URINARY TRACT INFECTION

Clinical Presentation of Renal Disease

Chronic renal failure (CRF)

Acute renal failure (ARF)
Hypertension

Asymptomatic proteinuria and persistent urinary

abnormalities
Nephrotic syndrome (NS)
Urinary tract infection (UTI)
Acute nephritis (Acute Glomerulonephritis)
Obstructive nephropathy
Renal stones
Renal tubular defects

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:

Classification
Upper UTI = Pyelonephritis
Lower UTI = Cystitis
Complicated UTI
Uncomplicated UTI

Classification of Urinary Tract Infection

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

Underlying factors associated

with complicated urinary tract infection
Systemic Conditions
Diabetes mellitus
Papillary necrosis (e.g. analgesic nephropathy)
Immunodeficient states (including immunosuppressive
drug therapy)
Abnormal drainage of urine
Renal calculi
Urinary obstruction
Vesicoureteric reflux
Pelvioureteric junction obstruction
Instrumentation of the urinary tract (including catheters)
Pregnancy

Patterns of Investigation in Urinary Tract Infection

Clincial UTI
Urinalysis

Urine microscopy, culture and

determination of antibiotic sensitivity

Further invstigation

Adult female
(lower UTI)

Male
(Any UTI)

Treat without
further
investigation

Ultrasound
? Cystoscopy
Check renal
cunction

Children
(Any UTI)

Upper UTI
or
Complicated UTI

Ultrasound
? MCU

Blood cultures
Ultrasound
? IVP
Check renal function

Diagnosis Urinary Tract Infection

1. Symptoms :
Lower UTI
Upper UTI

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

Clinical features of acute lower and

upper urinary tract infection in adult

Lower UTI

Upper UTI

Dysuria
Frequency
Suprapubic pain
Malodorous urine
Haematuria
Normal temperature

Systemically unwell
Fever rigors
Loin pain and tenderness
Nausea and vomiting
Hypotension and shock
Features of lower urinary
tract infection

Variation in the significant bacterial count in urine

according to the technique used for urine collection

Midstream urine

Significant bacterial
count (cells/ml)
> 100.000

Slide-hole catheter

>30.000

Open end catheter

1000

Suprapubic aspiration

Type of collection

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

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

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

Hospitalization with initial

parenteral therapy

No resolution
in 5 days

Resolution
in 5 days

Urologic evaluation

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

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