URINARY TRACT INFECTION

UPDATE
Dr. S. Arunkumar M.S(GEN).,M.Ch (URO)
Consultant urologist and Andrologist
Kauvery hospital, Hosur
 Symptoms of Urinary Tract Infection

• Dysuria
• Increased frequency
• Hematuria
• Fever
• Nausea/Vomiting (pyelonephritis)
• Flank pain (pyelonephritis)
Classification
Asymptomatic bacteriuria in adults
• Asymptomatic bacteriuria (ABU), is common
• relates to commensal colonisation
 Epidemiology, aetiology
• 1-5% of healthy pre-menopausal females,
• 4-19% in otherwise healthy elderly females
and men,
• 0.7-27% in patients with diabetes,
• 2-10% in pregnant women,
• 15-50% in institutionalised elderly populations
• 23-89% in patients with spinal cord injuries
 Asymptomatic bacteriuria
• mid-stream sample of urine (MSU), showing
bacterial growth ≥ 10*5 cfu/mL, in two
consecutive samples in women
• in a single sample in men
• Diagnostic work-up:
– measurement of residual urine
– Cystoscopy and/or imaging of the upper urinary
tract
– Digital rectal examination (DRE) to rule out
prostate diseases
Recommendations for the management of ABU
• Do not screen or treat asymtomatic bacteriuria in
the following conditions:
women without risk factors;
patients with well-regulated diabetes mellitus;
post-menopausal women;
elderly institutionalised patients;
patients with dysfunctional and/or reconstructed
lower urinary tracts;
patients with catheters in the urinary tract;
patients with renal transplants;
patients prior to arthoplasty surgeries;
patients with recurrent urinary tract infections
 Asymtomatic bacteriuria
• One RCT investigated the effect of ABU
treatment in female patients with recurrent
symptomatic UTI and without identified risk
factors
• treatment of ABU increases the risk of a
subsequent symptomatic UTI episode.
• In men with recurrent symptomatic UTI and
ABU, chronic bacterial prostatitis must be
considered
 When hv to treat???????
• Screen for and treat asymptomatic bacteriuria
in pregnant women with standard short
course treatment.
• Screen for and treat asymptomatic bacteriuria
prior to urological procedures breaching the
mucosa.
 Pregnant women

• single dose treatment was associated with a

significantly lower rate of side effects but a
significantly higher rate of low birthweight.
• Therefore, standard short course treatment
should be applied to treat ABU in
pregnancy,((2-7 days)
 Uncomplicated cystitis
• Uncomplicated cystitis is defined as acute,
sporadic or recurrent cystitis limited to non-
pregnant, premenopausal women with no
known anatomical and functional abnormalities
within the urinary tract or comorbidities.
 Epidemiology, aetiology
• Almost half of all women will experience at least
one episode of cystitis during their lifetime
• Risk factors
– sexual intercourse,
– use of spermicide,
– new sexual partner,
– mother with a history of UTI and
– history of UTI during childhood.
• E. coli being the causative pathogen in 70-95% of
cases
 Diagnostic evaluation
• Clinical diagnosis:
– focused history of lower urinary tract symptoms
(dysuria, frequency and urgency)
– absence of vaginal discharge or irritation
• Laboratory diagnosis
– Urine dipstick testing
– Urine cultures
 Laboratory diagnosis
• Requires collection collection of a clean voided
midstream sample
• Urine dipstick tests can be used to test for UTI
• One tests for nitrite‐most urinary pathogens can
reduce nitrate to nitrite
• Another tests for leucocyte esterase, suggesting the
presence of neutrophils. If either test is positive, UTI
is probable and if both are negative, UTI is unlikely
• Microscopic examination or cytometry for white and
red cells
 Urine cultures
• Urine cultures should be done in the following
situations:
– suspected acute pyelonephritis;
– symptoms that do not resolve or recur within two
to four weeks after the completion of treatment;
– women who present with atypical symptoms
– pregnant women;
– males with suspected UTI
• A colony count of 10*3 cfu/mL of
uropathogens is microbiologically diagnostic in
women
 Disease management
• Drugs Of First Choice:
– fosfomycin trometamol 3 g single dose
– pivmecillinam 400 mg three times a day for three to five
days
– nitrofurantoin macrocrystal 100 mg twice daily for 5 days
• Alternative antimicrobials
– trimethoprim alone
– Co-trimoxazole (160/800 mg twice daily of three days
– Fluoroquinolones
• ampicillin/sulbactam or amoxicillin/clavulanic acid and
oral cephalosporins
– not effective as short-term therapy and are not
recommended for empirical therapy
 Cystitis in pregnancy
• Short courses of antimicrobial therapy
• penicillins, cephalosporins,
fosfomycin,nitrofurantoin
• trimethoprim (not in the first trimenon) and
sulphonamides (not in the last trimenon
 Cystitis in men
• Uncomplicated cystitis without involvement of
the prostate is uncommon
• antimicrobials penetrating into the prostate
tissue is needed in males with symptoms of
UTI
– trimethoprim sulphamethoxazole
– Fluoroquinolone
• A treatment duration of at least seven days is
recommended
 Recurrent UTIs
• Recurrences of uncomplicated and/or
complicated UTIs, with a frequency of at least
three UTIs/year or two UTIs in the last six
months
• Repeated pyelonephritis should prompt
consideration of a complicated aetiology.
• Diagnosis of rUTI should be confirmed by
urine culture
 Risk factors
• Reinfection by different bacteria.
• Persistence : same organism from focus
within the urinary tract.
• Struvate stone.
• Bacterial prostatitis.
• Fistula
• Urethral diverticulum.
• Atrophic infected kidney
 Disease management and follow-up
• avoidance of risk factors,
• non-antimicrobial measures
• antimicrobial prophylaxis
 Behavioural modifications
• reduced fluid intake,
• habitual and post-coital delayed urination,
• wiping from back to front after defection,
• douching and wearing occlusive underwear
 Non-antimicrobial prophylaxis
• Hormonal replacement(vaginal oestrogen
replacement)
• Immunoactive prophylaxis OM-89 (Uro-Vaxom®)
• Prophylaxis with
– probiotics (Lactobacillus spp.)
– Cranberry
– D-mannose
– Endovesical instillation
 Antimicrobials for preventing rUTI
• Continuous low-dose antimicrobial prophylaxis
and post-coital prophylaxis:
• Regimens include
– nitrofurantoin 50 mg or 100 mg once daily,
– fosfomycin trometamol 3 g every ten days,
– During pregnancy cephalexin 125 mg or 250 mg or
cefaclor 250 mg once daily
• continuous low-dose prophylaxis for longer
periods (three to six months)
• patients should be counselled regarding possible
side effects.
 Self-diagnosis and self-treatment
• In patients with good compliance, self-
diagnosis and self-treatment with a short
course regimen of an antimicrobial agent
should be considered
 Uncomplicated Pyelonephritis
• Pyelonephritis limited to non-pregnant, pre-
menopausal women with no known urological
abnormalities or co morbidities.
• fever (> 38°C), chills, flank pain, nausea,
vomiting, or costovertebral angle tenderness
• Urinalysis, urine culture and antimicrobial
susceptibility testing
• ultrasound of the upper urinary tract to
exclude obstructive pyelonephritis
• unenhanced helical computed tomography.
 Disease management-op
• Fluoroquinolones and cephalosporines are the
only microbial agents that can be
recommended for oral empirical treatment of
uncomplicated pyelonephritis
• other acceptable choices include
trimethoprim-sulfamethoxazole (160/800 mg)
or an oral betalactam
 Inpatient treatment
• treated initially with an intravenous
antimicrobial regimen such as a
fluoroquinolone, an aminoglycoside (with or
without ampicillin), an extended-spectrum
cephalosporin, an extended-spectrum
penicillin, or a carbapenem
Recommendations for empirical oral antimicrobial
therapy in uncomplicated pyelonephritis
 In men
• In men with febrile UTI, pyelonephritis, or
recurrent infection, or whenever a
complicating factor is suspected
• A minimum treatment duration of two weeks
is recommended,
• preferably with a fluoroquinolone since
prostatic involvement is frequent
 Complicated UTIs
• Factors associated with complicated UTIs
 Special cases of Complicated cystitis
• Indwelling foley catheter
– Try to get rid of foley if possible!
– Only treat patient when symptomatic (fever, dysuria)
• Leukocytes on urinalysis
• Patient’s with indwelling catheters are frequently colonized with great
deal of bacteria.
– Should change foley before obtaining culture, if possible
• Candiduria
– Frequently occurs in patients with indwelling foley.
– If grows in urine, try to get rid of foley!
– Treat only if symptomatic.
– If need to treat, give fluconazole (amphotericin if resistance)
Classification of prostatitis and
CPPS according to NIDDK/NIH
 Bacterial Prostatitis
• Site of pain Percentage of patients
• Prostate/perineum 46%
• Scrotum and/or testes 39%
• Penis 6%
• Urinary bladder 6%
• Lower back 2%
 Assessment
• Digital rectal examination to assess the condition of the
prostate
• mid-stream urine culture in patients with acute
prostatitis-related symptoms for diagnosis and targeted
treatment
• Meares and Stamey four-glass test in patients with
chronic bacterial prostatitis
• Perform transrectal ultrasound only in selected cases
to rule out the presence of prostatic abscess,
calcification in the prostate and dilatation of the
seminal vesicles
• Ejaculate analysis and prostate specific antigen
measurement should not be performed as routine
 Drainage and surgery
• Approximately 10% of men with acute
prostatitis will experience urinary retention
• The use of catheterisation without evidence of
retention may increase the risk of progression
to chronic prostatitis
• In case of prostatic abscess, both drainage and
conservative treatment strategies appear
feasible
 Empiric antibiotic regimens from
existing guidelines
Low risk of gonorrhoea (e.g. Likely gonorrhoeal acute
no discharge) epididymitis
• A fluoroquinolone active • Ceftriaxone 500 mg
against C. trachomatis orally intramuscularly single dose
once daily for ten to plus Doxycycline 200 mg
fourteen days OR initial dose by mouth and
• B. Doxycycline 200 mg initial then 100 mg twice daily for
dose by mouth and then ten to fourteen days*
100 mg twice daily for ten
to fourteen days* plus an
antibiotic active against
Enterobacteriaceae** for
ten to fourteen days*
THANK YOU