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Urinary Tract Infection
DR BADRIYA AL-MAHROUQI
By the end of this presentation the participants will be able to:
◦ list lower and upper urinary tract parts.
◦ Define urinary tract infection.
◦ Explain the pathophysiology of urinary tract infection
◦ List the most risk factors for urinary tract infection
◦ Diagnose urinary tract infection
◦ Manage urinary tract infection in different sex and age
A urinary tract infection (UTI) is an infection in any part of
your urinary system — your kidneys, ureters, bladder and
urethra. Most infections involve the lower urinary tract —
the bladder and the urethra.
Women are at greater risk of developing a UTI than are
men. Among adults aged 20 to 50 years, UTIs are about 50-
fold more common in women.
In women in this age group, most UTIs are cystitis or
In men of the same age, most UTIs are urethritis or
The incidence of UTI increases in patients > 50 years, but
the female: male ratio decreases because of the increasing
frequency of prostate enlargement and instrumentation in
The bacteria that most often cause cystitis and pyelonephritis are the following:
Enteric, usually gram-negative aerobic bacteria (most often)
Escherichia coli : 75 to 95% of cases.
Gram-positive bacteria (less often)
Staphylococcus saprophyticus is isolated in 5 to 10% of bacterial UTIs.
Enterococcus faecalis (group D streptococci)
Streptococcus agalactiae (group B streptococci)
In hospitalized patients, E. coli accounts for about 50% of cases. The gram-negative species Klebsiella, Proteus,
Enterobacter, Pseudomonas, and Serratia account for about 40%, and the gram-positive bacterial cocci, E.
faecalis, S. saprophyticus, and Staphylococcus aureus account for the remainder.
Part of urinary tract affected Signs and symptoms
Kidneys (acute pyelonephritis)
•Upper back and side (flank) pain
•Shaking and chills
•Lower abdomen discomfort
•Frequent, painful urination
•Blood in urine
•Burning with urination
Uncomplicated UTI is usually considered to be
cystitis or pyelonephritis that occurs in
premenopausal adult women with no structural or
functional abnormality of the urinary tract and who
are not pregnant and have no significant
comorbidity that could lead to more serious
Complicated UTI can involve either sex at any age. A
UTI is considered complicated if:
1. the patient is a child, is pregnant,
2. the patient has any of the following:
◦ A structural or functional urinary tract abnormality and obstruction
of urine flow
◦ A comorbidity that increases risk of acquiring infection or resistance
to treatment, such as poorly controlled diabetes, chronic kidney
disease, or immunocompromise.
◦ Recent instrumentation or surgery of the urinary tract
Recurrent infections, especially in women who experience two or more
UTIs in a six-month period or four or more within a year.
Permanent kidney damage from an acute or chronic kidney infection
(pyelonephritis) due to an untreated UTI.
Increased risk in pregnant women of delivering low birth weight or
Urethral narrowing (stricture) in men from recurrent urethritis, previously
seen with gonococcal urethritis.
Sepsis, a potentially life-threatening complication of an infection,
especially if the infection works its way up your urinary tract to your
- Urinary tract infection
- Upper or lower
- Simple or complicated
clean-catch, midstream specimen,
A specimen obtained by catheterization
If a sexually transmitted disease (STD) is suspected, a
urethral swab for STD testing is obtained prior to
Nitrate positive: is highly specific for UTI, but the test is not very sensitive.
The leukocyte esterase test is very specific for the presence of > 10 WBCs/μL and is fairly
Pyuria : Most truly infected patients have > 10 WBCs/μL.
The presence of bacteria in the absence of pyuria:due to contamination during sampling.
Microscopic hematuria occurs in up to 50% of patients, but gross hematuria is uncommon.
WBC casts: pyelonephritis, glomerulonephritis, and noninfective tubulointerstitial nephritis.
Pyuria in the absence of bacteriuria and of UTI is possible, for example, if patients have
nephrolithiasis, a uroepithelial tumor, appendicitis, or inflammatory bowel disease or if the
sample is contaminated by vaginal WBCs.
Cultures are recommended in complicated UTI or an indication for
treatment of bacteriuria. Common examples include the following:
Patients with urinary tract abnormalities or recent
Patients with immunosuppression or significant
Patients whose symptoms suggest pyelonephritis or sepsis
Patients with recurrent UTIs (≥ 3/yr)
Urinary tract imaging choices include ultrasonography, CT, and IVU.
Occasionally, voiding cystourethrography, retrograde urethrography, or
cystoscopy is warranted.
Children with UTI often require imaging.
Most adults do not require assessment for structural abnormalities
unless the following occur:
The patient has ≥ 2 episodes of pyelonephritis.
Infections are complicated.
Nephrolithiasis is suspected.
There is painless gross hematuria or new renal insufficiency.
Fever persists for ≥ 72 h.
First-line, non-invasive imaging
Contrast radiographic imaging
Nuclear scans DMSA and MAG3Radioisotope nuclear
•Kidney: size, shape, location
•Urinary tract: obstructions, dilatations
•Posterior urethral valves
•Gold standard for VUR diagnosis
Suspicion of renal damage
DMSA: Gold standard for renal scar detection
•Faster, less radiation
•Renal excretion enables micturition study
•Atypical UTI organisms
• Staphylococcus aureus
•UTI <3 years old
•Non/inadequate response to 48hrs of IV antibiotics
•First febrile UTI and no prompt follow up assured
•Significant electrolyte derangement
•No antenatal renal tract imaging in second to third
•Abnormal renal ultrasound
• Thick bladder wall
• Renal scarring
•Abnormal voiding post-febrile UTI
•Post-second febrile UTI
• posterior urethral valves
•Clinical suspicion of renal injury
•Reduced renal function
•Suspicion of VUR
•Suspicion of obstructive uropathy on ultrasound in
older toilet-trained children
•Does not asses function
•Cannot diagnose VUR
•Radiation exposure ~1 mSv
•Unpleasant to perform post-infancy
•May require sedation
•Requires prophylactic antibiotics
•Dynamic renal excretion study requires toilet training
•False positives if <3 months post-UTI, therefore can’t
use in acute phase (0–4 weeks)
•May require sedation
•Cannot determine old versus new scarring
Acute urethral syndrome: which occurs in women, is a syndrome involving dysuria, frequency, and
pyuria (dysuria-pyuria syndrome), which thus resembles cystitis. However, in acute urethral syndrome
(unlike in cystitis), routine urine cultures are either negative
Urethritis: is a possible cause because causative organisms include Chlamydia trachomatis and
Ureaplasma urealyticum, which are not detected on routine urine culture.
anatomic abnormalities (eg, urethral stenosis),
physiologic abnormalities (eg, pelvic floor muscle dysfunction),
hormonal imbalances (eg, atrophic urethritis),
GI system symptoms, and inflammation.
Sexually active patients with symptoms are usually treated presumptively for
STDs pending test results. A typical regimen is ceftriaxone 250 mg IM plus either
azithromycin 1 g po once or doxycycline 100 mg po bid for 7 days.
First-line treatment of uncomplicated cystitis is nitrofurantoin 100 mg po bid for
3 days (it is contraindicated if creatinine clearance is < 60 mL/min),
trimethoprim/sulfamethoxazole (TMP/SMX) 160/800 mg po bid for 3 days,
Antibiotics are required. Outpatient treatment with oral antibiotics is possible if all of the
following criteria are satisfied:
Patients are expected to be adherent
Patients are immunocompetent
Patients have no nausea or vomiting or evidence of volume depletion or septicemia
Patients have no factors suggesting complicated UTI
Ciprofloxacin 500 mg po bid for 7 days
A 2nd option is usually trimethoprim/sulfamethoxazole (TMP/SMX) 160/800 mg po bid for 14
cranberry concentrates : for adult
Increase fluid intake
Ural : urine alkiniser
Consider empirical treatment with an antibiotic for
otherwise healthy women aged less than 65 years
presenting with severe or ≥ 3 symptoms of UTI.
Explore alternative diagnoses and consider pelvic
examination for women with symptoms of vaginal itch or
Use dipstick tests to guide treatment decisions in otherwise
healthy women under 65 years of age presenting with mild
or ≤2 symptoms of UTI.
Antibiotic treatment of LUTI
Do not treat non-pregnant women (of any age) with
asymptomatic bacteriuria with an antibiotic.
Treat non-pregnant women of any age with symptoms or signs
of acute LUTI with a three day course of trimethoprim or
Particular care should be taken when prescribing nitrofurantoin
in the elderly, who may be at increased risk of toxicity.
Take urine for culture to guide change of antibiotic for patients
who do not respond to trimethoprim or nitrofurantoin.
Standard quantitative urine culture should be performed routinely at
first antenatal visit.
Confirm the presence of bacteriuria in urine with a second urine
Do not use dipstick testing to screen for bacterial UTI at the first or
subsequent antenatal visits.
Treat asymptomatic bacteruria in pregnant women with antibiotics
Treat symptomatic UTI in pregnant women with an antibiotic.
Take a single urine sample for culture before empiric antibiotic
treatment is started.
A seven day course of treatment (amoxicillin – cephalexin-
augmentin)is normally sufficient.
Given the risks of symptomatic bacteriuria in pregnancy, a urine
culture should be performed seven days after completion of
antibiotic treatment as a test of cure.
Urinary tract infections in men are generally viewed as complicated because they result from an
anatomic or functional anomaly or instrumentation of the genitourinary tract.
Conditions like prostatitis, chlamydial infection and epididymitis should be considered in the
differential diagnosis of men with acute dysuria or frequency and appropriate diagnostic tests should
In all men with symptoms of UTI a urine sample should be taken for culture.
Due to their ability to penetrate prostatic fluid, quinolones (ciprofloxacillin) rather than nitrofurantoin
or cephalosporins are indicated.
Treat bacterial UTI empirically with a quinolone in men with symptoms suggestive of prostatitis.
four week course is appropriate for men with symptoms suggestive of prostatitis.
Refer men for urological investigation if they have symptoms of upper urinary tract infection, fail to
respond to appropriate antibiotics or have recurrent UTI.
Patients On Catheter
Do not rely on classical clinical symptoms or signs for predicting the
likelihood of symptomatic UTI in catheterised patients.
Signs and symptoms compatible with catheter-associated UTI
◦ new onset or worsening of fever, rigors
◦ altered mental status, malaise, or lethargy
◦ flank pain or costovertebral angle tenderness
◦ acute haematuria
Patients On Catheter
Do not use dipstick testing to diagnose UTI in patients with
Do not treat catheterised patients with asymptomatic
bacteriuria with an antibiotic.
Do not routinely prescribe antibiotic prophylaxis to prevent
symptomatic UTI in patients with catheters.
Drink plenty of liquids, especially water.
Drink cranberry juice.
Wipe from front to back.
Empty your bladder soon after intercourse.
Avoid potentially irritating feminine products.
Change your birth control method.
In women who experience ≥ 3 UTIs/yr, behavioral measures are
recommended, If these techniques are unsuccessful, antibiotic
prophylaxis should be considered. Common options are continuous
and postcoital prophylaxis.
Continuous prophylaxis commonly begins with a 6 mo trial. If UTI
recurs after 6 mo of prophylactic therapy, prophylaxis may be
reinstituted for 2 or 3 yr.
TMP/SMX 40/200 mg po once/day or 3 times/wk,
nitrofurantoin 50 or 100 mg po once/day, cephalexin 125 to 250 mg
Postcoital prophylaxis in women may be more effective if
UTIs are temporally related to sexual intercourse. Usually, a
single dose of one of the drugs used for continuous
prophylaxis is effective.
In postmenopausal women, antibiotic prophylaxis is similar
to that described previously. Additionally, topical estrogen
therapy markedly reduces the incidence of recurrent UTI in
women with atrophic vaginitis or atrophic urethritis.
Refer infant less than 3 months with UTI
Treat children 3 months and older with UTI using Amoxicillin/ Augmnetin, send
culture and consider request for ultrasound
Treat non-pregnant women with 3 days Nitrofurantoin
Treat asymptomatic bacteruria in pregnant women
Consider STI and prostitis in male
Do not give prophylaxis for adult with catheter and do not treat asymptomatic
1 month-old boy presented with fever of one day duration. He has
no associated symptoms. The child is stable but look irritable. Vitals
normal apart from temperature 38.5. systemic examination is
unremarkable. What is your management ?
A. Ask for urine sample
B. Prescribe Antibiotics
C. Prescribe Paracetamol
D. Refer for admission
5 year-old girl presents with abdominal pain and fever for
the last 2 days. You want o role out urinary tract infection in
this girl. Which one is the most suitable test for this
A. Urine dipstick
B. Urine microscopy
C. Urine culture
What is the positive test finding ?
Positive finding : positive nitrate and
25 year-old pregnant lady. She is 10 weeks gestation. She presents
for booking visit. You reviewed her booking investigations. They are
normal apart from bacteruria. Patient has no symptoms suggestive
of urinary tract infection. What is management?
A. Reassure and advice her to increase fluid intake
B. Repeat urine microscopy for confirmation
C. Send for urine culture and manage accordingly
D. Send urine culture and start antibiotics
C. Send for urine culture and manage accordingly
20 year-old male present with dysuria of two days duration. He has
no fever or abdominal pain. Urine microscopy shows:
WBC 20 , RBC 4. What is most appropriate management:
A. Do sexual transmitted infection screening
B. Request for ultrasound
C. Send for urine culture for sensitivity and Start antibiotics
D. Start antibiotics and repeat urine microcopy after one week
C. Send for urine culture for sensitivity and Start
28 year-old non-pregnant women presents with dysuria and lower
abdominal pain for the last 3 days. Urine microscopy shows: WBC 40,
RBS: 2 . what the is the best antibiotics for this patiatent:
A. Amoxicillin 500 mg tid 3 days
B. Augmentin 275/125 tid 7days
C. Ceftriaxone 125 mg iv single dose
D. Nitrofurantoin 100 mg bid 3 days
D. Nitrofurantoin 100 mg bid 3 days