill into the urine and encourage the growth of bacteria. Also, nerve damage related to diabetes can prevent the bladder from fully emptying Diabetic patients have an increased risk of certain symptomatic urinary tract infections such as acute cystitis, emphysematous infections, renal and perinephric abscess, and Candida infections

Menopause
Estrogen has a protective effect in the urinary tract, but levels of this hormone drop off significantly during menopause. Low estrogen levels can make it easier for bacteria to thrive in the vagina or urethra. For this reason, women may be more susceptible to UTIs after menopause.

Clinical presentation
Cystitis: Dysuria, frequency, urgency, suprapubic pain and fever. Urine often becomes grossly cloudy and it is bloody in 30% of cases. Physical examination generally reveals only tenderness of the urethra or the suprapubic area.

 Pyelonephritis: Symptoms generally develop rapidly over a few hours or a day and include fever, chills, nausea and vomiting. Physical examination reveals marked tenderness on deep pressure in one or both costovertebral angles In severe pyelonephritis fever subsides more slowly and may not disappear for several days even after appropriate antibiotic

 UTIs in the Elderly The most common infections in the elderly. But the symptoms may not follow the classic pattern. Agitation, delirium, or other behavioral changes may be the only sign of a UTI in elderly men and women.

 UTIs in Infants Babies occasionally develop UTIs.Here are some signs to watch for: An unexplained fever Strange-smelling urine Poor appetite or vomiting Fussy behavior

Urinalysis
Urine collected in a normal individual by suprapubic aspiration of the bladder is sterile and does not contain leukocytes. It is, however, not performed routinely in clinical practice in which urine samples are generally obtained after natural micturition; in this setting, some degree of artifactual contamination with normal urethral organisms must be accepted.

 A high number of white blood cells in the urine is usually a symptom of urinary tract infection Epithelial cells from the skin surface or the outer urethra may appear in the urine. Their significance is that possible contamination of the specimen with the skin flora

 Among patients with symptoms suggestive of a UTI the diagnosis can be confirmed by sending a clean-catch specimen for culture and for urinalysis The standard definition of a positive urine culture is 10(5) CFU/mL together with pyuria

 July-Oct 2012 > Total 969 urinary cultures. 376 positive (38.8 %) > E. coli: total 194. Among these are the following numbers sensitive: Cipro: 67, Azithromycin: 81, Norfloxacin: 48, Amoxicillin, 30, Ceft 38,Chloro 38, CoTrim 48, Genta 109, Doxy 57, Nitrofurantoin 148, Amoxiclav 68.

Asymptomatic bacteriuria
WHOM TO TREAT Pregnancy Screening for and treatment of asymptomatic bacteriuria is warranted for pregnant women Urologic intervention Screening for and treatment of asymptomatic bacteriuria is warranted for patients undergoing transurethral resection of the prostate and other urologic procedures in which mucosal bleeding is anticipated

 WHOM NOT TO TREAT There is no role for screening for or treatment of asymptomatic bacteriuria in the following populations: women (premenopausal, nonpregnant) diabetic patients the elderly patients with spinal cord injury or indwelling urethral catheters. Avoiding treatment of asymptomatic bacteriuria is important for reducing development of antibiotic resistance, and a hospital and ambulatory performance measure for not treating asymptomatic bacteriuria in adults has been proposed