Urinary Tract Infections

Hongbiao (Hank) Liu MD PhD

Luna Medical Care

Urinary Tract Infections

Leading cause of morbidity and health

care expenditures in persons of all ages.

An estimated 50 % of women report

having had a UTI at some point in their lives.

8.3 million office visits and more than 1

million hospitalizations, for an overall annual cost > $1 billion.

Acute Uncomplicated Cystitis

Sexually active young

women.
Causes: anatomy and

certain behavioral factors, including delays in micturition, sexual activity, and the use of diaphragms and spermicides tract.
Aggressive diagnostic

work-ups are unwarranted in young women presenting with an uncomplicated episode of cystitis.

Acute Uncomplicated Cystitis

The microbiology is limited

to a few pathogens.
70%- 85% are caused by

Escherichia coli
5-20%are caused by

coagulase-negative Staphylococcus saprophyticus

5-12% are caused by other

Enterobacteriaceae such as Klebsiella and Proteus.

Acute Uncomplicated Cystitis

Clinical Features:

dysuria, frequency, urgency, suprapubic pain, hematuria.

Fever >38C, flank pain, costovertebral angle tenderness, and nausea or vomiting suggest upper tract infection.

Acute Uncomplicated Cystitis

Diagnosis: direct history and PE
PE: Temperature, abdominal exam,

assessment of CVA tenderness, pelvic exam.

H/o

STDs, new sexual partner, partner with urethral symptoms, gradual onset.

Acute Uncomplicated Cystitis

Guidelines for tx of acute cystitis

recommend empiric antibiotic tx. Unnecessary antibiotic use?? Clinical criteria for Dx:
Dysuria, presence of > trace urine leukocytes, and presence of nitrites or... Dysuria and frequency in the absence of vaginal discharge.

Acute Uncomplicated Cystitis

UA: Evaluation of midstream urine for pyuria. White blood cell casts in the urine are Dx of upper tract infection. Urine Culture: Not necessary Warranted in: Suspected complicated infection, persistent symptoms following tx, symptoms recur < 1 mo after tx.

Acute Uncomplicated Cystitis

Urine dipsticks: Leukocyte esterase (pyuria), sensitivity 75-90%, specificity 95% Nitrite (Enterobacteriacea), sensitivity 35-85%, specificity 95%, false positive with phenazopyridine, beets. Microscopic evaluation for pyuria or a culture is indicated in pt with negative leukocyte esterase that have urinary symptoms.

Acute Uncomplicated Cystitis

Susceptibility: E.coli

30% isolates resistance to ampicillin and sulfonamides Increasing of resistance to TMP-SMX Resistance to nitrofurantoin is <5% Resistance to fluoroquinolones <5% 3% resistant to TMP-SMX 0% resistant to nitrofurantoin 0.4% resistant to ciprofloxacin

S.saprophyticus

Acute Uncomplicated Cystitis

Treatment: Short course vs. prolonged tx

Short course preferred except with beta-lactam agents

TMP-SMX

(160/800mg BID x 3) first-line tx

if: no allergy to the drug, no antibiotics in the past

3 mo, no recent hospitalization.
Nitrofurantoin

(100mg BID x 5 days) Analgesia: Phenazopyridine 200mg TIDx2

Acute Urethral Syndrome

Acute symptomatic women with dysuria

and frequency with a midstream culture containing < 10(5) CFU/mL. > 10(2) CFU/mL in women with acute symptomatic pyuria = UTI Tx as an uncomplicated UTI Mycoplasma genitalium, Ureaplasma urealyticum

Acute Complicated Cystitis

UTI when/with structural, functional or metabolic

abnormalities (polycystic, solitary, transplant kidney;DM, CRF, indwelling cath, neurogenic bladder) or elderly, male, child, pregnant or h/o recurrent UTI) E.coli accounts for fewer than one third of complicated cases.
Clinically, the spectrum of complicated UTIs may

range from cystitis to urosepsis with septic shock.

Acute Complicated Cystitis

Urine culture and susceptibility are necessary.
These infections are usually associated with high-

count bacteriuria (> 10(5) CFU/mL).

MO: Proteus, Klebsiella, Pseudomonas, Serratia, and

Providencia, enterococci, staphylococci and fungi AND E.coli

Acute Complicated Cystitis

Empiric therapy for these patients should include an

agent with a broad spectrum of activity against the expected uropathogens: fluoroquinolone, ceftazidime, cefepime, aztreonam, imipenemcilastatin. (Obtain Ucx prior to Tx) Tx x 7-14 days Follow-up urine culture should be performed within 14 days after treatment???

Recurrent Cystitis
Up to 27% of young women with acute cystitis

develop recurrent UTIs. The causative organism should be identified by urine culture. Relapse: infection with the same organism (multiple relapses = complicated UTIs). Recurrence: infection with different organisms.

Recurrent Cystitis
>3 UTI recurrences documented by urine Cx within

one year can be managed using one of three preventive strategies: 1. Acute self-treatment with a three-day course of standard therapy. 2. Postcoital prophylaxis with one-half of a TMP-SMX double-strength tablet (80/400 mg). 3. Continuous daily prophylaxis TMP-SMX one-half tablet per day (40/200 mg); nitrofurantoin 50 to 100 mg per day; norfloxacin 200 mg per day.

Uncomplicated Pyelonephritis
Suspect if:
Cystitis-like

illness and accompanying flank

pain Severe illness with fever, chills, nausea, vomiting, abdominal pain Gram-negative bacteremia.

Uncomplicated Pyelonephritis
DX: Clinical, confirm with:
UA:

pyuria and/or WBC casts UCx with > 10 (5) CFU/mL (80%)
Tx: 14 days total
Oral:

TMP/SMX, fluoroquinolones IV: 3rd gen cephalosporin, aztreonam, quinolones, aminoglycoside

Uncomplicated Pyelonephritis
Pt with symptoms after 3 days of

appropriate antimicrobial tx should be evaluated by renal US or CT for obstruction or abscess.

UTI in Men
At risk: Older men with prostatic

disease, UT instrumentation, anal sex, or partner colonized with uropathogens. UCx: 10 (3) CFU/mL sensitivity and specificity 97%. Additional studies?
Not

necessary in young healthy men who have a single episode.

UTI in Men
Tx:
Uncomplicated

cystitis:

TMP/SMX or fluoroquinolones x 7 days

Complicated

cystitis:

Fluoroquinolones x 7-14 days

Bacterial

prostatitis:

Fluoroquinolone x 6-12 weeks

Catheter-Associated UTI
Risk of bacteriuria is ~ 5%/day (long

term catheter bacteriuria is inevitable). 40% of nosocomial infections Most common source of gram-negative bacteremia. Dx: Ucx 10 (2) CFU/mL
MO:

E.coli, Proteus, Enterococcus, Pseudomona, Enterobacter, Serratia, Candida

Catheter-Associated UTI
Mild to mod: oral quinolones10-14days
Severe infection: IV/oral 14-21days Asymptomatic bacteriuria in pt with

an indwelling Foley should not be Tx unless they are immunosuppressed, have risk of bacterial endocarditis or pt who are about to undergo urinary tract instrumentation.

Asymptomatic Bacteriuria
UCx: > 10(5)CFU/mL with no symptoms
Three groups of pt with asymptomatic

bacteruria have been shown to benefit from tx:

Pregnant Renal

transplant Pt who are about to undergo urinary tract procedures.

Pregnant patients
Asymptomatic bacteriuria: two

consecutive voided urine specimens with isolation of the same bacterial strain >10(5) or a single cath urine specimen.
Nitrofurantoin

100mg BID x 5-7 days Amoxi/Clav 500mg BID or 250 TID x 7days Fosfomycin 3g PO x 1

Interstitial Cystitis
Frequency, urgency, urge incontinence

with periurethral and suprapubic pain on bladder filling that is improved by voiding. Terminal hematuria may be present. Etiology. Unclear (autoimmune, altered glycosaminoglycal layer, allergic)

Interstitial Cystitis
TX
Refer

to urology for cystoscopy. Dietary modifications Behavioral modifications Rx:

Pyridium Pentosan polysulfate 100mg TID x 6mo to 2 years. Amitriptyline 10-75mg QHS

Interstitial Cystitis
Intravesical therapies
Dimethyl

Sulfoxide instillations q1-2 wks BCG instilled q1wk x 6-8 wks Hyaluronic acid instilled q1wk x 4-6wk.