When the urinary tract is anatomically & physiologically normal, and the local & systemic defense mechanism

are intact, bacteria are confined to the lower end of urethra.

UTIs

Implies multiplication of organism in the urinary tract. UTI is a term that is applied to a variety of clinical condition ranging from asymptomatic presence of bacteria in the urine to sever infection of the kidney with resultant sepsis.

 The

presence of more than 100,000colony/ ml in a mid stream sample of urine (MSU).

:Method of urine collections

Suprapubic: any gram negative organisms in the culture indicate infection >99% if any Colony on culture.
Catheterization :>100,000 Colony/ml 95% have

UTI.
Clean catch method:

:Epidemiology of UTI

In newborns up to 1 year of age bacteriuria is present in 2.7% of boys and 0.7% of girls. Incidence of UTI in uncircumcised child is higher that circumcised child. In children after 5years the incidence of UTI in male decrease to0.5% while in girls increased to 4.5%. For patients older that 65 years the incidence of UTI continue to increase in both sexes. The morbidity and mortality of UTI is greatest in patients under 1 year and older than 65 years.

UTI :Predisposing

Factors

Female sex Sexual intercourse D.M Immunosuppression Pregnancy

Menopause Urinary tract obstruction Renal stone Instrumentation Malformation

UTI :Bacterial Etiology

G negative orginasms E-coli klebsiella Proteus mirabilis Other bacilli

G positive orgnasims

Enterococci staphylococci

Hospital acquired UTI cause by Pseudomonas and staphylococcus spp.

:Pathogenesis of UTI
Bacterial entry
3. 4.

5.

ascending infection : the commonest, periuretheral bacteria ascending into the urinary tract cause most UTI. Hematogenous spread: uncommon, mostly in immunocompromised patients and in neonate, Staphylococcus aureus, Candida species and mycobacterium TB. Lympatogenous spread: through rectal, colonic and periuterine lymphatics.

4.direct extension from adjacent structures (intraperitoneal abscesses & fistulas).

UTI :Symptoms & Signs

Symptoms of upper UTIs:

Fever Rigors Vomiting Loin pain & tenderness oligouria

Symptoms of lower UTIs:

Frequency Dysuria Urgency Strangury Heamturia Suprapubic pain

UTI :Symptoms & Signs

Symptoms of prostatitis :
Flu-like symptoms Low backache or perineal pain urinary symptoms(irritative &obstractive) Swollen & tender prostate

UTI :Symptoms & Signs

Symptoms of UTIs in young children:

Excessive crying Diarrhea Loss of appetite Fever Nausea & Vomiting Failure to thrive

UTI:

Investigations

Investigation Urine analysis

Indication

All Patients Urine culture

CBC
Plasma (urea, creatinine & (electrolytes Bl.culture
Infant,children,adult with acute pyelonephritis or prostatitis recurrent UTIs + // Fever, rigors or evidence of septic shock

:Urine analysis

Leukocyte esterase: breakdown of WBC Urinary Nitrite: reduction of the dietary Nitrate into Nitrite.

Microscopically WBC more than 3 WBC/ hpf. Presence of bacteria. Urinary pH.

:Urine culture

The gold standard for identification of UTI is the quantitative culture of urine for specific bacteria. Each bacterium will form a single colony on the culture plate. The numbers of colonies is counted and adjusted per milliliter of urine CFU/ml.

Investigation .Pelvic exam .Rectal exam Renal U.S I.V.U Cystoscopy CT scan
(Men (prostate

Indication
Women with recurrent UTIs

Infant,children,men after single UTI, women with: Acute Pyelonephritis, recurrent UTI Alternative to U.S Patient with chronic haemturia or suspected bladder lesion In Pyelonephritis: segmental perfusion defects, renal enlargement, attenuated parenchyma, and compressed collecting .system CT scan is not necessary unless the Dx unclear, or Pt not responding to Rx

Localization study

.VB1: urethral sample .VB2 Bladder sample VB3:prostatic sample with prostatic massage

All patients with signs of acute pyelonephritis or systemic infection must be fully investigated.

Men & children with recurrent simple infection must be fully investigated.

 Covert

Bacteruria:

The presence of >100,000 organism/ml in MSU of apparently healthy asymptomatic patient

Sterile

pyuria:

The presence of pus cells in the urine without growth at culture media

 Advice

UTI :Treatment
:

Drink plenty Urinate often Double voiding Wipe front to back after micturation

Antibiotics:

Result of urine culture & sensitivity should be available before treatment. The urinary concentration of antibiotic is much more important than serum concentration in the treatment of UTIs

Management of UTI
Antibiotic therapy: The goal of treatment is to eradicate the infection by selecting the appropriate antibiotic.
5. 6.

7.

The general principle for selecting the appropriate antibiotic include consideration of infecting pathogens. patient, (allergic, underlying diseases, age, previous antibiotic therapy, other medication currently taken, out patient or inpatient and pregnancy). site of infection ( kidney vs. bladder vs. prostate)

Trimethoprine-sulfamethoxazole: Interfere with bacterial metabolism of folate. Highly effective. Inexpensive. Side Effects: 7. Hypersensitivity reactions. 8. Rash 9. GI upset. 10. Leucopenia and thrombocytopenia. 11. not used in patient with AIDS, G6PD deficiency, and in pregnancy.

Fluroquinolones: Broad spectrum antibiotic. Interfere with bacterial DNA gyrase and prevent bacterial replication. Nitrofurantoin Highly effective in UTI and inexpensive. Side Effects. GI upset. Peripheral polyneuropathy. Hepatotoxicity.

Aminoglycoside. Used in complicated UTI specially when combined with ampicillin.

Inhibit bacterial RNA and DNA synthesis. Side effect:

Nephrotoxicity and ototoxicity Cephalosporins. Aminopenicilline

 Until

the organism is known:

Cystitis: Trimethoprim 200mg/12h (3d) Acute pyelonephritis: cephalosporine, eg.

Cefuroxime 1.5g/8h iv or 250mg/12h PO

Prostatits: Ciprofloxacine 500mg/12h PO for 4wks

Kidney infection.1

Types
Acute

pyelonephritis pyelonephritis

Chronic

Pyonephrosis Renal

abcess

Acute pyelonephritis

More common in females More in the right Frequently bilateral Clinically diagnosed

Can be symptomatic or asym. Sym. In neonates are non specific In children & adults (more specific):Fever, chills and rigor, costovertebral angel pain. Often accompanied by LUTS. Sepsis may occur in 20-30% E-coli in 80% of the cases

Treatment : The treatment should be prompt, appropriate, and prolonged A full investigation to exclude urinary tract abnormality While awaiting the bacteriological report, amoxicilline or gentamicine parenterally If the urine is acid alkalinisation of the urine by potasium citrate may help by inhibiting the growth When the pain is sever, analgesic drugs The patient should encourged to drink copiously ,if this not possible because of nausea and vomiting , an IV line

Chronic pyelonephritis

So often associated with VUR that named reflux nephropathy. It is an important cause of renal damage & death from EDRF. May be symptomatically silent Lead to progressive renal scaring Symptoms & signs: Lumbar pain, dull non-specific in ccc, Increase urinary frequency & dysuria Hypertension 40% Constitutional symptoms 30% DMSA(dimercaptosuccinc acid) scan is the best imaging study to diagnose renal scarring

Emphysematous Pyelonephritis
Necrotizing infection, characterized by the presence of gas in the renal .parenchyma, or perinephric tissues

.Most Pts are Diabetic pts .Mostly caused by E-coli

xanthogranulomatous Pyelonephritis
Caused by Ecoli &proteus Preseent with a mass & infec. Resulting in obstruction Dx is pathological, using CT it mimic RCC

Pyonephrosis

The kidney is converted into multilocular sac contaning pus or purulent urine Can result from infection of a hydronephrosis, follow acute pyelonephritis, arise as complication of renal calculus disease Usually unilateral
symptoms:

anemia, fever, and a swelling in the loin Symptoms of cystits may be prominent

Diagnosis :

The plain radiograph may show calculus & an ultrasonogram may show dilatation of the renal pelvis and calyces. The IVU will show poor function and the features of hydronephrosis on the affected side Treatment: It is a surgical emergency Parenteral antibiotics should be given immediately and the kidney drained The stone should be removed

Pyonephrosis

CT scan with images through the kidneys showing dilation of the collecting system, increased renal pelvic wall thickness, and the presence of renal pelvic debris.

:Renal abscesses
In the past Hematogenous spread( mostly* in diabetic, intravenous drug abuser and .(Pts on Hemodialysis .-coli and proteusNowadays mostly E* Fever, chills, flank pain, dysuria which* persist for more than 2 weeks &Flank .mass

Diagnosis:

The white cell count is always markedly raised but there are characteristically no pus cells or orgnaism in the urine The psoas shadow is obscured on the plain abdominal radiograph. There may be reactionary scoliosis and elevation and immobility of the diaphragm on the affected side. U.S & CT are dignostic Treatment Collections of pus in or around the kidney should be drained surgically if they cant be aspirated by percutaneous needling

Bladder infection.2

F>M LUTS Ttt:fluid replacement,AB A simple cystitis can cause pyelon. Depending on virulance of microorg. &host defense mechanism

:Recurrent cystitis Either Bacterial persistence or reinfection with another .organism Identification of the cause of recurrent infection is important because management of bacterial persistence and .reinfection are distinct if bacterial persistence is the cause of recurrent UTI, the .removal of the infected source is often curative preventive Therapy is effective in treating reinfection

:Prostate infection.3

:Acute bacterial infection

Ascending urethral infection, or reflux of infected .urine from the bladder to the prostate ducts .Common in men younger than 50 year .Uncommon in prepubertal boys .E-coli most common

O/E .Tender, enlarged gland, well defined and warm .Urethral catheterization should be avoided :Management .Empiric therapy directed to Gram negative Bacteria, till the culture ready .Long duration Tx for 4 6 weeks to have complete sterilization of urine :Indication for hospitalization*** .Pts with sepsis, Immunocompromised or urinary retention

:Chronic Bacterial Prostatitis

Recurrent Dysuria, urgency, frequency,* Nocturia, low back pain/Perineal pain.milder than acute Recurring UTI caused by the the same* .organism is the whole mark of ch. Pros P/E :at first there is a boggy mass then a small* hardness due to fibrosis :Management* .Long course of antibiotic

Prostate abscess
.Mostly followed acute prostatitis :Management Antibiotic, incision and drainage through either through transrectal (directed with TRUS) or transurethral

:Non bacterial prostatitis

M.C Unknown cause(-ve culture & -ve pus (cells Ttt: a-blocker, analgesia ,reassurance

:Urethritis.

pts present with urethral discharge Ttt should include both husband & his wife organism Ttt of choice Trichomonas metronidazole monilia Mycoplasma chlamydia nystatin Tetracycline doxycycline