Uti

Urinary Tract InfectionUrinary Tract Infection
Dr Biplave KarkiDr Biplave Karki
MD ResidentMD Resident
KUSMSKUSMS

DEFINITIONSDEFINITIONS
UTIUTI
 Asymptomatic (subclinical infection) or symptomaticAsymptomatic (subclinical infection) or symptomatic
(disease)(disease)
 Asymptomatic bacteriuria (ASB)Asymptomatic bacteriuria (ASB)
 CystitisCystitis
 ProstatitisProstatitis
 PyelonephritisPyelonephritis
 Catheter-associated bacteriuriaCatheter-associated bacteriuria
 symptomatic (CAUTI) or asymptomaticsymptomatic (CAUTI) or asymptomatic

Asymptomatic bacteriuria (ASB)Asymptomatic bacteriuria (ASB)
 Clinical criterionClinical criterion
 No local or systemic symptoms or signs referable toNo local or systemic symptoms or signs referable to
the urinary tractthe urinary tract
 Microbiologic criterionMicrobiologic criterion
 ≥≥10105
bacterial CFU/mLbacterial CFU/mL
 except in catheter-associated disease, in which ≥10except in catheter-associated disease, in which ≥1022
CFU/mL is the cutoff.CFU/mL is the cutoff.

CystitisCystitis
 Dysuria, urinary frequency, and urgencyDysuria, urinary frequency, and urgency
 Nocturia, hesitancy, suprapubic discomfort, andNocturia, hesitancy, suprapubic discomfort, and
gross hematuriagross hematuria
 Unilateral back or flank painUnilateral back or flank pain
 upper urinary tractupper urinary tract
 FeverFever
 invasive infection of either the kidney or the prostateinvasive infection of either the kidney or the prostate

PyelonephritisPyelonephritis
 Mild pyelonephritisMild pyelonephritis
 low-grade feverlow-grade fever
 with or without lower-back or costovertebral-angle painwith or without lower-back or costovertebral-angle pain
 Severe pyelonephritisSevere pyelonephritis
 high fever, rigors, nausea, vomiting, and flank and/or loinhigh fever, rigors, nausea, vomiting, and flank and/or loin
painpain
 Symptoms are generally acute in onsetSymptoms are generally acute in onset
 Symptoms of cystitis may not be presentSymptoms of cystitis may not be present
 Fever of pyelonephritisFever of pyelonephritis
 high spiking “picket-fence” pattern and resolves over 72 h of therapyhigh spiking “picket-fence” pattern and resolves over 72 h of therapy
 Bacteremia develops in 20–30% of cases of pyelonephritis.Bacteremia develops in 20–30% of cases of pyelonephritis.

Pyelonephritis cont..Pyelonephritis cont..
 DiabetesDiabetes
 obstructive uropathy associated with acute papillaryobstructive uropathy associated with acute papillary
necrosisnecrosis
 sloughed papillae obstruct the uretersloughed papillae obstruct the ureter
 Papillary necrosis also evident inPapillary necrosis also evident in
 pyelonephritis complicated by obstruction, sickle cellpyelonephritis complicated by obstruction, sickle cell
disease, analgesic nephropathy, or combinations of thesedisease, analgesic nephropathy, or combinations of these
conditionsconditions
 Bilateral papillary necrosisBilateral papillary necrosis
 Rapid rise in the serum creatinine levelRapid rise in the serum creatinine level

 EmphysematousEmphysematous
pyelonephritispyelonephritis
 Production of gas inProduction of gas in
renal and perinephricrenal and perinephric
tissuestissues
 Exclusively in diabeticExclusively in diabetic
patientspatients

 Xanthogranulomatous pyelonephritisXanthogranulomatous pyelonephritis
 Chronic urinary obstruction (staghorn calculi), togetherChronic urinary obstruction (staghorn calculi), together
with chronic infection, leads to suppurative destruction ofwith chronic infection, leads to suppurative destruction of
renal tissuerenal tissue
 On pathologic examinationOn pathologic examination
 residual renal tissue frequently has a yellow coloration, withresidual renal tissue frequently has a yellow coloration, with
infiltration by lipid-laden macrophagesinfiltration by lipid-laden macrophages
Staghorn calculus, which has
been removed,
leaving a depression
Large staghorn
calculus
Areas of hemorrhage and necrosis with
collapse of cortical areas

 Intraparenchymal abscess formationIntraparenchymal abscess formation
 continued fever and/or bacteremia despite antibacterialcontinued fever and/or bacteremia despite antibacterial
therapytherapy

ProstatitisProstatitis
 Infectious and noninfectiousInfectious and noninfectious
 InfectionsInfections
 acute or chronicacute or chronic
 almost always bacterialalmost always bacterial
 less common than the noninfectious entity i.e.less common than the noninfectious entity i.e.
 Chronic pelvic pain syndrome (formerly known asChronic pelvic pain syndrome (formerly known as
Chronic prostatitis)Chronic prostatitis)

Prostatitis cont..Prostatitis cont..
 Acute bacterial prostatitisAcute bacterial prostatitis
 Dysuria, frequency, and pain in the prostatic pelvic orDysuria, frequency, and pain in the prostatic pelvic or
perineal areaperineal area
 Fever and chillsFever and chills
 Symptoms of bladder outlet obstructionSymptoms of bladder outlet obstruction
 Chronic bacterial prostatitisChronic bacterial prostatitis
 more insidious onset as recurrent episodes of cystitismore insidious onset as recurrent episodes of cystitis
 sometimes with associated pelvic and perineal painsometimes with associated pelvic and perineal pain
 Men who present with recurrent cystitis should beMen who present with recurrent cystitis should be
evaluated for a prostatic focusevaluated for a prostatic focus

Complicated / Uncomplicated UTIComplicated / Uncomplicated UTI
 Uncomplicated UTIUncomplicated UTI
 acute cystitis or pyelonephritisacute cystitis or pyelonephritis
 non-pregnant outpatient womennon-pregnant outpatient women
 without anatomic abnormalities or instrumentation of thewithout anatomic abnormalities or instrumentation of the
urinary tracturinary tract
 Complicated UTIComplicated UTI
 symptomatic episode of cystitis or pyelonephritis in a man orsymptomatic episode of cystitis or pyelonephritis in a man or
womanwoman
 with an anatomic predisposition to infection,with an anatomic predisposition to infection,
 with a foreign body in the urinary tract, orwith a foreign body in the urinary tract, or
 with factors predisposing to a delayed response to therapywith factors predisposing to a delayed response to therapy

EPIDEMIOLOGY ANDEPIDEMIOLOGY AND
RISK FACTORSRISK FACTORS
 UTIUTI
 More common in females than in malesMore common in females than in males
 Except among infants and the elderlyExcept among infants and the elderly
 Neonatal periodNeonatal period
 Congenital urinary tract anomaliesCongenital urinary tract anomalies
 After 50 years of ageAfter 50 years of age
 Prostatic hypertrophyProstatic hypertrophy
 Prevalence of ASBPrevalence of ASB
 5% among women between ages 20 and 405% among women between ages 20 and 40
 May be as high as 40–50% among elderly women and menMay be as high as 40–50% among elderly women and men
 50–80% of women in the general population50–80% of women in the general population
 at least one UTI during lifetime (uncomplicated cystitis)at least one UTI during lifetime (uncomplicated cystitis)

RISK FACTORS cont..RISK FACTORS cont..
 Independent risk factors for acute cystitisIndependent risk factors for acute cystitis
 Recent use of a diaphragm with spermicideRecent use of a diaphragm with spermicide
 Frequent sexual intercourseFrequent sexual intercourse
 History of UTIHistory of UTI
 Diabetes mellitusDiabetes mellitus
 IncontinenceIncontinence

 Many factors predisposing women to cystitis also
increase the risk of pyelonephritis
 Factors independently associated with pyelonephritis in
young healthy women
 Frequent sexual intercourse
 New sexual partner
 UTI in the previous 12 months
 Maternal history of UTI
 Diabetes
 Incontinence
 Pyelonephritis can occur without clear antecedent
cystitis

 About 20–30% of women who have had one
episode of UTI will have recurrent episodes
 Early recurrence (within 2 weeks)
 Regarded as relapse rather than reinfection
 Need to evaluate the patient for a sequestered focus

 In pregnant womenIn pregnant women
 ASB has clinical consequences, and both screeningASB has clinical consequences, and both screening
for and treatment of this condition are indicatedfor and treatment of this condition are indicated
 Preterm birthPreterm birth
 Perinatal death of the fetusPerinatal death of the fetus
 Pyelonephritis in the motherPyelonephritis in the mother
 Treatment of ASB in pregnant women decreases theTreatment of ASB in pregnant women decreases the
risk of pyelonephritis in mother by 75%risk of pyelonephritis in mother by 75%

 Men with UTIMen with UTI
 Functional or anatomic abnormality of the urinaryFunctional or anatomic abnormality of the urinary
tracttract
 Urinary obstruction secondary to prostatic hypertrophyUrinary obstruction secondary to prostatic hypertrophy
 Lack of circumcisionLack of circumcision

 Women with DiabetesWomen with Diabetes
 2-3 fold higher rate of ASB and UTI than women without2-3 fold higher rate of ASB and UTI than women without
diabetesdiabetes
 There is insufficient evidence to make a correspondingThere is insufficient evidence to make a corresponding
statement about menstatement about men
 Risk factors associated with UTI in women with diabetesRisk factors associated with UTI in women with diabetes
 Increased duration of diabetesIncreased duration of diabetes
 Use of insulin rather than oral medicationUse of insulin rather than oral medication
 Poor bladder functionPoor bladder function
 Obstruction in urinary flowObstruction in urinary flow
 Incomplete voidingIncomplete voiding
 Impaired cytokine secretionImpaired cytokine secretion

ETIOLOGYETIOLOGY
 Uropathogens causing UTI vary by clinical syndromeUropathogens causing UTI vary by clinical syndrome
 Enteric gram-negative rods predominateEnteric gram-negative rods predominate
 Acute uncomplicated cystitisAcute uncomplicated cystitis
 E. coliE. coli
 75–90%75–90%
 Staphylococcus saprophyticusStaphylococcus saprophyticus
 5–15%5–15%
 particularly frequent isolation from younger womenparticularly frequent isolation from younger women
 Klebsiella, Proteus, Enterococcus, and Citrobacter species, along withKlebsiella, Proteus, Enterococcus, and Citrobacter species, along with
other organismsother organisms
 5–10%5–10%
 The spectrum of agents causing uncomplicated pyelonephritis isThe spectrum of agents causing uncomplicated pyelonephritis is
similar, with E. coli predominatingsimilar, with E. coli predominating

ETIOLOGY cont..ETIOLOGY cont..
 In Complicated UTIIn Complicated UTI
 E. coli remains the predominant organismE. coli remains the predominant organism
 Aerobic gram-negative rodsAerobic gram-negative rods
 Pseudomonas aeruginosa and Klebsiella, Proteus,Pseudomonas aeruginosa and Klebsiella, Proteus,
Citrobacter, Acinetobacter, and Morganella speciesCitrobacter, Acinetobacter, and Morganella species
 Gram-positive bacteriaGram-positive bacteria
 Enterococci and Staphylococcus aureusEnterococci and Staphylococcus aureus
 YeastsYeasts

PATHOGENESISPATHOGENESIS
 Ascending infection from the urethra to the bladder,Ascending infection from the urethra to the bladder,
continuing ascent up the ureter to the kidneycontinuing ascent up the ureter to the kidney
 Any foreign body in the urinary tract, such as a urinaryAny foreign body in the urinary tract, such as a urinary
catheter or stone, provides an inert surface for bacterialcatheter or stone, provides an inert surface for bacterial
colonizationcolonization
 Abnormal micturition and/or significant residual urineAbnormal micturition and/or significant residual urine
volume promotes true infectionvolume promotes true infection
 In the simplest of terms, anything that increases theIn the simplest of terms, anything that increases the
likelihood of bacteria entering the bladder and staying therelikelihood of bacteria entering the bladder and staying there
increases the risk of UTI.increases the risk of UTI.

PATHOGENESIS cont..PATHOGENESIS cont..
 Hematogenous spreadHematogenous spread
 <2% of documented UTIs<2% of documented UTIs
 Bacteremia caused by relatively virulent organismsBacteremia caused by relatively virulent organisms
 Salmonella and S. aureusSalmonella and S. aureus
 Focal abscesses or areas of pyelonephritis within a kidney andFocal abscesses or areas of pyelonephritis within a kidney and
result in positive urine culturesresult in positive urine cultures
 Also the common route causing CandiduriaAlso the common route causing Candiduria
 The presence of Candida in the urine of a non-instrumented-The presence of Candida in the urine of a non-instrumented-
immunocompetent patient impliesimmunocompetent patient implies
 genital contaminationgenital contamination
 potentially widespread visceral disseminationpotentially widespread visceral dissemination

PATHOGENESIS cont..PATHOGENESIS cont..

Environmental FactorsEnvironmental Factors
 Vaginal EcologyVaginal Ecology
 Colonization of the vaginal introitus and periurethral areaColonization of the vaginal introitus and periurethral area
with organisms from the intestinal flora (usually E. coli)with organisms from the intestinal flora (usually E. coli)
 Sexual intercourseSexual intercourse
 Nonoxynol-9 in spermicideNonoxynol-9 in spermicide
 toxic to the normal vaginal microfloratoxic to the normal vaginal microflora
 increased risk of E. coli vaginal colonization and bacteriuriaincreased risk of E. coli vaginal colonization and bacteriuria
 In postmenopausal womenIn postmenopausal women
 previously predominant vaginal lactobacilli are replaced withpreviously predominant vaginal lactobacilli are replaced with
colonizing gram-negative bacteriacolonizing gram-negative bacteria

Environmental Factors cont..Environmental Factors cont..
 Anatomic and Functional AbnormalitiesAnatomic and Functional Abnormalities
(Permits urinary stasis or obstruction)(Permits urinary stasis or obstruction)
 Foreign bodiesForeign bodies
 Stones, urinary cathetersStones, urinary catheters
 Vesicoureteral refluxVesicoureteral reflux
 Ureteral obstruction secondary to prostaticUreteral obstruction secondary to prostatic
hypertrophyhypertrophy
 Neurogenic bladderNeurogenic bladder
 Urinary diversion surgeryUrinary diversion surgery

Host FactorsHost Factors
 Genetic backgroundGenetic background
 Women with recurrent UTIWomen with recurrent UTI
 first UTI before the age of 15 yearsfirst UTI before the age of 15 years
 maternal history of UTImaternal history of UTI
 Persistent vaginal colonization with E. coli, evenPersistent vaginal colonization with E. coli, even
during asymptomatic periods.during asymptomatic periods.
 Vaginal and periurethral mucosal cells from suchVaginal and periurethral mucosal cells from such
women bind threefold more uropathogenic bacteriawomen bind threefold more uropathogenic bacteria
than do mucosal cells from other womenthan do mucosal cells from other women

Host Factors cont..Host Factors cont..
 Mutations in host response genesMutations in host response genes
 Toll-like receptors and IL-8 receptorToll-like receptors and IL-8 receptor
 Linked to recurrent UTI and pyelonephritisLinked to recurrent UTI and pyelonephritis
 Polymorphisms in the IL-8-specific receptor genePolymorphisms in the IL-8-specific receptor gene
CXCR1CXCR1
 Increased susceptibility to pyelonephritisIncreased susceptibility to pyelonephritis
 Lower-level expression of CXCR1 on the surface ofLower-level expression of CXCR1 on the surface of
neutrophils impairs neutrophil-dependent host defenseneutrophils impairs neutrophil-dependent host defense
against bacterial invasion of the renal parenchymaagainst bacterial invasion of the renal parenchyma

Microbial FactorsMicrobial Factors
 Genetic virulence factorsGenetic virulence factors
 Surface adhesinsSurface adhesins
 P fimbriaeP fimbriae
 Type 1 pilus (fimbria)Type 1 pilus (fimbria)
 Mediate binding to specific receptors on the surfaceMediate binding to specific receptors on the surface
of uroepithelial cellsof uroepithelial cells

Microbial Factors cont..Microbial Factors cont..
 P fimbriaeP fimbriae
 Hair like protein structures that interact with a specificHair like protein structures that interact with a specific
receptor on renal epithelial cellsreceptor on renal epithelial cells
 P denotes the ability of these fimbriae to bind to bloodP denotes the ability of these fimbriae to bind to blood
group antigen P, which contains a D-galactose-D-group antigen P, which contains a D-galactose-D-
galactose residuegalactose residue
 Pyelonephritis and subsequent bloodstream invasion fromPyelonephritis and subsequent bloodstream invasion from
the kidneythe kidney

Microbial Factors cont..Microbial Factors cont..
 Type 1 pilus (fimbria)Type 1 pilus (fimbria)
 All E. coli strains possess but not all E. coli strains expressAll E. coli strains possess but not all E. coli strains express
 Play a key role in initiating E. coli bladder infectionPlay a key role in initiating E. coli bladder infection
 Mediate binding to uroplakins on the luminal surface ofMediate binding to uroplakins on the luminal surface of
bladder uroepithelial cellsbladder uroepithelial cells
 initiates a complex series of signaling events that leads toinitiates a complex series of signaling events that leads to
apoptosis and exfoliation of uroepithelial cells, with the attachedapoptosis and exfoliation of uroepithelial cells, with the attached
E. coli organisms carried away in the urineE. coli organisms carried away in the urine

DIAGNOSTIC TOOLSDIAGNOSTIC TOOLS
 HistoryHistory
 High predictive value in uncomplicated cystitisHigh predictive value in uncomplicated cystitis
 Women presenting with at least one symptom of UTIWomen presenting with at least one symptom of UTI
(dysuria, frequency, hematuria, or back pain) and without(dysuria, frequency, hematuria, or back pain) and without
complicating factorscomplicating factors
 the probability of acute cystitis or pyelonephritis is 50%the probability of acute cystitis or pyelonephritis is 50%
 If vaginal discharge and complicating factors are absent andIf vaginal discharge and complicating factors are absent and
risk factors for UTI are presentrisk factors for UTI are present
 the probability of UTI is close to 90%, and no laboratory evaluationthe probability of UTI is close to 90%, and no laboratory evaluation
is neededis needed
 Combination of dysuria and urinary frequency in the absenceCombination of dysuria and urinary frequency in the absence
of vaginal dischargeof vaginal discharge
 increases the probability of UTI to 96%increases the probability of UTI to 96%

DIAGNOSTIC TOOLS cont..DIAGNOSTIC TOOLS cont..
 Limitation of history alone as diagnostic toolLimitation of history alone as diagnostic tool
 Did not enroll children, adolescents, pregnantDid not enroll children, adolescents, pregnant
women, men, or patients with complicated UTIwomen, men, or patients with complicated UTI
 Sexually transmitted disease, caused by ChlamydiaSexually transmitted disease, caused by Chlamydia
trachomatis in particular, may be inappropriatelytrachomatis in particular, may be inappropriately
treated as UTItreated as UTI
 Female patients under the age of 25Female patients under the age of 25

 Differential diagnosis (women with dysuria)Differential diagnosis (women with dysuria)
 CervicitisCervicitis
 C. trachomatis, Neisseria gonorrhoeaeC. trachomatis, Neisseria gonorrhoeae
 VaginitisVaginitis
 Candida albicans, Trichomonas vaginalisCandida albicans, Trichomonas vaginalis
 Herpetic urethritisHerpetic urethritis
 Interstitial cystitisInterstitial cystitis
 Noninfectious vaginal or vulvar irritationNoninfectious vaginal or vulvar irritation

 Urine Dipstick TestUrine Dipstick Test
 UrinalysisUrinalysis
 Urine CultureUrine Culture

 Urine Dipstick TestUrine Dipstick Test
 NitriteNitrite
 Leukocyte esterase testLeukocyte esterase test
 BloodBlood
 Enterobacteriaceae convert nitrate to nitrite, and enough nitriteEnterobacteriaceae convert nitrate to nitrite, and enough nitrite
must accumulate in the urine to reach the threshold of detectionmust accumulate in the urine to reach the threshold of detection
 If a woman with acute cystitis is forcing fluids and voiding frequently, theIf a woman with acute cystitis is forcing fluids and voiding frequently, the
dipstick test for nitrite is less likely to be positive, even when E. coli isdipstick test for nitrite is less likely to be positive, even when E. coli is
presentpresent
 Leukocyte esterase testLeukocyte esterase test
 detects this enzyme in the host’s polymorphonuclear leukocytes in thedetects this enzyme in the host’s polymorphonuclear leukocytes in the
urine, whether the cells are intact or lysedurine, whether the cells are intact or lysed

 Negative dipstick testNegative dipstick test
 not sufficiently sensitive to rule out bacteriuria innot sufficiently sensitive to rule out bacteriuria in
pregnant womenpregnant women, in whom it is important to detect, in whom it is important to detect
all episodes of bacteriuriaall episodes of bacteriuria
 Performance characteristics of the dipstick testPerformance characteristics of the dipstick test
 MenMen
 highly specifichighly specific
 Non-catheterized nursing home residentsNon-catheterized nursing home residents
 highly sensitivehighly sensitive

 Urine microscopyUrine microscopy
 Pyuria in nearly all cases of cystitisPyuria in nearly all cases of cystitis
 Hematuria in ~30% of casesHematuria in ~30% of cases

 Urine cultureUrine culture
 Diagnostic “gold standard” for UTIDiagnostic “gold standard” for UTI
 Women with symptoms of cystitisWomen with symptoms of cystitis
 Colony count threshold of >102 bacteria/mL is moreColony count threshold of >102 bacteria/mL is more
sensitive (95%) and specific (85%) than a threshold ofsensitive (95%) and specific (85%) than a threshold of
105/mL105/mL
 Acute cystitis in womenAcute cystitis in women
 MenMen
 Minimal level indicating infection appears to be 103/mLMinimal level indicating infection appears to be 103/mL

TREATMENTTREATMENT
 Antimicrobial therapy is warranted for any symptomaticAntimicrobial therapy is warranted for any symptomatic
UTIUTI
 The choice of antimicrobial agent and the dose andThe choice of antimicrobial agent and the dose and
duration of therapy depend onduration of therapy depend on
 Site of infectionSite of infection
 Presence or absence of complicating conditionsPresence or absence of complicating conditions
 Antimicrobial resistance patternAntimicrobial resistance pattern
 E. coli ST131E. coli ST131
 predominant multilocus sequence type found worldwide aspredominant multilocus sequence type found worldwide as
the cause of multidrug-resistant UTIthe cause of multidrug-resistant UTI

UNCOMPLICATED CYSTITIS INUNCOMPLICATED CYSTITIS IN
WOMENWOMEN
 In 1999, TMP-SMX was recommended as the first-lineIn 1999, TMP-SMX was recommended as the first-line
agent for treatment of uncomplicated UTIagent for treatment of uncomplicated UTI
 Collateral damageCollateral damage
 Adverse ecologic effects of antimicrobial therapy, includingAdverse ecologic effects of antimicrobial therapy, including
killing of the normal flora and selection of drug-resistantkilling of the normal flora and selection of drug-resistant
organismsorganisms
 Drugs with minimal effect on fecal floraDrugs with minimal effect on fecal flora
 Pivmecillinam, Fosfomycin, and NitrofurantoinPivmecillinam, Fosfomycin, and Nitrofurantoin
 Drugs that affect the fecal flora more significantlyDrugs that affect the fecal flora more significantly
 Trimethoprim, TMP-SMX, quinolones, and ampicillinTrimethoprim, TMP-SMX, quinolones, and ampicillin
TREATMENTTREATMENT

WOMEN cont..WOMEN cont..
 First-line agentsFirst-line agents
 TMP-SMX and NitrofurantoinTMP-SMX and Nitrofurantoin
 Second-line agentsSecond-line agents
 Fluoroquinolone and β-lactamsFluoroquinolone and β-lactams
 Optimal setting for empirical use of TMP-SMXOptimal setting for empirical use of TMP-SMX
 uncomplicated UTI in a female patientuncomplicated UTI in a female patient
 who has an established relationship with the practitionerwho has an established relationship with the practitioner
 who can thus seek further care if her symptoms do notwho can thus seek further care if her symptoms do not
respond promptlyrespond promptly
TREATMENTTREATMENT

 NitrofurantoinNitrofurantoin
 Resistance is lowResistance is low
 Highly active against E. coli and most non–E. coliHighly active against E. coli and most non–E. coli
isolatesisolates
 Proteus, Pseudomonas, Serratia, Enterobacter, andProteus, Pseudomonas, Serratia, Enterobacter, and
yeasts are all intrinsically resistant to this drugyeasts are all intrinsically resistant to this drug
 Does not reach significant levels in tissue and cannotDoes not reach significant levels in tissue and cannot
be used to treat pyelonephritis.be used to treat pyelonephritis.
TREATMENTTREATMENT

 Most fluoroquinolones (ofloxacin, ciprofloxacin, andMost fluoroquinolones (ofloxacin, ciprofloxacin, and
levofloxacin)levofloxacin)
 Highly effective as short-course therapy for cystitisHighly effective as short-course therapy for cystitis
 ExceptionException
 MoxifloxacinMoxifloxacin
 may not reach adequate urinary levelsmay not reach adequate urinary levels
 Fluoroquinolone resistanceFluoroquinolone resistance
 Emergence of C. difficile outbreaks in hospital settingsEmergence of C. difficile outbreaks in hospital settings
 Most experts now call for restricting fluoroquinolones to specificMost experts now call for restricting fluoroquinolones to specific
instancesinstances
 uncomplicated cystitis in which other antimicrobial agents are not suitableuncomplicated cystitis in which other antimicrobial agents are not suitable
 Use in adults >60 years of ageUse in adults >60 years of age
 increased risk of Achilles tendon ruptureincreased risk of Achilles tendon rupture
TREATMENTTREATMENT

 Except for pivmecillinam, β-lactam agentsExcept for pivmecillinam, β-lactam agents
 generally not preferred as TMP-SMX or fluoroquinolones ingenerally not preferred as TMP-SMX or fluoroquinolones in
acute cystitisacute cystitis
 Urinary analgesicsUrinary analgesics
 PhenazopyridinePhenazopyridine
 NauseaNausea
 Combination of analgesics withCombination of analgesics with
 urinary antiseptics (methenamine, methylene blue)urinary antiseptics (methenamine, methylene blue)
 urine-acidifying agent (sodium phosphate)urine-acidifying agent (sodium phosphate)
 antispasmodic agent (hyoscyamine)antispasmodic agent (hyoscyamine)
TREATMENTTREATMENT

Treatment Strategies for Acute Uncomplicated Cystitis

PYELONEPHRITISPYELONEPHRITIS
 Acute uncomplicated pyelonephritisAcute uncomplicated pyelonephritis
 FluoroquinolonesFluoroquinolones
 First-line therapyFirst-line therapy
 7-day course of therapy with oral ciprofloxacin (500 mg twice daily,7-day course of therapy with oral ciprofloxacin (500 mg twice daily,
with or without an initial IV 400-mg dose)with or without an initial IV 400-mg dose)
 Oral TMP-SMX (one DS tablet twice daily for 14 days)Oral TMP-SMX (one DS tablet twice daily for 14 days)
 If the pathogen’s susceptibility is not known and TMP-SMX is used,If the pathogen’s susceptibility is not known and TMP-SMX is used,
an initial IV 1-g dose of ceftriaxone is recommendedan initial IV 1-g dose of ceftriaxone is recommended
 Options for parenteral therapyOptions for parenteral therapy
 Fluoroquinolones, extended-spectrum cephalosporin with or withoutFluoroquinolones, extended-spectrum cephalosporin with or without
an aminoglycoside, or a carbapeneman aminoglycoside, or a carbapenem
TREATMENTTREATMENT

PYELONEPHRITIS cont..PYELONEPHRITIS cont..
 Combinations of a β-lactam and a β-lactamase inhibitorCombinations of a β-lactam and a β-lactamase inhibitor
 Ampicillin-sulbactamAmpicillin-sulbactam
 Ticarcillin-clavulanateTicarcillin-clavulanate
 Piperacillin-tazobactamPiperacillin-tazobactam
 Imipenem-cilastatinImipenem-cilastatin
TREATMENTTREATMENT
 More complicated historiesMore complicated histories
 Previous episodes of pyelonephritisPrevious episodes of pyelonephritis
 Recent urinary tract manipulationsRecent urinary tract manipulations

UTI IN PREGNANT WOMENUTI IN PREGNANT WOMEN
 Nitrofurantoin, ampicillin, and cephalosporinsNitrofurantoin, ampicillin, and cephalosporins
 Relatively safe in early pregnancyRelatively safe in early pregnancy
 Sulfonamides should be avoided both inSulfonamides should be avoided both in
 First trimesterFirst trimester
 Possible teratogenic effectsPossible teratogenic effects
 Near termNear term
 KernicterusKernicterus
 Fluoroquinolones are avoidedFluoroquinolones are avoided
 Possible adverse effects on fetal cartilage developmentPossible adverse effects on fetal cartilage development
 Asymptomatic or symptomatic UTIAsymptomatic or symptomatic UTI
 Ampicillin and cephalosporinsAmpicillin and cephalosporins
 Overt pyelonephritisOvert pyelonephritis
 Parenteral β-lactam with or without aminoglycosidesParenteral β-lactam with or without aminoglycosides
TREATMENTTREATMENT

UTI IN MENUTI IN MEN
 GoalGoal
 To eradicate the prostatic infection as well as the bladderTo eradicate the prostatic infection as well as the bladder
infectioninfection
 7-14 day course of a fluoroquinolone or TMP-SMX7-14 day course of a fluoroquinolone or TMP-SMX
 Acute bacterial prostatitisAcute bacterial prostatitis
 2-4 weeks course2-4 weeks course
 Documented chronic bacterial prostatitisDocumented chronic bacterial prostatitis
 4-6 weeks course4-6 weeks course
 Recurrences (chronic prostatitis)Recurrences (chronic prostatitis)
 12 weeks course12 weeks course
TREATMENTTREATMENT

COMPLICATED UTICOMPLICATED UTI
 Therapy for complicated UTITherapy for complicated UTI
 must be individualized and guided by urine culture resultsmust be individualized and guided by urine culture results
 Xanthogranulomatous pyelonephritisXanthogranulomatous pyelonephritis
 NephrectomyNephrectomy
 Emphysematous pyelonephritisEmphysematous pyelonephritis
 Percutaneous drainage can be used as the initial therapyPercutaneous drainage can be used as the initial therapy
followed by elective nephrectomy as needed.followed by elective nephrectomy as needed.
 Papillary necrosis with obstructionPapillary necrosis with obstruction
 intervention to relieve the obstruction and to preserve renalintervention to relieve the obstruction and to preserve renal
function.function.
TREATMENTTREATMENT

ASYMPTOMATIC BACTERIURIAASYMPTOMATIC BACTERIURIA
 Treatment of ASBTreatment of ASB
 Pregnant womenPregnant women
 Persons undergoing urologic surgeryPersons undergoing urologic surgery
 Neutropenic patientsNeutropenic patients
 Renal transplant recipientsRenal transplant recipients
TREATMENTTREATMENT

CATHETER-ASSOCIATED UTICATHETER-ASSOCIATED UTI
 CAUTICAUTI
 Bacteriuria and symptoms in a catheterized patientBacteriuria and symptoms in a catheterized patient
 Signs and symptomsSigns and symptoms
 Localized to the urinary tractLocalized to the urinary tract
 Unexplained systemic manifestations, such as feverUnexplained systemic manifestations, such as fever
 Threshold for bacteriuria to meet the definition of CAUTI isThreshold for bacteriuria to meet the definition of CAUTI is
≥10≥1033
CFU/mLCFU/mL
 Catheter changeCatheter change
 7-14 day course of antibiotics is recommended7-14 day course of antibiotics is recommended
 Intermittent catheterization may be preferable toIntermittent catheterization may be preferable to
certain populations (e.g., spinal cord-injured persons)certain populations (e.g., spinal cord-injured persons)
TREATMENTTREATMENT

CANDIDURIACANDIDURIA
 Common complication of indwelling catheterizationCommon complication of indwelling catheterization
 patients in the intensive care unitpatients in the intensive care unit
 broad-spectrum antimicrobial drugsbroad-spectrum antimicrobial drugs
 diabetes mellitusdiabetes mellitus
 >50% of urinary Candida isolates>50% of urinary Candida isolates
 non-albicans speciesnon-albicans species
 Clinical presentationClinical presentation
 asymptomatic laboratory finding to pyelonephritis and evenasymptomatic laboratory finding to pyelonephritis and even
sepsissepsis
 Removal of the urethral catheter in asymptomatic casesRemoval of the urethral catheter in asymptomatic cases
TREATMENTTREATMENT

CANDIDURIACANDIDURIA
 Treatment for candiduriaTreatment for candiduria
 Symptomatic cystitis or pyelonephritisSymptomatic cystitis or pyelonephritis
 High risk for disseminated diseaseHigh risk for disseminated disease
 NeutropeniaNeutropenia
 Undergoing urologic manipulationUndergoing urologic manipulation
 Clinically unstableClinically unstable
 Low-birth-weight infantsLow-birth-weight infants
 Fluconazole (200–400 mg/d for 14 days)Fluconazole (200–400 mg/d for 14 days)
 Candida isolates with high levels of resistance to fluconazoleCandida isolates with high levels of resistance to fluconazole
 oral flucytosine and/ or parenteral amphotericin Boral flucytosine and/ or parenteral amphotericin B
 Bladder irrigation with amphotericin B generally is not recommendedBladder irrigation with amphotericin B generally is not recommended
TREATMENTTREATMENT

PREVENTION OFPREVENTION OF
RECURRENT UTI INRECURRENT UTI IN
WOMENWOMEN Recurrence of uncomplicated cystitis inRecurrence of uncomplicated cystitis in
reproductive-age women is commonreproductive-age women is common
 Preventive strategy is indicated if recurrent UTIsPreventive strategy is indicated if recurrent UTIs
are interfering with a patient’s lifestyleare interfering with a patient’s lifestyle
 Three prophylactic strategies are available:Three prophylactic strategies are available:
 ContinuousContinuous
 PostcoitalPostcoital
 Patient-initiated therapyPatient-initiated therapy

PREVENTION OF RECURRENTPREVENTION OF RECURRENT
UTI IN WOMEN cont..UTI IN WOMEN cont..
 Continuous prophylaxis and post-coital prophylaxisContinuous prophylaxis and post-coital prophylaxis
 Low doses of TMP-SMX, a fluoroquinolone, orLow doses of TMP-SMX, a fluoroquinolone, or
nitrofurantoinnitrofurantoin
 Prescribed for 6 months and then discontinued, at whichPrescribed for 6 months and then discontinued, at which
point the rate of recurrent UTI often returns to baselinepoint the rate of recurrent UTI often returns to baseline
 If bothersome infections recur, the prophylactic program canIf bothersome infections recur, the prophylactic program can
be reinstituted for a longer periodbe reinstituted for a longer period
 Patient-initiated therapyPatient-initiated therapy
 Supplying the patient with materials for urine cultureSupplying the patient with materials for urine culture
 Course of antibiotics for self-medication at the firstCourse of antibiotics for self-medication at the first
symptoms of infectionsymptoms of infection
 Urine culture is refrigerated and delivered to the physician’sUrine culture is refrigerated and delivered to the physician’s
office for confirmation of the diagnosisoffice for confirmation of the diagnosis

PROGNOSISPROGNOSIS
 CystitisCystitis
 Risk factor for recurrent cystitis and pyelonephritisRisk factor for recurrent cystitis and pyelonephritis
 ASBASB
 Common among elderly and catheterized patientsCommon among elderly and catheterized patients
 Does not in itself increase the risk of deathDoes not in itself increase the risk of death
 In the absence of anatomic abnormalitiesIn the absence of anatomic abnormalities
 Recurrent infection in children and adults does not lead to chronic pyelonephritisRecurrent infection in children and adults does not lead to chronic pyelonephritis
or to renal failureor to renal failure
 Chronic interstitial nephritisChronic interstitial nephritis
 Analgesic abuse, obstruction, reflux, and toxin exposureAnalgesic abuse, obstruction, reflux, and toxin exposure
 In the presence of underlying renal abnormalities (particularly obstructingIn the presence of underlying renal abnormalities (particularly obstructing
stones)stones)
 Infection as a secondary factor can accelerate renal parenchymal damageInfection as a secondary factor can accelerate renal parenchymal damage
 In spinal cord–injured patientsIn spinal cord–injured patients
 Long term indwelling bladder catheter is a well-documented risk factor forLong term indwelling bladder catheter is a well-documented risk factor for
bladder cancerbladder cancer

THANK YOUTHANK YOU
REFERENCESREFERENCES
 Harrison’s Principle of Internal Medicine 19Harrison’s Principle of Internal Medicine 19thth
ed.ed.
 Kumar and Clarks clinical medicine 19Kumar and Clarks clinical medicine 19thth
eded
 Davidson’s Principle and Practice of MedicineDavidson’s Principle and Practice of Medicine
2222ndnd
eded

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