Common and painful human illness
Rapidly responsive to modern antibiotics..
NFT in 1950 was 1st effective drug
Most common presentation is acute cystitis (infection of the bladder)
Asymptomatic Bacteuria(ABU)-Occurs in the absence of symptoms attributable to the bacteria in the urinary tract
Cystitis - Symptomatic infection of bladder
Pyelonephritis-symptomatic infection of kidneys
Uncomplicated UTI- Acute cystitis or pyelonephritis in nonpregnant women without anatomic defect or instrumentation of urinary tract
Complicated UTI encompasses all other forms of UTI
• As many as 50–80% of women in the general population acquire at least 1 UTI during their lifetime.
Approximately 7% of patients require hospitalization.
20–30% of pregnant women with asymptomatic bacteriuria subsequently develop pyelonephritis.
Between 1 year and ~50 years of age, UTI and recurrent UTI are predominantly diseases of females.
During the neonatal period, the incidence of UTI is slightly higher among males than among females.
Male infants more commonly have congenital urinary tract anomalies.
After 50 years of age, the incidence of UTI is almost as high among men as among women. The reason being obstruction from prostatic hypertrophy becomes common.
Recent use of diaphragm with spermicide
Frequent sexual intercourse
Diabetes mellitus(compromised immune status)
Urinary obstruction( Prostatic hypertrophy ,stone disease)
Urinary incontinence(can lead to hygiene issues)
Gram negative organisms
E coli mc (75-90%)
Staph saphrophyticus (5-15%)
In majority of UTI bacteria ascend from urethra to bladder and kidneys
Interplay of host, pathogen and environmental factors leads to symptomatic disease
Presence of stone or catheter(presence of foreign body) provides an inert surface for colonization
Hematogenous spread in only 2% cases; the most common seen in candiduria
ABU- No symptoms; incidental bacteriuria on routine screening
• Cystitis- frequency, urgency and dysuria, nocturia , hesitancy, suprapubic discomfort. Sometimes it may present as gross hematuria may be seen
• Pyelonephritis- High grade fever, nausea, vomiting, low back or loin pain
• Picket fence pattern of fever which resolves over 72 hrs of therapy
• It may lead to intraparenchymal abscess formation (if there is immunocomprsied patient, delay in diagnosis and treatment or wrong antibiotics).
It should be suspected in patient continued to be febrile despite of antibiotic therapy
Papillary necrosis- Analgesic nephropathy
Sickle cell disease
Diabetes and pyelonephritis
• Emphysematous pyelonephritis:Severe infection associated with production of gas in renal and perinephric tissues;commonly seen in diabetics
Occurs due to chronic obstruction most commonly by staghorn calculi together with chronic infection
Leads to suppurative destruction of kidneys
Residual renal tissue is replaced by yellowish discolouration with lipid laden macrophages
Ø Infectious or noninfectious
Ø Acute or chronic prostatitis
Ø Acute prostatis presents as fever with chills, dysuria,frequency and pelvic or perineal pain
Ø Chronic prostatis presents as recurrent episodes of cystitis without classic manifestations of UTI; there can be dull pain in perineum or painful ejaulation
History: use of diaphragm, recent sexual act(honeymoon cystitis)
Presence of any one symptom of UTI gives the probability of cystitis to be 50%
Along with complicating factors it rises to 90%
Detailed evaluation of risk factors discussed earlier
Urine dipstick test
Nitrite test- Positive test shown by members of enterobacteriaceae family
Leucocyte esterase test detects enzyme which converts nitrate to nitrite
Either of test positive test can be used to make diagnosis
Both test negative indicates consideration of other diseases
Negative test is not sufficient to rule out bacteriuria in pregnant women
Urine analysis and urine culture:
Reveals pyuria in almost all cases and hematuria in 30% cases
Automated tests are not more reliable than patient clinical presentation
Urine culture is gold standard
Colony count of 10o/ml in women and 1000/ml in men is considered to be sensitive and specific
USG abdomen and pelvis and CT scans are used in evaluation of complicated pyelonephritis
Urological evaluation in cases of males with recurrent episodes of cystitis
Each patient warrants a different approach to treatment based on particular clinical syndrome
Other factors are:
1. site of infection
2. presence or absence of complications
Antimicrobials are warranted for every symptomatic case
TMP-SMX and NFT are first line agents recommended
Fluoroquinolone and beta lactam agents are second line agents
NFT does not reach significant levels in tissue and cannot be used to treat pyelonephritis( we see this drug commonly used in upper tract infection and patient subsequently going into fulminant infection)
Moxifloxacin cannot be used as it does not reach adequate urinary levels
NFT 100 mg bid 5-7 days
Tmp-smx 1 DS bid for 3 days
Fluoroqinolone 3 days regimen
Fluoroquinoles are first line therapy as much resistance is noted with septran
Other options are aminoglycosides with or without ampicillin, an extended spectrum cephalosporin, or a carbapenam
Combinations of beta lactam with beta lactamase inhibitor is used in patients with complicated histories previous episodes and recent instrumentations
UTI in pregnancy:
In cases of pyelonephritis parenteral beta lactams with or without aminoglycosides.
UTI in men:
7 to 14 day course of septran or fluoroquinolone in uncomplicated cases
2-4 weeks antimicrobials in acute prostatitis based on cultures
4-6 weeks for chronic bacterial prostatitis-Pruliflox 600 mg once a day for 1 month has been our drug of choice. Prostate massage or frequent ejaculation can be helpful in chronic prostatitis to flush out the bacteria.
Treatment must be based on cultures
Need for urological interventions
Xanthogranulomatous pyelonephritis is treated by nephrectomy
Percutaneous drainage and elective nephrectomy in emphysematous pyelonephritis(the risk stratification is necessary and the final decision the surgeon has to take whether to treat medically with pigtail drainage with higher antibiotics or elective nephrectomy)
Surgical drainage in cases of abscesses
Does not require treatment
Treatment is to be done in pregnant women and patients undergoing urological procedures
Treatment is guided by cultures
Catheter Associated UTI
Change of catheter
Urine and blood cultures
Antibiotics for 7-14 days
• Candida albicans and non albicans
Clinically varies from asymptomatic to pyelonephritis and to even sepsis
Treatment is recommended only for patients with symptomatic cystitis or pyelonephritis and those who are at risk for disseminated disease
Fluconazole 200-400mg/day for 14 days is first line.Amphotericin B and Caspofungin
Renal abscesses >5 cm managed with percutaneous drainage with antimicrobial therapy
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For abscesses that are not amenable to percutaneous drainage, surgical drainage and/or rescue nephrectomy may be required in severe cases for which medical treatment has failed.
Nephrectomy may also be warranted in a small, chronically pyelonephritic and poorly functioning kidney destroyed by previous episodes of infection.
Drainage catheters should remain in place until drainage is minimal (usually up to seven days). Follow-up imaging should be performed.