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Urinary Tract Infections. I would like to tell you something…Will you listen to me…?. Overview of UTI. 7 million office visits yearly 1 million hospitalizations About 2/3rds of patients are women 40% to 50% of women have UTI at some point during their lives

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overview of uti
Overview of UTI
  • 7 million office visits yearly
  • 1 million hospitalizations
  • About 2/3rds of patients are women
    • 40% to 50% of women have UTI at some point during their lives
  • Important complications of pregnancy, diabetes mellitus, polycystic disease, renal transplantation, conditions that impede urine flow (structural and neurologic)
  • Urinary tract infection
  • Significant bacteriuria
  • Asymptomatic bacteriuria
  • Acute pyelonephritis
  • Chronic pyelonephritis
  • Chronic interstisial nephritis
  • Pyuria
  • Urethral syndrome
UTI: the finding of microorganisms in bladder urine with or without clinical symptoms and with or without renal disease

Women: Presence of at least 100,000 colony-forming units (cfu)/mL in a pure culture of voided clean-catch urine.

Men: Presence of just 1,000 cfu/mL

  • Significant bacteriuria: the number of bacteria in the voided urine exceeds the number that can be expected from contamination (i.e. ≥ 10⁵ cfu/ml)
Asymptomatic bacteriuria: Significant bacteriuria (>105 cfu/ml) without clinical symptoms.
  • Acute bacterial pyelonephritis: a clinical syndrome of fever, flank pain, and / or tenderness
Chronic bacterial pyelonephritis: Long-standing infection associated with active bacterial growth in the kidney; or the residum of lesions caused by such infection in the past
  • Chronic interstitial nephritis: renal disease with histologic findings resembling chronic bacterial pyelonephritis but without evidence of infection
Pyuria: the presence of pus (WBC’s) in urine, which may or may not be caused by UTI. The preferred method for quantification is enumeration in unspun urine. The leukocyte esterase nitrite test has a sensitivity of between 70% and 90% for symptomatic UTI
  • Urethral syndrome: characterized by frequency, dysuria, and suprapubic discomfort without demonstrable infection
presentation of utis
Presentation of UTIs
  • Urethritis
      • The inflammation and infection is limited to the urethra
      • It is usually a sexually transmitted disease.
      • Present in men and women
  • Cystitis
      • Irritation of the lower urinary tract mucosa (i.e. bladder)
      • Dysuria (painful urination)
      • Urgency & frequency but small
      • Suprapubic tenderness
      • Pyuria
  • Haemorrhagic cystitis
      • Large quantities of visible blood in the urine
      • Caused by an infection (bacterial or viral)
      • Irritation when voiding
  • Pyelonephritis
      • Kidney infection from lower UTI infection
      • Complications – Sepsis, septic shock and death
uncomplicated vs complicated uti
Uncomplicated vs Complicated UTI
  • Uncomplicated UTI: infection that occurs in a structurally and neurologically normal urinary tract

Females > Males

  • Complicated UTI: infection in a urinary tract with functional or structural abnormalities (including indwelling catheters and renal calculi)

Females = Males

  • In elderly men are always considered complicated
  • In women are complicated when:
    • Hx of recurrent UTI
    • Secondary to structural abnormalities
    • Catheters
    • Stones
    • Urinary retention
    • Abscess formation or urosepsis
primary vs recurrent
Primary Vs. Recurrent

Primary UTI

Infection that occurs in the urinary tract for the first time. No previous episodes of infections.

Recurrent UTI

Presence of past history of urinary tract infection

recurrent relapse vs reinfection
RecurrentRelapse Vs. Reinfection


Recurrence within 2 weeks of treatment and mainly due to treatment failure, the initial organism is not totally cleared.

The Same Organism

Occurs in case of:

  • Acute Upper UTI.
  • Presence of obstruction like stone disease.

Recurrence within several weeks after the antibiotic therapy has cleared up the initial episode.

Different Organisms

Lower Urinary Tract Infection(Urethritis and Cystitis)VsUpper Urinary tract Infection(Pyelonephritis)
acute uncomplicated cystitis
Acute Uncomplicated Cystitis
  • Acute bacterial cystitis is usually characterized by sudden onset, multiple urinary symptoms, pyuria, and sometimes hematuria
  • Acute dysuria in young women usually indicates: acute bacterial cystitis; the urethral syndrome; or vaginitis
  • Although most patients have lower urinary symptoms only, 30% to 50% may have subclinical renal involvement
  • Causes: E. coli (80%), S. saprophyticus (10% to 15%), and occasionally Klebsiella, Proteus mirabilis, and other microorganisms.
acute uncomplicated pyelonephritis
Acute Uncomplicated Pyelonephritis
  • Largely a clinical diagnosis
  • Pyuria is usually present; about 20% have positive blood cultures; causative organisms the same as with cystitis
  • Predisposing factors: structural abnormalities; strains of E. coli with unique markers; genetically-determined carbohydrate receptors on uroepithelial cells
  • Highly significant!
  • Presence of WBC casts suggests pyelonephritis
urinary tract infections1
Urinary Tract Infections
  • Risk Factors
  • Organisms
  • Rout of Infection
  • Symptoms - History
  • Signs – Physical Exam
  • Differential Diagnosis
  • Investigation
  • Treatment
  • Complications
risk factors1
Risk Factors

General Conditions

  • Diabetes
  • Previous urinary tract infection
  • Kidney Problems
  • Immunosuppression
  • Sickle Cell Disease
  • Functional or mental impairment
  • Urinary Stone Disease
  • Urinary Tract Anomalies
  • NeurogenicBladde
  • Urologic instrumentation or surgery
  • Urethral catheterization
  • Renal transplantation
  • spinal injury
risk factors2
Risk Factors

Specific for Females

  • Structure of Urinary Tract.
  • Sexual Behavior. It is not STD
  • Contraception.
  • Pregnancy
  • Menopause
risk factors3
Risk Factors

Specific for Males

  • Benign Prostatic Hypertrophy
  • Prostatitis
risk factors4
Risk Factors

Specific for Children

  • Uncircumcised Males
  • Vesicoureteral Reflux Disease.
Frequency distribution of symptomatic UTI and prevalence of asymptomatic bacteriuria by age and sex

(Male – shaded area; Female – line)




Gram Negative Organisms

  • E.ColiIn Acidic Urine (most common)
  • Proteus In Alkali Urine
  • Klebsiella
  • Citrobacter
  • Pseudomonas

Gram Positive Organisms

  • Staphylococcus Aureus
  • Staphylococcus Epidermidis
  • Streptococcus Feacalis

Fungal Infections

  • Mainly in Diabetic Patients.
  • Candida Species
rout of infection1
Rout of Infection
  • Ascending Infection.
    • The common route of nearly all forms of urinary tract infection (bacteria initially colonize periurethral tissues)
    • Common in females than in males because of shorter urethra
    • Single bladder catheterization can result in UTI in 1% of the ambulatory population
  • Lymphatic Spread.

Increase bladder pressure can cause lymphatic flow to be directed toward the kidney

  • Local Spread.
rout of infection2
Rout of Infection
  • Hematogenous Spread.
    • Frequently seen with Staphylococcus aureus bacteremia or endocarditis
    • Also seen to occur in experimental models with Candida
    • Infections with gram negative bacilli rarely occurs by this route
  • Descending From the Kidneys
  • Local Spread.
symptoms history1
Symptoms - History

Lower Urinary Tract Infection

  • Frank Hematurea.
  • Painful Micturation.
  • Discomfort in the lower abdomen.
  • Urinary Frequency.
  • Urinary Urgency.
symptoms history2
Symptoms - History

Upper Urinary Tract Infection

  • High Grade Fever, chills and rigor.
  • Flank Pain.
  • Nausea and Vomiting
  • Lower UTI Symptoms.
signs physical exam1
Signs – Physical Exam
  • Vital Signs
  • Suprapubic Tenderness
  • Flank Tenderness
Based on the symptoms both
  • a clinical diagnosis of a UTI and a differentiation between lower (cystitis) or upper (pyelonephritis) UTI should be made
differential diagnosis1
Differential Diagnosis

Lower UTI

  • Stones.
  • Vaginitis and STD
  • Interstitial Cystitis.
  • Menopausal Changes.
  • Prostate Disease.
differential diagnosis2
Differential Diagnosis

Upper UTI

  • Pneumonia.
  • Cholecystitis.
  • Appendicitis.
  • Kidney Stones.

Dipstick Test

  • Nitrites Test
  • Leukocyte Esterase Test.
  • Blood.
  • Proteins.

Microscopic Examination

  • WBC’s Count.
  • RBC’s Count.
  • Cellular and Hyaline Casts.

Clinical Symptoms


Suggestive Dipstick


Suggestive Microscopic Exam


Urinary Tract Infection (75%)


Gram Stain and Urine Culture

  • Urine culture is gold standard.
  • Used in every positive dipstick and urinalysis.
  • Used in negative dipstick and urinalysis if:- Age less than 2 Years.

- UTI symptoms (25%).


Helpful Laboratory Tests

  • CBC
  • Serum Electrolytes
  • KFT
  • Blood Culture.

Imaging Studies

  • Recurrent cases of pyelonephritis
  • Structural abnormalities are suspected.
  • No response to treatment.
  • Suspicion of obstruction.
  • Children: age 2 - 24 months


  • Screening for hydronephrosis.
  • Kidney Stones.
  • Kidney Abscess.

Nuclear Scan

  • Kidney Scar.


  • Stones.
  • Structural Abnormalities.
  • Urethral Narrowing.
  • Incomplete Bladder Emptying.
  • Examples:- MCUG- IVP and KUB

Upper UTI

  • Good Hydration.
  • Oral TMP-SMX or Quinolones for 2 weeks.
  • Oral amoxicillin and clavulanic acid for 2 weeks.

Lower UTI

  • Good Hydration.
  • Oral TMP-SMX or Quinolones for 1 week.
  • Relapses are best treated with the same AB, long period.


  • Long term AB prophylaxis.
  • Surgical reimplantation of the ureters >>> VUR disease

Failure of Treatment

  • Compliance and AB Dose.
  • Bacterial Resistance.
  • Polymicrobial UTI.
  • Azotemia.
  • Papillary Necrosis.
  • Staghorn Calculi.
prophylaxis of recurrent cystitis with antimicrobial agents
Prophylaxis of recurrent cystitis with antimicrobial agents
  • prophylaxis should be considered when more than3 infections per year
  • prophylaxis to continue for 6 months
  • if infections recur after prophylactic treatment, the prophylaxis is re-commenced for 6 – 12 months
drugs of choice in uti prophylaxis
Drugs of choice in UTI prophylaxis

First choice:

  • trimethoprim 100 mg in the evenings
  • nitrofurantoin 50 - 75 mg in the evenings

Second choice:

  • methenamine hippurate 1 g twice daily
  • norfloxacin 200 mg daily or on 3 evenings per week
  • nitrofurantoin (not if serum creatinine is above 150 μmol/l)
  • quinolones (in cases where there is no response with other prophylactic medication or tolerance to other medications is poor)

During pregnancy:

  • nitrofurantoin 50 mg daily or
  • methenamine hippurate 1 g daily for the rest of the pregnancy
  • particularly if recurrent bacteriuria is diagnosed in early pregnancy
  • Spread of Infection- Sepsis.- Prostatitis.- Epididymitis.
  • Persistence of Infection- Perinephric Abscess.- Chronic Infection.
  • Obstruction.
  • Kidney Scar.
  • Kidney Stones