Urinary Tract Infections

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Urinary Tract Infections

• Ravi Gudavalli

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Anatomy

• Lower urinary tract ( superficial )
• Urethra
• Bladder
• Upper urinary tract ( tissue invasion)
• Prostate
• Kidney Acute Pyelonephritis, abscess

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UTIs

• Asymptomatic Bacturia
• Uncomplicated/Complicated Cystitis
• Acute/Chronic Prostatitis
• Uncomplicated/Complicated Pyelo
• Intrarenal and Perinephric Abscesses
• Nosocomial vs. Community-Acquired

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Epidemiology

• Catheter associated ( nosocomial)
• Non-catheter associated (community acquired)
• Young sexually active women

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• Where are the bugs coming from ????

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Etiology/Microbiology

• Gram ve rods
• _____________ 70-95 of episodes.
• Staphylococcus saprophyticus most of remainder.
• Proteus, Klebsiella ( stones) , enterococci,
  Serratia, Pseudomonas ( instrumentation)

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• Dont forget Chlamydia, Niesseria, Herpes
  simplex ( urethritis ) in young sexually active
  patients with sterile pyuria

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• Why does voiding after sexual intercourse reduce
  incidence of UTIs ??

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Pathogenesis

• Normal flora
• Altered flora
• Females with short urethra (4 cm), proximity of
  the urethra to the anus
• Use of spermicidal agents (change in flora)
• Males more than 50 BPH Obstruction

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• Pregnancy decreased ureteral tone, peristalsis,
  increased vesicoureteral reflux
• Obstruction tumor, stricture, stone, BPH
• ( important to recognize any obstruction as
  this can cause rapid destruction of tissue when
  complicated with infection)
• Neurogenic bladder
• Vesico-ureteral reflux

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• Virulence factors
• Uropathogenic strains
• P-factor

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UTIs Risk Factors

• Sexual Intercourse esp. with spermicide
• MSM - unprotected
• Lack of Circumcision
• AIDS and CD4lt200
• Diabetes (only in females, not males)
• Post-menopausal State
• BPH
• Pregnancy (mostly for asxatic bacturia)

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Risk Factors

• Anatomic abnormalities
• Vesicoureteral Reflux
• Ureteral Obstruction
• Foreign Body
• BPH
• Incomplete Bladder Emptying
• Instrumentation

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• Signs and Symptoms

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UTIs Signs and Symptoms

• Dysuria, Frequency, Nocturia, Urgency,
  Suprapubic/Back pain, Malodorous Urine,
  Hematuria, Cloudy urine.
• Pyelo Fever, Chills, Nausea, Vomiting, Loin
  Pain, with or without above symptoms. CVA
  tenderness, tachycardia.
• Prostatitis Chills, dysuria, urgency, frequency,
  perineal/back/pelvic pain. Prostate
  tender/enlarged/indurated. Chronic is much more
  occult.

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UTIs - Urinalysis

• Growth of _____ organisms/ml from a clean catch
  specimen.
• 102 104 colonies significant with SP catheter
  aspiration, straight cath, or typical symptoms.
• Pyuria, Microscopic/Gross Hematuria, Bacteriuria,
  WBC Casts.
• Unspun midstream urine gt10 WBC/hpf considered
  abnormal.

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• Pyuria and Hematuria

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• Dipstick UA
• Detect pyuria by _____________and
  Enterobacteriaceae via____________.
• Both fairly sensitive for high count UTIs, LE
  better for intermediate (Bacteriuria lt105
  colonies.)

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UTIs What about Cultures?

• Urine cultures
• Not necessary in routine uncomplicated cystitis.
• Role of pre-treatment cultures currently being
  evaluated because of emerging resistance among
  uropathogens.
• _____________ 15 50 y/o should have cultures.

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UTIs Therapy

• Depends on clinical situation
• Male vs. Female
• Young vs. Old
• Catheter-associated or not
• Hx of recurrent infections or not
• Lower vs. Upper Urinary Tract

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Acute Cystitis

• Usually a ________ regimen
• __________________________________________________
  _________________________ are good choices
  empirically.
• One day regimens, even with the new drug
  Fosfomycin, not as effective as 3 days of above
  meds.
• Nitrofurantoin not unreasonable, but is a 7-day
  regimen.
• Increased hydration may dilute the antibiotic so
  is not recommended.
• Cranberry juice IS an effective for prophylaxis,
  but shows no benefit in treatment.
• Phenazopyridine Pyridium.
• Culture IF symptoms fail to resolve.

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UTIs - Therapy

• Recurrent Infection
• Counseling post-coital voiding, cranberry
  juice, change BC from spermicide.
• 3 or more episodes in one year
• ___________________
• ___________________
• ___________________
• Relapsing Infection
• Same strain Radiologic/Urologic Eval.

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UTIs - Therapy

• Men with UTI
• NO short-course therapy.
• 7-14 days of Bactrim or a Quinolone.
• gt50, check the prostate.
• Acute prostatitis
• 4 wks Bactrim, 2 wks FQ.
• Recurrence treat 4 6 weeks. Recurrent
  recurrence treat 12 weeks.
• Rec. Rec. Recurrence? Tx again, Long-term
  suppression, Prostatectomy

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Acute cystitis in Pregnancy

• ____________ the Urine!
• Treat Asymptomatic Bacteriuria.
• Watch closely for pyelo Admit in this case.
• Treat for 3-7 days.
• Reasonable regimens Amoxicillin, Nitrofurantoin,
  Cephalexin.
• Also Augmentin, Bactrim (not 3rd trimester),
  Cefpodoxime.
• Not quinolones.
• _________________________ in one to two weeks.

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UTIs - Therapy

• Post-menopausal Women Evaluate for need for
  ________________ preparations.

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Complicated cystitis

• Resistant organisms
• Empirically quinolones, tailor to culture
  result
• Failure to respond clinically within 24 48
  hours requires UT imaging and repeat cultures.
• Duration usually 7 14 days.

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• Acute Uncomplicated Pyelo
• Not too sick, No N/V
• Cipro/other FQ 7 days.
• Bactrim reasonable, too.
• Sicker, N/V
• Admit, IV AB AmpGent, IV Bactrim, FQ, 3rd Gen.
  Cephalosporin.
• D/C once afebrile for 24 hours.
• Switch to oral total of 14 days.

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• Complicated UTI
• Treat only if symptomatic, unless preg.
• Sterilize urine if planning on instrumentation.
• Broad spectrum, and tailor to cultures.
• Try to correct underlying abnormality.
• X-ray evaluation
• IVP, Voiding cystourethrogram, Ultrasound,
  Helical CT (with and without contrast

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Catheter-associated

• 40 of nosocomial infections
• Prevention BIG TIME! (Proper technique,
  isolation, closed system, etc.)
• Symptomatic treat, change out catheter, and
  culture.
• Therapy for asymptomatic patients just selects
  for resistant organisms, so just watch and hope
  for the best.

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