Urinary Tract Infections David Spellberg, M.D., FACS

UTI OVERVIEW Cystitis Urethritis Trigonitis Urethral syndrome

Cystitis Inflammation of the bladder, can be bacteriologic, non-bacterial,complicated vs. uncomplicated

Urethritis Inflammation of the urethra; difficult to distinguish from cystitis in women

Trigonitis Localized hyperemia of the trigone and floor of the bladder

Urethral Syndrome Frequency, urgency, dysuria, suprapubic discomfort and pressure, voiding difficulties, with pyuria in the absence of organic pathology ( negative urine C&S)

Risk factors Female: male ratio 8:1 60% adult females have had a UTI in their lifetime Increasing incidence with age Inefficient bladder emptying Decreased functional ability Hospital nosocomial infections

Routes of infection Ascending Hematogenous Lymphatic

Microbiology 80% of bacteriuria in UTI’s are gram negative bacilli E. coli most common Gram positives: staph, strep, enterococcus Yeast Rarely anaerobes, tapeworms

Female risk factors Physiologic changes: decreased vaginal glycogen and rising pH Sexual intercourse, diaphragm & spermicide use Constipation Systemic factors: diabetes, incontinence, dementia, neurologic disorders

Host defenses Urine osmolality and low pH Normal & complete periodic voiding Vaginal estrogen levels

Symptoms Lower tract: dysuria, frequency, nocturia, suprapubic pressure, urgency Upper tract: fever, chills, flank pain

Diagnosis History Physical exam: temperature, abd and flank exam Urine sample

Bacterial Virulence Ability to adhere to mucosal cells Develop drug resistance Indwelling catheters,urinary obstruction, stone disease

Urine dipstick Nitrite positive; very specific but not sensitive. False positive with beets, meds Leukocyte esterase; both specific and sensitive. Enzyme in neutrophil granules.

Urine microscopy Uncentrifugated. 2-6 leukocytes/hpf. Greater then 10 WBC’s/ml Culture not necessary generally with history and above findings.

Urine cultures Collect if screening urine is inconclusive, recurrent infection, prior infection unresolved with antibiotics, sign or symptoms of upper tract UTI

Culture results Traditionally > 100,000 colonies per field Now> 100 colonies in symptomatic pts

Imaging Ultrasound CT urogram IVP VCUG

TREATMENT Rest Hydration Cranberry juice Urinary analgesics; Prosed DS,

Antibiotics Ideal antibiotic; higher bladder concentration than other tissues. Ampicillin- 25% yeast vaginitis tetracycline- 80% yeast vaginitis nitrofurantoin- no serum level TMP-SMX- moderate bowel effects but 39% E.coli resistance

First infection Single dose regimens; higher failure in diabetes, pregnancy, anatomic abnormalities 3 day vs. 7 day; some studies show equal effectiveness, less side effects, better compliance

Treatment Start 3 day TMP-SMX, cefadroxil, or cephalexin, (uncomplicated acute cystitis, no allergy, no recent antibiotics, no hospitalization) Nitrofurantoin; 7 day treatment Quinolones; if allergic to above, complicated cystitis, severe symptoms, failed previous treatment

Recurrence C & S helps distinguish relapse of same bug vs. re-infection Upper tract evaluation cystoscopy

Long term management Behavior changes; stop spermicides, post coital voiding, bowel programs, increased water intake Old fashioned treatment- daily suppressive antibiotic days then re-evaluate Newer treatment- postcoital prophylaxis, self treatment for symptoms 3-7 days, office visit if not better.

Post menopausal women Initiate vaginal estrogen replacement Bladder Control treatment Bowel programs

Questions?