Urinary Tract Infections

1. Urinary Tract Infections Dr. Sameh Ahmad Muhamad abdelghany Lecturer Of Clinical Pharmacology Mansura Faculty of medicine

2. OBJECTIVES • Describe pathogenesis & clinical characteristics of Urinary tract infections • Identify most likely etiologic organism(s) • Review appropriate drug therapy

3. CONTENTS  INTRODUCTION  Classification Urinary Tract Infections  RISK FACTORS  Diagnosis  Treatment

4. INTRODUCTION

5. INTRODUCTION • Urinary tract infection is one of the most common bacterial infection managed in general medical practice • Accounts for 1‐3% of consultations • Up to 50% of women will have a UTI at some point in their life • UTI uncommon in men except over the age of 60 when urinary tract obstruction due to prostatic hypertrophy may occur

6. INTRODUCTION • Symptomatic presence of micro-organisms within the urinary tract i.e., kidney, ureters, bladder and urethra. • Associated with inflammation of urinary tract.

7. INTRODUCTION • Significant bacteriuria: • presence of at least 105 bacteria/ml of urine. • Asymptomatic bacteriuria : • bacteriuria with no symptoms. • Urethritis: infection of anterior urethral tract. • Cystitis: infection to urinary bladder

8. UTI - Terminology • Acute pyelonephritis: • infection of one/both kidneys. • Chronic pyelonephritis: • particular type of pathology of kidney; may/may not be due to infection.

9. UTI - Terminology • Uncomplicated: UTI without underlying renal or neurologic disease. • Complicated: UTI with underlying structural, medical or neurologic disease. • Recurrent : > 3 symptomatic UTIs within 12 months following clinical therapy. • Reinfection: recurrent UTI caused by a different pathogen at any time • Relapse: recurrent UTI caused by same species causing original UTI within 2 wks after therapy

10. CLASSIFICATION

11. Classification Of UTI • Upper UTI: • Acute pyleonephritis • Chronic pyleonephriitis • Interstitial pyleonephritis • Renal abscess • Perirenal abscess. • Lower UTI: • Cystitis • Prostatitis • Urethritis • Both upper & lower UTI are further divided into complicated and uncomplicated.

12. Epidemiology • Seen in all age groups • Infants up to 6 months – 2/1000 • More common in boys than girls • Women :at greater risk than men; prevalence 40-50% in women and 0.04% in men. • 10% women have recurrent UTI in their life • 7 million new cases of lower UTI / year • 1 million hospitalizations / year • Incidence of UTI increases in old age; 10% of men and 20% of women are infected.

13. Etiology • Acute uncomplicated UTI: • Escherichia coli : cause about 80% of UTI • 20% of UTI caused by Gram negative enteric bacteria – Klebsiella, Proteus • Gram positive cocci : Streptococcus faecalis , Staphylococcus saprophyticus

14. Etiology • Complicated UTI: • Pseudomonas aeruginosa, Enterobacter & Serratia • Isolated in hospital acquired infections and catheter associated UTI. • Viruses : Rubella, Mumps and HIV • Fungi : Candida, Histoplasma capsulatum • Protozoa : T. vaginalis, S. haematobium

16. RISK FACTORS

17. Risk Factors • Aging: • diabetes mellitus • urine retention • impaired immune system • Females: • shorter urethra • incomplete bladder emptying with age • Males: • prostatic hypertrophy • bacterial prostatitis

18. Host Factors Predisposing to Infection • Extra-renal obstruction • Posterior urethral valves • Urethral strictures • Renal calculi • Incomplete bladder emptying • Neurogenic bladder • Immunocompromised individuals (e.g. DM, transplant recipients)

19. DIAGNOSIS

20. UTI-CLINICAL PRESENTATION • Clinical manifestations depends on • site of infection • age of patient.

21. Clinical manifestations depending on site of infection • Urethritis: • Discomfort in voiding • Dysuria • Urgency • frequency

22. Clinical manifestations depending on site of infection • Cystitis: • dysuria, urgency and frequent urination • Pelvic discomfort • Abdominal pain • Pyuria • Hemorrhagic cystitis: • Visible blood in urine. • Irritating voiding symptoms

23. Clinical manifestations depending on site of infection • Pyleonephritis: • Invasive nature • Suprapubic tenderness • Fever and chills • White blood cell casts in urine • Loin pain • Nausea and vomiting • Complications : • sepsis, septic shock and death.

24. SYMPTOMS OF PYELONEPHRITIS

25. COMMON SYMPTOMS OF UTI

26. Clinical manifestations depending on age • Babies and infants: • Failure to thrive • Fever • Apathy • Diarrhea • Children: • Dysuria, urgency, frequency • Hematuria • Acute abdominal pain • Vomiting

27. Clinical manifestations depending on age • Adults: • Lower UTI: frequency, urgency, dysuria, haematuria • Upper UTI: fever, rigor and lion pain and symptoms of lower UTI. • Elderly patients: • Mostly asymptomatic • Not diagnostic as the symptoms are common with age.

28. Investigations • Microscopic examination of urine • Urinalysis • Urine culture • Imaging techniques: CT scan and MRI

29. Laboratory examination • Uncontaminated, midstream urine sample used.

30. Laboratory findings

31. Microscopic examination of urine Multiple white cells seen in the urine of a person with

32. Urinalysis • Presence of pus, white blood cells, red blood cells • Bacterial count > 105 /ml – significant bacteriuria

33. Urine culture • For pyelonephritis • Not a rapid diagnostic tool • >105 bacteria /ml • Differential leukocyte count (increased neutrophils)

35. Diagnostic tests for adults with recurrent UTI • Intravenous pyelography / excretory urography

36. TREATMENT

37. UTI - management • Symptomatic UTI: antibiotic therapy • Asymptomatic UTI: no treatment required except in special situations. • Non- specific therapy: • more water intake. • Maintaining acidity of urine by fluids like cranberry juice or use of ascorbic acid.

38. Anti-microbial therapy • Goals of therapy: • Elimination of infection • Relief of acute symptoms • Prevention of recurrence and long term complications

39. Anti-microbial therapy • Principles of anti microbial therapy : • Levels of antibiotic in urine but not in blood • Blood levels of antibiotic –important in pyelonephritis • Penicillins and cephalosporins –drugs of choice for UTI with renal failure.

40. Anti-microbial therapy • Treatment duration: • Single dose therapy • 3 day course • 7 day course • 10 – 14 day course

41. Anti-microbial therapy • Single dose therapy: • Trimethoprim- sulfamethaxole • Amoxicillin- clavulnate 500mg • Amoxcillin 3gm • Ciprofloxacin 500mg • Norfloxacin 400mg

42. Anti-microbial therapy • 3 day therapy: • Efficacy same as 7 day therapy with less adverse effects • Drugs used include • quinolines • TMP-SMZ • betalactam antibiotics

43. Anti-microbial therapy • 7 day therapy: • Used less for uncomplicated UTI • Useful in : • recurrent cases • pregnancy • UTI with other risk factors

44. Anti-microbial therapy • 14 day therapy: • For complicated UTI • High risk of mortality and morbidity

45. Pathogen specific treatment

46. Infection specific treatment • Lower UTI: • 3day therapy preferred • Trimethoprim • Nitrofurantoin • Ciprofloxacin -Norfloxacin • Co-amoxiclav • Amoxicillin • Cephalexin

47. Infection specific treatment • Acute pyelonephritis • Paranteral antibiotics • Cefuroxime – 750mg i.v. Q8h • Gentamycin - 80-120g i.v. Q12h • Ciprofloxacin – 200mg i.v. Q12h • 10-14 days treatment • Ceftazimide, imipenam, ciprofloxacin for hospital acquired pyelonephritis

48. Infection specific treatment • Asymptomatic bacteriuria • Children : • treatment same as symptomatic bacteriuria • Adults : • treatment required in cases of • pregnancy • patient with obstructive structural abnormalities

49. Infection specific treatment • Bacteriuria in pregnancy • To prevent risk of pyelonephritis • 7 day course with following antibiotics • Cephalaxin • Nitrofurantoin • Amoxicillin • Therapy continued at regular intervals of pregnancy.

50. Infection specific treatment • Relapsing UTI • 7-10 day course • If fails – 2week course / 6week course • Structural abnormalities corrected by surgery • 6week course: • children • adults with continuous symptoms • high risk of renal damage