URINARY TRACT INFECTIONS By Dr Dave Maharajh MD

Bacteria Preparing to Attack

URINARY TRACT INFECTIONS MISURY

MISURY

PREGNANCY

CLASSIFICATIONS • UPPER URINARY TRACT • Complicated and Uncomplicated • LOWER URINARY TRACT • Complicated and Uncomplicated • COMBINED UPPER AND LOWER TRACTS • Complicated and Uncomplicated

Epidiemiology • Adults: F>M 18 -60 yrs (11%/yr) • Children: F>M 5 -Puberty • Approx. 50 -60% of Adult Women report a • • urinary tract infection during lifetime Adult Female: 3 UTI/yr. > refer and inv. Adult Male: 1 infection. Refer and inv. Children: M(1) and F(>3 refer and inv. ) Children: F>M except neonates < 5 yrs refer

WHEN LENGTH MATTERS

MECHANISMS OF ACTION • • • Direct Contamination: invasive procedures Migration Hematogenous ( TB and Staph. ) Ascending Infection Foreign Bodies ( Catheters and others) Coexisting Conditions Fistulas, Crohn’s/UC, Diverticular disease IBS, DM, Neurogenic bladder, Calculi. Immunosuppression, Nonsecretors of blood group substances (Toll-like receptors (TLR-1 and TLR-4> Chemokines CXCL 8

URINARY TRACT INFECTIONS CLINICAL VARIATIONS Asymptomatic Bacteruria Trivial Voiding Irritation Septic Shock

Clinical Symptoms • Upper Tract: • Flank Pain, Fever, Chills, nausea/vomitting • Lower Tract: • Frequency, Urgency, Dysuria, Hematuria, Odour, Cloudy urine, Suprapubic pain, Sense of incomplete emptying. • Constitutional symptoms: Malaiase, lack of energy and appetitite, confusion.

DIFFERENTIAL DIAGNOSIS • Vulvovaginitis ( Yeast, Trichomonas etc) • Urethritis ( Chlamydia, GC) • STD’s • Sterile Pyuria • Postmenopausal atrophic vaginitis

LABORATORY INVESTIGATIONS • Urinalysis: • Urine dipstick • MSU • Urine Culture and Sensitivity • Catheterized urine • Suprapubic aspirate • Nephrostomy tube collection

DIAGNOSTICS • Urine dipstick: RBC/ WBC and Nitrites • Usually detects >10/`5 colony/ml • Beware of sterile pyuria, age of sticks • Evaluate with clinical scenario • Must do MSU or centrifuged urine • Treat and await culture/sensitivity • Repeat MSU not dipstick after Rx.

DIAGNOSTICS • MSU: • Colony count > 10`5 or 10`8 • Culture and Sensitivity to follow • Contamination (Multiple bact. Identified) • Fungi and Chlamydia need different media, suspect if neg. culture and symptomatic

Diagnostics • Radiological Investigations: • Ultrasound ( Kidney and Bladder) • CT Scan ( Abd/Pelvis) • VCUG • MRI • Non Radiological: • Cystoscopy • Urodynamics and Uroflow

ORGANISMS COMMONLY FOUND • E. Coli >70% • Klebsiella Pneumoniae • Proteus Mirabilis • Enterococcus Fecalis • Staphylococcus Saprophyticus • Enterobactae

URINARY TRACT INFECTIONS Non Antimicrobial Therapies • Personal Hygiene • Avoid Bubble Baths and Hot Tubs • Beware of Spermicide Use • Cranberry Juice • Increased daily Fluid Intakes • Development of a Vaccine

Strategies to Prevent UTI • Simple measures • Increase Fluid intake • Void before and after • • • intercourse Personal Hygiene (wipe front to back) Avoid feminine hygiene sprays Take showers instead of baths Cranberries / Juice Assess voiding pattern • Cranberries

TREATMENT Uncomplicated UTI • Young Woman first • episode Single dose • TMP-SMZ • 320/1600 mg, 2 • • Young Male first • episode • • Treat , investigate and • refer • double strength tabs Amoxicillin 3 gm Cephaloridine 2 gm Gentamycin 5 mg/kg Doxycycline 300 mg Quinolones

TREATMENT Uncomplicated UTI • Young woman first • • episode Short course 3 -5 days 10 -14 days Treat according to sensitivity Repeat urine culture after treatment • TMP-SMZ • Nitrofurantoin/ • • Macrobid Ciprofloxacin Noroxin Amoxil Quinolones

TREATMENT COMPLICATED UTI • Specific Pharmacotherapy • Investigate with Radiology • Refer to appropriate specialty • Consider low dose prophylaxis while awaiting referral and diagnostics • Admit patient if not responding to treatment and refer

Common Scenarios • Young female with recurrent UTI and relapses after treatments >3 • Simple measures as discussed • Do U/S kidney and bladder with PVR • May need VCUG • Refer to Specialty • Consider low dose prophylaxis

COMMON SCENARIOS • Young Females (Pediatric age group) • Avoid excessive baths • Treat and eliminate constipation • Encourage frequent voids • Proper Potty Training • Proper Genital Hygeine • Recurrent UTI (Investigate and refer) • U/S, VCUG

Common Scenarios • Postmenopausal woman with recurrent UTI. • Simple measures as discussed • Treat constipation and avoid baths • Use Premarin/ estrogen cream locally • Consider low dose prophylaxis • Do U/S kidney and Bladder with PVR • Refer to Specialty

Common Scenarios • Chronic indwelling catheters • No need for Rx. Unless symptomatic • Change catheter every 4 -6 weeks • Use of Silastic catheters less infection • Local hygiene to the catheter and Urethral • meatus helpful Irrigation of the Catheter helpful in certain situations. ( Mucus production and sediments)

Common Scenarios • Pregnancy • Treat all Asymptomatic Bacteruria with the appropriate antibiotic for trimester of Pregnancy • Always do and U/S Kidney and bladder with PVR • Refer to specialty if needed

Common Scenarios • Young and Old Males • Treat with appropriate antibiotics • Always do diagnostic Imaging (U/S or CT) • Examine Genitalia and Prostate • Refer to Specialty

Common Scenarios • Patients with Neurogenic Bladders • Do appropriate Imaging • Personal Hygiene • Techniques of Clean Intermittent Catherizations) • Treat with culture sensitive antibiotics • Refer to Specialty as needed • Beware Autonomic dysreflexia

References • Update in Adult Urinary Tract Infection • Lindsay Nicolle Curr. Infect. Dis. Rep • (2011) 13: 552 -560 • Dept. Of Internal Medicine and Medical • • Microbiology. U. Of Manitoba An Update on Uncomplictaed UTI in Women Current Opinion in Urology 2009 19: 368 -374 Florian. M. Wagenlehner

Urinary Tract Infections • QUESTIONS

• Structural and functional abnormalities of the • genitourinary tract associated with complicated urinary infection Obstruction. Ureteric or urethral strictures. Tumours of the urinary tract. Urolithiasis. Prostatic hypertrophy. Diverticulae. Pelvicalyceal obstruction. Renal cysts. Congenital abnormalities. Instrumentation. Indwelling urethral catheter. Intermittent catheterization. Ureteric stent. Nephrostomy tube. Urological procedures. Impaired voiding. Neurogenic bladder. Cystocele. Vesicoureteral reflux. Ileal conduit. Metabolic abnormalities. Nephrocalcinosis. Medullary sponge kidney. Renal failure. Immunocompromised. Renal transplant

• The diagnosis of symptomatic urinary tract infection in patients without indwelling urological devices should be considered only when localizing genitourinary signs or symptoms are present (AII). • For patients with indwelling urological devices, systemic symptoms, such as fever in the absence of localizing genitourinary signs and symptoms, may be consistent with symptomatic urinary tract infection (AII). • A urine specimen should be obtained for culture and susceptibility • testing before institution of antimicrobial therapy for every episode of complicated urinary tract infection (AI). – A single urine specimen with a quantitative count of at least 108 cfu/L (at least 105 cfu/m. L) is consistent with urinary infection in symptomatic subjects (AII). – A quantitative count of at least 108 cfu/L (at least 105 cfu/m. L) on two consecutive specimens is the appropriate diagnostic criteria to identify asymptomatic bacteriuria in women (BII). – Any quantitative count of organisms is consistent with bacteriuria for individuals with urine specimens obtained by bladder catheterization (AII).