URINARY TRACT INFECTIONS

URINARY TRACT INFECTIONS
by Dr FARAZ AZIM NIAZ Consultant Nephrologist MRCP(UK), SSC-Nephro(KSA) King Khalid University Hospital, Riyadh

Epidemiology of UTI Worldwide, 150 million cases / year
90 % cystitis, 10 % pyelonephritis 75 % sporadic 25 % recurrent 2 % complicated

Prevalence of urinary tract infections (UTI)
almost half of all women will have at least one UTI in their lives. the risk of UTI in women increases after menopause after a UTI: % will have a recurrence recurring infections are usually reinfections. asymptomatic bacteriuria in women ↑with age & occurs in % of year olds 9.3% of over 65 year olds % of over 80 year olds

Prevalence of UTIs 2 10% of those living at home,
UTI is rare in young and middle-aged men & often with catheterisation or urological procedures. bacteriuria in elderly men occurs in 10% of those living at home, 20% of those living in nursing homes & 30% of those who are in hospitals urinary catheter increases the risk almost ten-fold in hospitalised patients and those in other care homes. pyelonephritis is common in patients who have been catheterised for over a month.

Gender and sexual contact
Infant and children : Male >> female Adolescent-menopause : Female >> male Older age : Female = = male Women: Short ureter Sexual contact : colonization of pathogens in bladder Spermicidal : Change of normal flora Men (<50) : Prostate infection, anatomical defects , Lack of circumcision, homosexuals

Symptomatic Infection
Asymptomatic bacteriuria

Classification of UTIs
Classification by Type of UTI Asymptomatic bacteriuria Cystitis Upper / Lower UTi Pyelonephritis Symptoms Symptomatic Asymptomatic Recurrence Sporadic < 1 UTI / 6 m Recurrent  1 UTI / 6m Complicating factors Uncomplicated Complicated

Urinary Tract Infection- Types
urethritis cystitis Lower prostatitis pyelonephritis intrarenal & Upper perinephric abscess

UTI- types by complicating factor
Uncomplicated UTi: infection in a structurally and neurologically normal urinary tract Complicated UTI: infection in tract with functional or structural abnormalities

Complicated or Un-Complicated UTI
Uncomplicated UTI is the one occurring in a healthy young nonpregnant woman, & a Complicated UTI is the one occurring in anyone else.

vs Pathophysiology

Host protective factors inUTI
Flushing mechanism of micturition Acid pH of urine (4.6- 6) anti-bacterial Acid vaginal pH ( )) suppresses colonization Urinary Tamm-Horsefall protein (secreted by ascending loop of Henle) & blocks E. coli Chemotactic factors - interleukin-8

Immune responses in UTI
Submucosal IgA-producing plasma cells in bacterial cystitis IgM & IgG antibodies produced against bacterial antigens Protective role of antibodies unclear, may limit damage within the kidney & prevent persistent colonization & thus recurrence of infection

Host Factors Complicating Bacteriuria
Residual bladder urine after voiding Turbulent urethral flow(stricture) Foreign bodies Atrophic vaginal mucosa Vesico-ureteral reflux Facilitate bacteriuria Worse prognosis of UTIs Childhood pyelonephritis Diabetic nephropathy Malignant hypertension Chronic pyelonephritis

Bacterial virulence factors in UTI
Escherichia coli strains expressing O-antigens cause high proportion of infections Capsular antigens of E. coli associated with clinical severity (antiphagocytic) P-fimbriae enhance attachment of E. coli) to uroepithelial cells Motile bacteria ascend the ureter against urine flow

Bacterial virulence factors in UTI
Bacterial urease (Proteus) splits urea →NH4 ion alkalinizes urine with loss of acid pH → stone formation → obstruction & survivial of bacteria within stones resisting eradication Gram-negative endotoxin decreases ureteral peristalsis Hemolysin damages renal tubular epithelium & promotes invasive infection Aerobactin of E. coli promote iron accumulation for bacterial replication

Pathogenesis of UTI Ascending route most common
Colonization of urethra and peri-urethral tissue is the initial event More in women than men due to short female urethra ,so urethral organisms enter bladder during micturition & in close proximity to perianal areas Once in the bladder , multiply, then pass up the ureters (esp. if vesico-ureteral reflux) to the renal pelvis & parenchyma Hospital infection associated with lower urinary tract instrumentation (catheterization, cystoscopy)

Pathogenesis of UTI- blood borne
Hematogenous seeding less frequent than ascending infection Kidney a common site of abscess formation in Staphylococcus aureus bacteremia, less often in candidemia, rarely with gram-negative bacteremia Hematogenous seeding of kidney also occurs with Salmonella (typhoid) and Mycobacterium tuberculosis Source of uropathogens: enteric bacteria

Pathogenesis of UTIs: Risk Factors
↓resistance of mucous membranes (e.g. in menopause) sexual intercourse disturbances in ureteral functioning in children the re-entering of urine back into the ureters (vesicoureteral reflux), Uterine prolapse Diabetes

Pathogenesis of UTIs - 2 Predisposing Conditions- contd benign prostatic hypertrophy any illness, eg diabetes, affecting the emptying -Neurogenic Bladder spinal injury →disturbances in bladder emptying or urinary catheter) Stones catheterisation & other urological procedures Renal Transplantation

Terminology of UTI Cystitis: localized infection of the bladder
Prostatitis: localized infection of the prostate = lower UTI Pyelonephritis: infection of the kidney with acute inflammation of the pelvis, medullary and cortical tubules, & intersititum = upper UTI Urosepsis: bacteremia ( in blood) due to pyelonephritis Perinephric abscess: associated with obstruction of an infected kidney with abscess formation in the peri-nephric space due to extension of infection across the renal capsule

Clinical Symptoms of UTI
Types of UTI Typical Symptoms & Signs Cystitis Frequent voiding, suprapubic pain Burning micturition Hematuria, cloudy urine Pyelonephritis Fever chills, flank pains, N/Vomiting Cystitis Sx  Urosepsis Fever- chills Shock

Urethritis ? Acute dysuria, frequency
Suspect sexually transmitted pathogens, no hematuria, no suprapubic pain, new sexual partner, cervicitis

Cystitis Symptoms: frequency, dysuria, urgency, suprapubic pain
Cloudy, malodorous urine (nonspecific) Leukocyte esterase positive = pyuria Nitrite positive (but not always) WBC (2-5 with sx) and bacteria on urine microscopy

Cystitis

Acute Pyelonephritis

Pyelonephritis Fever, chills Nausea/Vomiting, diarrhea, tachycardia,
Costo-vertebral angleTenderness or deep abdominal tenderness Leukocytosis Urine microscopy: Pyuria + WBC casts, bacteria & hematuria Possibly signs of Gram negative sepsis

? Pyelonephritis Complications: sepsis, papillary necrosis, abscess,
ureteral obstruction ↓renal function if scarring, in pregnancy – ↑incidence of preterm labor

Diagnosis of UTI History Physical exam Lab parameters:
Urinalysis with microscopy for WBC, bacteria Urine culture with sensitivities Diagnose acute uncomplicated cystitis in women based on Hx, PE, and UA alone, no need for culture to treat

Diagnosis Urinalysis Leukocyte-esterase positive. = pyuria
Nitrite positive from urease producing bacteria eg proteus (but not always) Microscopy – WBC ( > 5 in pt with symptoms) -- Bacteria

Diagnosis algorithm

Dipstick Methods pH, Sp.Gravity, protein, glucose, blood, ketone,
Leukocyste esterase + Pyuria Nitrite + Gram(-) bacteriuria except pseudomonas

FACTS NITRITE: Screening test for bacteria in urine
Gm –ve bact convert urine nitrate to nitrite False –ve: enterococcus, ascorbate, urine <4 hrs LEUCOCYTE – ESTERASE by granulocytes Test threshold is 5 – 15 WBC/HPF False –ve in : glycosuria, high sp. Gravity, cephalexin, tetracyclin, ↑oxalates, vaginal debris

Microscopic Examination
Pyuria: WBC > 5 / HPF in spun urine Bacteriuria > 105 cfu/ml

Diagnosis of UTI Urinalysis : Leukocyte esterase : On Dipstick exam
Nitrate nitrite : On Dipstick exam gram negative bacteria except pseudomonas Pyuria : > 5 WBC /HPF, WBC cast Bacteriuria : > 105 cfu/ml

Collecting a sample in adults, mid stream urine (MSU) sample usually reliably represents the urine in the bladder. samples from urinary bags or bedpans should not be used as they invariably will be contaminated the most reliable sample is obtained via a suprapubic puncture urine in bladder >4 hours (any shorter time will increase the risk of false negative findings)

Diagnosis- interpretation
Urine culture 105 colonies per mL considered standard for diagnosis - but misses up to 50% Now, 103 to 104 accepted as significant if patient symptomatic if several bacterial strains are grown on culture; contamination of the sample is the likely cause Sensitivities for better tailoring of therapy

Significant bacteriuria

Asymptomatic bacteriuria
microbiological diagnosis Positive Urine culture repeatedly (105 cfu/ml) in the absence of signs of UTI pyuria does not affect interpretation Investige & treat asymptomatic bacteriuria → only in pregnant women Its prevalence varies from 1-5% to 100% in selected population groups. .

Causative agents of UTIs
Escherichia coli most common 80% of community - acquired 50% of hospital-acquired Others: enterococci Staphylococcus saprophyticus and klebsiella pseudomonas and proteus are more rare

% of Organisms in UTI

% of types of Organisms in UTI

Localization of UTI Ultrasonography No definite standard method IVP
Abdominal CT / MRI Tc-99m DMSA renal scan

CT images at different levels –> hypodense areas of ?pyelonehritis
B C D CT images at different levels –> hypodense areas of ?pyelonehritis

MRI – Fluid (abscess) in lower pole
T1 MRI- hypointense area T2 MRI- hyperintense area Axial MRI- hyperintense area MRI – Fluid (abscess) in lower pole

(A gas forming infection of renal parenchyma & perinephric tissues )
Emphysematous Pyelonehritis: (a) CT – air in wall of U.B (b) Plain X ray- mottling in UB (A gas forming infection of renal parenchyma & perinephric tissues )

Enlarged cystic areas + a stone in the pelvis
Xanthogranulomatous Pyelonephritis Enlarged cystic areas + a stone in the pelvis

Indentation at upper pole
Tc-99m DMSA Renal Scan ↓Renal cortical uptake DDx Scar Renal infarction Indentation at upper pole

Sterile Pyuria- causes
Pyuria in the absence of bacterial infection Recent UTI treated with antibiotics Glucocorticoid therapy Acute febrile episode Cyclophosphamide Pregnancy Renal transplant rejection Genitourinary tract trauma Prostatitis and cystourethritis Renal T.B.

Therapy in UTIs - 1 Acute uncomplicated cystitis: in women
patient with typical symptoms, not belonging to any of the risk groups, is treated without laboratory investigations if the symptoms are atypical, a strip test urinalysis may be carried out to support diagnosis if the strip test is negative, the urine should be cultured and other reasons for the symptoms should be considered

Treatments of UTI - options
Lower UTI (Cystitis) : in women 3-7 days course of antibiotics ( short is preferable) Trimethoprin/SMX = 1st choice Cephalosporines ( Cefpodoxime)/ Nitrofurantoin Fluoroquinolone ( ciprofloxacin, Norfloxacin etc) Lower UTI (Cystitis) : in men Longer course for 7 days TMP/SMX Flouroquinolones B-lactams( Augmentin) or Nitrofurantoin: not recommended If no improvement→ consider Prostatis

Treatment of pyelonephritis-
Uncomplicated pyelonephritis: Mild to moderate pts can be treated orally as outpatient with either a quinolone ( ciprofloxacin or levofloxacin) sulpha-trimethoprim for Duration : days course of antibiotics B- lactams, Nitrofurantoin: not favoured If Amoxil: then give for 14 days. Inpatient management is appropriate in the following : Severe illness with high fevers, pain, and marked debility Pt unable to maintain oral hydration or take oral medications Pregnancy Concerns about patient compliance

Oral drugs

Treatment of pyelonephritis-Complicated
ie :progression to renal corticomedullary abscess, perinephric abscess, emphysematous pyelonephritis, or papillary necrosis Consider underlying anatomic or functional abnormalities An unwell patient should be admitted to hospital Parentral treatment is commenced with either Cephalosporines i.v. ( ceftriaxone ) or fluoroquinolone orally/ I.V & change to oral, when response is obvious Note: Antibiotics alone may not be successful unless underlying conditions are corrected

I.V Drugs

Prevention of UTI Recurrent UTI
Women with > 3 episodes of UTI per year Avoidance of spermicidal or diaphragm frequent and complete voiding Immediate voiding after sexual contact Good hydration Antibiotics after sexual contact Low dose antibiotics prophylaxis

Prophylaxis of recurrent UTI with antimicrobial agents
prophylaxis should be considered when more than 3 infections per year or 2 in 6 months prophylaxis to continue for 6 months if infections recur after prophylactic treatment, the prophylaxis is re-commenced for 6 – 12 months (D)

Pregnancy and UTI Incidence of UTI in pregnant women: 2-8 %
20-30 % of pregnant women with asymptomatic bacteriuria :  Upper UTI (pyelonephritis) in 2nd-3rd trimester b/c Ureteral dilatation, reflux Effects ofUTI in pregnancy : Increased incidence of fetal death and growth retardation

UTI in Pregnancy - TREATMENT
Flouroqinolones are CONTRA-INDICATED Low urinary tract infection : 7 day course antibiotics Ampicillin, cephalosporine Pyelonephritis: 2-4 weeks course antibiotics Cephalosporins, extended spectrum penicillins Parenteral treatment Thereafter, follow-up urine culture, monthly Asymptimatic bacteriuria Antibiotics Tx & f/u

Treatment during pregnancy
asymptomatic bacteriuria & cystitis are treated in the same way Requires longer tx of 7-14 days Cephalosporin, nitrofurantoin, augmentin, sulfonamides (do not use near term b/c risk of kernicterus single-dose treatment is not recommended due to foetal risk fluoroquinolones should be avoided during the whole of pregnancy, and sulphatrimethoprim during the latter part of pregnancy

Treatment of UTI in diabetics
Cystitis in diabetics drugs of choice for initial treatment are same as for uncomplicated UTI antibiotic treatment must always be based on the results of urine culture treatment to continue for 7 days Acute pyelonephritis in diabetics treatment is the same as for uncomplicated pyelonephritis consider urological imaging earlier than normal, if there is no response to appropriately chosen medication the causative agents of recurrent UTI’s in diabetics are often unusual, resistant microbes (species of pseudomonas, enterococci and enterobacter) and various candida species.

Treatment of Complicated UTI
Catheter - related Ampicillin/gentamycin or Tazocyn or ticaricillin/clav or imipenem or meropenem x 2-3 weeks Switch to PO FQ or TMP/SMX when possible Rule out obstruction Watch out for enterococci and pseudomonas

UTI in CHILDREN- Needs prompt recognition & treatment
Symptoms, non-specific,so difficult to distinguish between upper & lower, however, in < 2 yrs old child History of UTI Temperature >40ºC most helpful Suprapubic tenderness Lack of circumcision

UTI in CHILDREN- in verbal children
Abdominal pain Back pain Dysuria, frequency, or both New onset urinary incontinence SAMPLING of Urine – difficult ( catheter, suprapubic) Diagnosis: in usual ways. Therapy : Dose of AB as per Weight

UTIs in men a UTI in men can be associated with either acute or chronic bacterial prostatitis prostatitis or epididymitis may play a part particularly in febrile UTI it is advisable to palpate both the prostate and scrotum chronic bacterial prostatitis, or at least the retention of bacteria in the prostatic ducts, should be suspected in relapses with the same causative bacteria

UTIs in men 2 Afebrile lower urinary tract infection in men:
if the infection is not associated with urinary stricture or prostatitis,it is treated with the same drugs as cystitis in women, but the treatment should continue for days nitrofurantoin should not be used in men as adequate prostatic concentrations are not achieved (D) Febrile urinary tract infection in men is treated with a long course of antibiotics with good prostatic and epididymal penetration first choice: a fluoroquinolone for 2 weeks

UTIs in men 3 UTI in men associated with acute bacterial prostatitis
treatment for weeks (depending how quickly patient responds to treatment) to be followed up with low dose prophylaxis with e.g. trimethoprim or nitrofurantoin Chronic bacterial prostatitis recurrent UTI’s and calcifications in prostate oral quinolones for 2 – 3 months (D) to be followed up with prophylactic medication

Lower UTIs in children treatment principles are the same as for adults
little evidence to support short term treatment in children (C) drugs of choice nitrofurantoin 5 mg/kg/day or trimethoprim 8 mg/kg/day treatment to continue for 5 days (C)

Probable lower UTI with generalised symptoms in children
treated so that any possible infection of the kidney is also covered, i.e. with antibiotics with high tissue penetrability oral medication acceptable drugs of choice sulphatrimethoprim (trimethoprim 8 mg/kg/day) cefalexin mg/kg/day in 3 divided doses cefuroxime axetil 20 mg/kg/day in 2 divided doses or mecillinam mg/kg/day in 3 divided doses treatment to continue for 7 days (C)

Treatment of pyelonephritis in children
all infants with febrile UTI should be admitted to hospital drugs of choice cefuroxime (100 mg/kg/day in 3 divided doses) or ceftriaxone (80 mg/kg/day daily) intravenous therapy until obvious response when obvious response to treatment is observed, medication is changed over to oral until the total course of treatment, i.e. 10 days, is completed follow-up treatment according to culture and sensitivity results, with an antibiotic with good tissue penetrability (e.g. sulphatrimethoprim or a cephalosporin)

Treatment ? Uncomp. cystitis with less than 48 hours of sx, non-pregnant, usu. 3 days tx sufficient Bactrim DS, Septra DS Cipro or other FQ (avoid in preg.) Nitrofurantoin (7 days) Augmentin Bladder analgesis, Pyridium

Asymptomatic ? Bacteriuria
105 org/mL growth Empiric treatment of all asymptomatic bacteriuria (ASB) in pregnancy. Screening at first visit. ASB if untreated = inc. PTD and LBW, 20-30% develop pyelo. Do TOC in 2 weeks and each trimester. Screen Sickle cell trait each trimester. Twofold inc. risk of ASB

Asymptomatic Bacteriuria
Treatment failures: repeat tx based on sensitivities for 1 week, then prophylactic therapy for remainder of pregnancy Prophylaxis: Nitrofurantoin, Ampicillin, TMP/SMX

Treatment of Pyelonephritis -- Outpatient
Uncomp. Nonpreg pyelo Primary – any FQ x 7 days, cipro Alt. -- Augmentin, TMP/SMX, or oral CSP for 14 days

Treatment of Pyelonephritis – Inpatient ?
Treat IV until patient is afebrile hours. Then, complete 2 week course with PO meds Use FQ or amp/gent or ceftriaxone or piperacillin If no improvement on IV, consider imaging studies to look for abscess or obstruction All pregnant patients with pyelo get inpatient tx, appropriate IV antibiotics immediately

Predisposing conditions
Neurogenic bladder: dysfunction or bladder diverticulum (incomplete emptying) Age - Postmenopausal women with uterine or bladder prolapse (incomplete emptying), lack of estrogen, decreased normal flora, concomitant medical conditions such as DM Vesicoureteral reflux Bacterial virulence Genetics Change in urine nutrients, DM, gout

Predisposing conditions to UTI
Female Short urethra, proximity to anus, termination beneath labia Sexual activity Pregnancy 2-3% have UTI in preg, 20-30% with asx bacteriuria  may lead to pyelonephritis Increased risk of pyelo = decreased ureteral tone, decreased ureteral peristalsis, temp. incomp of vesicoureteral valves

Symptoms of UTIs 1 Cystitis:
typical symptoms include frequency and burning sensation when passing urine. Pyelonephritis: only some patients have difficulties in micturition temperature (> 38oC) and flank or back pain nausea in the elderly or sudden collapse in health status (”off-legs”)

Symptoms of UTIs 2 incontinence or offensive urine in the elderly should not be considered as UTI as such; even though they may be indicative signs of an infection almost any signs of infection in infants may be indicative of a UTI (C) in a small child a temperature alone, without any other signs of an infection, should raise a suspicion of a UTI UTI in children and the elderly may manifest itself as incontinence or retention.

Complicated UTIs are those occurring in…
Men Children Pregnancy People with suspected pyelonephritis People with recurrent UTI Failed antibiotic treatment or persistent symptoms Catheterised patients Hospital-acquired infections Recent urinary tract instrumentation People with abnormalities of genitourinary tract People with renal impairment and People with impaired host defences

Catheter-Associated UTI
10-15% of hosp. pts with catheter develop bacteriuria Risk of infection is 3-5% per day of catheterization UTI after one-time bladder cath approx. 2% Gram neg. bacteremia- most significant complication Greater antimicrobial resistance

Urine Culture Study Significant bacteriuria Midstream clean technique:
105 CFU/ml Suprapubic puncture, catheter collected urine: 102 CFU/ml Women with symptomatic cystitis Pyuria +102 CFU/ ml Symptomatic pyelonephritis patients Pyuria +104 CFU/ml

Diagnosis of UTIs 1 No need to do any urinalysis, if a female patient, who does not belong to any of the risk groups, clearly has occasional cystitis based on her symptoms Urine microscopy is not usually necessary to diagnose cystitis

Diagnosis of UTIs 2 Bacterial culture of urine should be carried out in all cases, except in uncomplicated cystitis, even though the results will not be available when medication is commenced (B) In early pregnancy bacterial culture should be carried out in all pregnant women if only to diagnose asymptomatic bacteriuria (A) In adult febrile infections with generalised symptoms, and in children’s infections, C-reactive protein (CRP) concentration above 40 mg/l is suggestive of a kidney infection (C)

Interpretation of Urine Cultures: General Guidelines
A single species of Enterobacteriaceae recovered at >105 cfu’s/mL urine: with patients symptomatic for urinary tract infection, 95% probability of true bacteriuria A single species of Enterobacteriaceae recovered at cfu’s/mL urine: with patients symptomatic for urinary tract infection, 33% probability of true bacteriuira Gram-positive, fungal, and fastidious uropathogens often present in lower numbers ( cfu’s/mL urine) Urethral commensals recovered at <104 cfu’s/mL urine

Commensal Microflora of the Urethra
Coagulase-negative staphylococci (except S. saprophyticus) Viridans and non-hemolytic streptococci Lactobacilli Diphtheroids (Corynebacterium except C. urealyticum) Saprophytic Neisseria Anaerobic bacteria

Common Bacterial Contaminants
Staphylococcus epidermidis Corynebacteria(diphtheroids) Lactobacillus Gardnerella vaginalis Anaerobic bacteria

Urine culture is not helpful for women with uncomplicated lower urinary tract infections as it does not improve outcomes. In women with classical presentation of uncomplicated UTI, treatment can begin based on the strength of clinical presentation. In women with dysuria and vaginal symptoms consider both a UTI and STIs. A dipstick positive to nitrites or leukocytes has a probability of a UTI of about 80% A dipstick negative to both nitrites and leukocytes, has a probability of a UTI of about 20%. Contents

When is urine culture helpful?
Urine culture should be performed for: Women with a UTI with complicating features All pregnant women Men with suspected UTI Suspected acute pyelonephritis Prostatitis Contents

Complicating features in women include:
Abnormal urinary tract e.g. stone, reflux, catheter, Impaired host defences e.g. pregnancy, diabetes, immunosupression, Impaired renal function, Suspicion of pyelonephritis, More than three UTIs in one year, or UTI recurrence within two weeks. Contents

Urine culture is recommended for pregnant women
Women with asymptomatic bacteriuria in early pregnancy have a fold increased risk of developing pyelonephritis, premature delivery and low birth weight infants. All pregnant women should be screened for asymptomatic bacteriuria at weeks gestation. If bacteriuria is detected by screening, the patient should be treated and a urine culture performed monthly throughout the pregnancy Contents

Urine culture is indicated for lower UTI in Men
All UTIs in men are considered complicated, therefore a urine culture is indicated, even if the urine dipstick is negative. Contents

A urine culture is indicated when acute pyelonephritis is suspected
Dipstick testing of the urine may be useful if clinical findings are equivocal Antibiotics should be commenced while waiting for culture results Post-treatment urine cultures are recommended one to two weeks after antibiotic therapy Contents

Screening for asymptomatic bacteriuria
Screening for asymptomatic bacteriuria is not recommended in: Non pregnant women Elderly people People with indwelling urinary catheter. People with spinal cord injuries. The prevalence of asymptomatic bacteriuria varies from 1-5% to 100% in selected population groups. Asymptomatic bacteriuria is a microbiological diagnosis based on the isolation of a specified count of bacteria in the absence of signs of UTI. Contents

Causative Microbes of APN-I
Microorganism No(%) E.Coli 191 (88) Klebsiella pneumoniae 8 (3.7) Staphylococcus species Enterococcus species 7 (3.2) Acinetobacter iwoffii 1 (0.5) Enterobacter aerogenes Xanthomonas maltophilia 민 등, 대한신장학회지 1998

Microorganisms in Urine(OPD)
% Escherichia coli 51 Enterococcus faecalis 13 Klebsiella pneumoniae ssp 6 Enterococcus faecium 3 Staphylococcus aureus Pseudomonas aeruginosa Proteus mirabilis 2 Enterobacter cloacae Klebsiella oxytoca 1 CNUH, 2003

Antibiotics Sensitivity for E. Coli
No(%) Ampicillin 27.3 Trimethoprim/Sulpha 43.9 Cefazolin 82.0 Amikacin 98.3 Imipenam 98.4 Ciprofloxacin 76.1 Gentamycine 79.8 이 등, 대한신장학회지 2002

Single-dose therapy phosphomycin 3 g norfloxacin 800 mg
single-dose therapy is slightly less effective than conventional therapy effective in infections caused by E. coli, but less so in S. saprophyticus infections recommended particularly when practical reasons warrant its use (e.g. self-care) Preparations: phosphomycin 3 g norfloxacin 800 mg ciprofloxacin mg ofloxacin 200 mg as a single dose

Antimicrobial therapy in UTIs 2
Reserve drugs: Quinolones (norfloxacin, ofloxacin or ciprofloxacin) for 3 days if first choice drugs are not suitable or if the infection has not responded to first choice drugs or recurrent infection within 4 weeks if there is a relapse, urine must be cultured and the treatment should be continued for 7 days In special cases: cefalexin or cefadroxil for 5 days (if the above are contraindicated) sulphatrimethoprim for 3 days (particularly if the level of infection is unclear) amoxicillin for 5 days (particularly in enterococcal infections)

Treatment of Recurrent uncomplicated UTI
3 or more episodes in one year, 2 in 6 months Bactrim DS ( or septra DS) QD for 3-6 months - once infection eradicated, self-admin.,Single dose at symptom onset or one DS tab post-coitus Measures for prevention: voiding after intercourse, good hydration, frequent and complete voiding

Underlying Conditions
Diseases Percents(%) Diabetes mellitus 56 (49.6) Urinary tract stone 22 (19.5) Congenital anomaly 7(6.2) Renal cyst 6(5.3) Pregnancy 5(4.4) Neurogenic bladder Vesico-Ureteral reflux 4(3.5) 민 등, 대한신장학회지, 1998

Drugs of choice in UTI prophylaxis
First choice: trimethoprim 100 mg in the evenings nitrofurantoin 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

Un-Complicated or complicated UTI
‘Uncomplicated’ UTI are occasional lower UTI in women with no predisposing factors ‘Complicated’ infections are all other UTIs including lower UTIs in men Children pregnant women catheter-induced infections

UTI - also categorized into
Non-catheter associated (community- acquired) Catheter associated (hospital- acquired) Any category may be symptomatic or asymtomatic

Causative organisms of AcutePyelonephritis
Microorganism No (%) E.Coli 122 (91.7) Enterococcus spp 4 (3.0) Pseudomonas spp 2 (1.5) S. viridans Proteus 1 (0.8) Coag.N.Staph Not isolated 113 이 등, 대한신장학회지 2002

Microorganisms in Urine (ER)
% Escherichia coli 51 Enterococcus faecalis 9 Klebsiella pneumoniae ssp 7 Alcaligenes xylosoxidans 5 Burkholderia cepacia Staphylococcus aureus 3 Proteus mirabilis Enterococcus faecium Enterobacter cloacae 2 CNUH, 2003

Xanthogranulomatous Pyelonephritis
Mass-like lesion of Ch.PN b/c obstruction due to infected renal stones

URINARY TRACT INFECTIONS

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