a presentation about UTI. information from various textbooks and different journals and also from many peoples presentation is accumulated in this one file. i worked very hard for this project.

1. Urinary Tract Infection
DR. ASIF AHMED IMON
HF-15
INTERN DOCTOR
SILVER UNIT
GYNAECOLOGY & OBSTETRICS
HOLY FAMILY RED CRESCENT MEDICAL COLLEGE

2. Urinary Tract Infection
 MOST COMMON BACTERIAL INFECTION IN
WOMEN & IMPORTANT CAUSE OF MORBIDITY.
 DURING LIFE TIME MORE THAN HALF OF
WOMEN WILL HAVE UTI.
 20% WOMEN BETWEEN 20-60 YEARS WILL HAVE
ONE ATTACK OF UTI IN A YEAR.

3. Urinary Track Anatomy

5. Urinary Track Infection
Infection in any part of urinary system –
kidney, ureter, urinary bladder & urethra is
called urinary track infection.

6. pyelonephritis
ureteritis
cystitis
urethritis

7. Factors In Female
1. Short PATULOUS urethra - 4cm (3-5cm)
 There are numerous tubular glands- paraurethral glands , which open
into the lumen through duct. Two are larger which are called skene’s
duct. These glands are the sites for harboring infection.
 Also there is no anatomical sphincter.
• Muscle fiber of bladder at internal meatus acts as internal sphincter.
• Pelvic floor which is the lower 1/3 of urethra acts as external sphincter.

10. Factors In Female
2. Close proximity of external urethral meatus to the
heavily contaminated areas with bacteria. ( Close
proximity to vagina & anus )
3. Urinary track is sterile , while vagina & anus have
plenty of POTENTIALLY PATHOGENIC MICROBES (PPM).
Any weakening of host immunity leads to these PPM
from vagina & anus to migrate into urethra.

11. 4. Sexual intercourse (increase ascent of
organism from urethra into bladder)
5. Immune-compromising state : diabetes
mellitus, atrophic urethritis, atrophic vaginitis.
6. Hypoestrogenic state :
In post-menopausal women, here defense of bladder &
urethral mucosa is decreased.
(near external meatus- non keratinized stratified squamous epithelium &
2/3 of the rest – pseudo epithelial transitional epithelium.)

12. Factors During Pregnancy
UTI is more common during pregnancy. So history should
be reviewed for evidence of chronic ante-partum infections.
Uterus directly sits on top of bladder. As uterus grows it’s
increased weight can block the drainage of urine. Which causes
stasis of urine in bladder → multiplication of bacteria → reflux of
infected urine into ureters & renal pelvis due to laxity of
vesicourethral sphincter (vesicoureteral reflex).

13. 2. CATHETERIZATION.
Also, progesterone is high in
pregnancy. So, progesterone
mediated smooth muscle
relaxation of bladder & ureter
occurs. Also the atony of
ureters.

14. During Puerperium
UTI is the commonest infection during puerperium.
Following delivery, the bladder & lower urinary tract
remain hypotonic with residual urine & reflux results. This
alters physiological state, in conjunction with
catheterization, birth trauma, conduction anesthesia,
frequent pelvic examination & nearly continues
contamination of perineum causes UTI during
puerperium.

15. Host Risk Factors
Bad perineal hygiene
Impaired voiding
Intercourse & meatal trauma
Urethral massage
Prolapse

16.  Spermicidal use (changes the normal flora)(chemical
contraception).
Medical condition like DM, obesity, anemia.
Pregnancy induced physiological change
(Vesicoureteral reflux).
Anatomical anomalies ( urinary tract calculi ).

17. Organism (Bacterial factor) -
Gram(-) bacteria
1. Escherichia coli ( E. Coli ) 80 -90%
2. Pseudomonas (hospital patient because their resistance to
antibiotics favors their selection in hospital patient)
3. Klebsiella
4. Proteus (renal stones, it produces potent urease which act on
ammonia rendering the urine alkaline.
normal pH 4.5 – 8 (6)

19. E. Coli
Strains expressing most of UTI is 0 -Ag.
Fimbriae : enhance attachment to Uro-epithelial cells.
Capsular Ag : Anti – phagocytic.
Endotoxin ureteral peristalsis.
Motile bacteria : can ascend the ureter against urine flow.

20. GRAM (+) BACTERIA
1. Staphylococcus saprophyticus (coagulase -)
active young women)
2.Enterococcus faecalis
3.Streptococcus agalactiae.

21. Host protective factors
Flushing mechanism
Acidic pH of urine (4.6-6) – anti-bacterial
Acidic pH of vagina ( 3.4-4.5) - inhibits colonization
Chemotactic factors- IL-8
THF (Tamm-Horsefall protein) secreted by Ascending Loop of
Henle – blocks E.coli .

22. Routes
Ascending – most common.
 Here, organism from ano - rectal region, lower vagina & vulva gain access
to urethra to the bladder, ureter & kidney.
 Retrograde menstruation, ascend with sperm migration.
Hematogenous – involving kidney from intestine or any other septic foci
( appendix, gall bladder, nasal sinus, liver)
Lymphatic – by the adjacent ascending colon or genital organs, kidney may
be affected through periureteral lymphatics.

24. Spectrum of presentation
• Bacteriuria – a. asymptomatic
b. symptomatic
• Urethritis
• Cystitis Location
• pyelonephritis
• Uncomplicated
• complicated
• recurrent Symptomatic
• Septicemia ( g- bacteria)

25. Bacteriuria
Presence of bacteria in urine.
Asymptomatic – It is used when a bacterial count of same
species are >105/ml in midstream urine on 2 occasions are
detected without symptoms of urinary infection.
• <105 ml indicates contamination of urine from the urethra or
external genitalia. 30% of women with asymptomatic
bacteriuria develops UTI, if left untreated.
Symptomatic / significant – It is a condition which is
symptomatic & urine show >105 /ml.

26. URETHRITIS
Inflammation & infection of urethra. Usually in sexually active
patient.
CYSTITIS
Inflammation of bladder.
Infection & inflammation that occurs due to coitus is called
LOWER URINARY TRACT INFECTION IS MOST COMMON.

27. ACUTE PYELONEPHRITIS
Infection of renal parenchyma. This should not be ignored & treated early
& aggressively to prevent complication.
RECURRENT UTI
Recurrence of symptoms after resolution of a previous UTI .
≥3 EPISODES / YEAR.
≥2 EPISODES / 6 MONTHS.
IT WILL OCCUR ABOUT 12-27 % CASES.
( RELAPSE – INFECTION WITH SAME ORGANISM
RECURRENCE – INFECTION WITH DIFFERENT ORGANISM)

28. UNCOMPLICATED UTI
Usually considered to be cystitis & usually occurs in
premenopausal adult women with no structural or functional
abnormality of urinary tract & who are not pregnant & have
no significant co-morbidity( DM , heart disease , AIDS ) that
can lead to more serious outcomes.

29. COMPLICATED UTI
A UTI is considered to be complicated if :
Patient is child or pregnant
Patient has any of the following -
1. A structural or functional urinary tract abnormality & obstruction of
urine flow.
 Structural – stone, fistula, strictures .
 Functional – neurogenic bladder, voiding dysfunction.
2. A co-morbidity that increase risk of acquiring infection or resistance to
treatment like uncontrolled DM, CKD or immunocompromise.

30. SYMPTOMS –
Frequency
Burning
Urgency
Nocturia
Dysuria
Hematuria
Supra-pubic pain
Loin pain
Low- grade fever
Urine may appear
cloudy and have an
unpleasant odor

32. INVESTIGATION –
1. Urine for microscopic examination , culture & sensitivity (C/S).
2. Blood for TC & DC of WBC, ESR.
Several ways for collection of a urine for microscopic examination, culture &
sensitivity (C/S) -
Clean-catch midstream technique (most common)
Catheterization
Suprapubic needle aspiration
Non-invasive method – in infants & children.

33. MIDSTREAM URINE COLLECTION
Hand should be washed before beginning. External genitalia is washed 2/3
times. The patient is then instructed to begin to urinate & patient passes urine
with labial separated. Then midstream urine is collected into a sterile
container(wide mouthed). This urine must be processed within 2hours or
refrigerated & processed within 24hrs for culture sensitivity.

34. Culture is done on blood agar (helps in isolation of fastidious
and extracting strains) or Mac.Conkey (differentiation of
lactose fermenting organism from non-lactose fermenting
pathogens) agar plates.

35. COLLECTION OF URINE OF
CATHETERIZED PATIENT-
Catheter is inserted through urethra into the bladder to avoids contamination
from the urethra/external
genitalia.

36. SUPRA -PUBIC ASPIRATION
May collect a urine sample by
inserting a needle directly into
bladder& draining the urine .
This method is used only when
a sample is needed quickly &
technically competent staffs
are available.

38. NON- INVASIVE METHOD
Safe & ideal for infants & children.
Broomhall et al method is used-
By tapping just above the pubis with 2 fingers place on suprapubic region after
1hour of feed. Tapping at the rate of 1tap/second for period of 1min. If not
successful tapping is repeated one again.
Child spontaneously pass the urine & to be collected in a sterile container.

39. INTERPRETATION
1. MICROSCOPIC EXAMINATION
PLENTY OF PUS CELL & OCCASIONAL RBC
2. CULTURE
104/ML – NORMAL
105/ ML OR ABOVE – SIGNIFICANT

41. Blood agar media Mac. Conkey’s agar media

43. DIPSTICK TESTS
Tested rapidly
 Nitrite positive : Is highly specific for UTI , but not very sensitive .
 Leukocyte esterase is very specific for the presence of >10 wbc /
µl .

44. UNCOMPLICATED UTI –
Urine sensitivity is only test required.
COMPLICATED UTI-
 USG of urinary tract
 Intravenous urography
 Cystoscopy

45. TREATMENT
1.GENERAL TREATMENT
 Bed rest
 Excessive oral fluids
 Voiding at short intervals
 Antispasmodics for pain

46. 2. ANTIMICROBIAL AGENTS
Short course of antibiotics ( 7-10 days) depending on culture & sensitivity.
a. Cap. Amoxicillin ( 500 mg TDS )
b. Cap. Co-amoxiclav ( 625mg TDS )
c. Tab. Nitrofurantoin ( 100mg QID )
d. Cap. Cefixime ( 200 mg BD )
e. Cap Cefuroxime ( 250 mg BD )
f. Tab . Ciprofloxacin ( 500 mg BD )

47. Cystitis
1st line of Rx is Nitrofurantoin 100mg BD for 3days.
2nd line of Rx is Trimethoprim/ sulfamethoxazole.
Pyelonephritis
1st line ciprofloxacin 500mg BD – 7days
2nd line trimethoprim 160/800mg BD – 14days

48. Children
Trimethoprim, Amoxycillin & clavulanic acid, Nitrofurantoin.
When prescribing nitrofurantoin, who may be risk of toxicity should be
evaluated, especially in elders.
Urine culture to guide & change accordingly.
Special attention should be given before prescribing anti-
biotics to pregnant women.

49. Following points should be kept in mind in treating
UTI –
Do-not treat non-pregnant women with asymptomatic bacteriuria
with an anti-biotic.
Treat non–pregnant women with symptoms/signs of LUTI.
Given the risk of symptomatic bacteriuria in pregnant women, a
urine culture should be performed seven days after completion of
anti-biotic Rx as a test of cure.
In post-menopausal women, anti-biotic Rx with additionally topical
estrogen therapy markedly reduces the incidence of recurrent UTI in
women with atrophic vaginitis or atrophic urethritis.

50. COMPLICATION
Permanent kidney damage from acute / chronic infection due to untreated
UTI
 Risk in pregnant women of delivery of LBW or premature baby
Pyelonephritis – papillary necrosis , abscess.
Sepsis.

51. Prevention
1. Drink at least eight glasses of water a day.
2. To maintain proper perineal hygiene, This consists of cleaning
the vulvar region at least daily, wiping the rectum away from
urethra.
3. Empty your bladder shortly before and after sex . Wash your
genital area with warm water before sex.

52. 4. Wear cotton underwear.
5. Don’t wear pants that are too tight.
6. Develop a habit of urinating as soon as the need is
felt and empty your bladder completely when urinate.
7. Avoid using strong soaps, antiseptic creams,
feminine hygiene sprays and powders.

53. 8. Don’t soak in the bathtub longer than 30minutes or
more than twice a day.
9. Oestrogen creams and oral oestrogen to
menopausal women.
10. Sexually active women suffering from recurrent UTI &
using spermicide should encourage to consider an
alternative form of contraception.

54. THANK YOU ALL.
PEACE BE UPON YOU.
HAVE A NICE DAY.