Urinary Tract Infection Dr.Abdulmalik Tayib Consultant & Assistant Professor. Department of Urology.

Urinary Tract InfectionUrinary Tract Infection

Dr.Abdulmalik TayibDr.Abdulmalik TayibConsultant & Assistant Professor.Consultant & Assistant Professor.

Department of UrologyDepartment of Urology

Non specific Urinary Tract InfectionNon specific Urinary Tract Infection

Common Organisms:Common Organisms:

-Aerobic gram negative rods : -Aerobic gram negative rods : E.Coli(most common), E.Coli(most common),

klebsiella sp,Proteus sp(mirabilis),Pseudomonasklebsiella sp,Proteus sp(mirabilis),Pseudomonas

aerugenosa.aerugenosa.

-Gram-positive cocci:enterococci,Staphylococcus-Gram-positive cocci:enterococci,Staphylococcus

aureus.aureus.

-Other pathogens:-Other pathogens:

Clamydiae(chlamydia trachomatis).Clamydiae(chlamydia trachomatis).

Myocoplasmas(Ureaplasma urealyticum).Myocoplasmas(Ureaplasma urealyticum).

DiagnosisDiagnosis

Urine collection:Urine collection: In menIn men: :

voided urine is generally adequate for voided urine is generally adequate for diagnostic purposes,no cleaning required in diagnostic purposes,no cleaning required in circumcised men:circumcised men:

11stst 10 mls represent urethral specimen. 10 mls represent urethral specimen. Midstream represents bladder specimen.Midstream represents bladder specimen. In femaleIn female:: Contamination is more common.Contamination is more common. Careful spread of labia, wash the introitus and Careful spread of labia, wash the introitus and

periurethral area before collecting a mid stream periurethral area before collecting a mid stream urine.urine.

Some time may require mid catheterized specimen. Some time may require mid catheterized specimen.

DIAGNOSISDIAGNOSIS

In infants or patientsIn infants or patients with spinal cord injury catheter with spinal cord injury catheter specimen is advisable.specimen is advisable.Urinalysis:Urinalysis:

Cloudy urine commonly used to represent pyuria or Cloudy urine commonly used to represent pyuria or large amount of amorphous phosphate.large amount of amorphous phosphate.

The odor rarely clinically significant.The odor rarely clinically significant. Bacteria and leukocyte:Bacteria and leukocyte: Nitrite: when +ve it suggests the presence of more Nitrite: when +ve it suggests the presence of more

than 100,000 organisms/ml,40-60% accurate.than 100,000 organisms/ml,40-60% accurate. False +ve test may occur in patients taking vit C.False +ve test may occur in patients taking vit C. Leukocyte estrase:It is good indicator of pyuria. Leukocyte estrase:It is good indicator of pyuria.

DiagnosisDiagnosisUrinalysisUrinalysis

Microscopic examination:Microscopic examination:

WBC >5-8/hpf. RBCs.WBC >5-8/hpf. RBCs.

Urine culture:Urine culture:

70% of patients with UTI will have 100 000 CFU 70% of patients with UTI will have 100 000 CFU (colony forming unit) /ml.(colony forming unit) /ml.

30% 100 - 10 000 CFU/ml.30% 100 - 10 000 CFU/ml.

ClassificationClassification

Natural History:Natural History: 11stst Infection. Infection. Recurrent Infection.Recurrent Infection. -Unresolved bacteruria.-Unresolved bacteruria. -Bacterial persistance.-Bacterial persistance. -Reinfection(most common cause).-Reinfection(most common cause).

Clinical and pathological presentation: Clinical and pathological presentation: Specific: caused by specific organisms,each of Specific: caused by specific organisms,each of which causes a clinically unique diseasewhich causes a clinically unique disease that lead to specific pathological tissuethat lead to specific pathological tissue reaction. reaction.

ClassificationClassification

Non Specific:Non Specific:

Organisms causing common clinical and tissueOrganisms causing common clinical and tissue

reactions.reactions.

Modes of Bacterial EntryModes of Bacterial Entry

4 modes of bacterial entry:4 modes of bacterial entry: 1-Ascending infection from the urethra:1-Ascending infection from the urethra: more in women: short urethra.more in women: short urethra. Rectal bacterial colonization in the Rectal bacterial colonization in the perineum and vaginal vestibule.perineum and vaginal vestibule. 2-Hematogenous spread: T.B.2-Hematogenous spread: T.B. staphylococci causing pri renal, renal abscesses.staphylococci causing pri renal, renal abscesses. Less common in adult.Less common in adult. 3-Lymphatogenous:3-Lymphatogenous: Little evidence lymphatic route play role in UTI. Little evidence lymphatic route play role in UTI. 4-Direct extension from neighboring organs: V.V.F4-Direct extension from neighboring organs: V.V.F Vesico-intestinal fistula, inflammatory bowelVesico-intestinal fistula, inflammatory bowel or pelvic diseases. or pelvic diseases.

Acute pyelonephritisAcute pyelonephritis

Definition: bacterial infection causing inflammation of the Definition: bacterial infection causing inflammation of the parenchyma and pelvis of the kidney.parenchyma and pelvis of the kidney.

E.coli (80%),Klebsiella,Proteus,Pseudomonas,Serratia…E.coli (80%),Klebsiella,Proteus,Pseudomonas,Serratia…

Mode of infection:Mode of infection:

Ascending from lower urinary tract as in VUR,urinary Ascending from lower urinary tract as in VUR,urinary obstruction.obstruction.

Hematogenous:staphylococi.Hematogenous:staphylococi.

Clinical features:Clinical features:

Fever(high),chills. Flank pain.Fever(high),chills. Flank pain.

Lower urinary tract symptoms. Nausea, vomiting. Lower urinary tract symptoms. Nausea, vomiting.

Physical Exam; Tachycardia, tender flank, paralytic ilius.Physical Exam; Tachycardia, tender flank, paralytic ilius.

DiagnosisDiagnosis

CBC:Leucocytosis.CBC:Leucocytosis.

Urinalysis: numerous Urinalysis: numerous WBCs,RBCs,Leucocyte WBCs,RBCs,Leucocyte casts, bacteria.casts, bacteria. Urine culture: always Urine culture: always positive.positive. Blood culture:Blood culture: Imaging Techniques:Imaging Techniques:

IVP.IVP. U.S:rule out obstruction.U.S:rule out obstruction. C.T : to diagnose intrarenal , C.T : to diagnose intrarenal ,

perirenal abscess formation.perirenal abscess formation.

U.Cyst.U.Cyst.

ManagementManagement

In toxic patient:In toxic patient:

Hospitalization. Bed rest.Hospitalization. Bed rest.

I.V fluids.I.V fluids.

Parentral antibiotics(Ampicillin,Aminoglycosides),Parentral antibiotics(Ampicillin,Aminoglycosides),

to cover both enterococci and pseudomonas spp.to cover both enterococci and pseudomonas spp.

In resistant cases Trimethoprim-SulfamethoxazoleIn resistant cases Trimethoprim-Sulfamethoxazole

combined with aminoglycoside or fluoroquinolonescombined with aminoglycoside or fluoroquinolones

or parentral third generation cephalosporins,for 10-or parentral third generation cephalosporins,for 10-15days.15days.

As out patient flouroquinolone or TMP-SMX.As out patient flouroquinolone or TMP-SMX.

ManagementManagement

Renal abscess requiring Renal abscess requiring drainage.drainage.

Complications: Septicemia.Complications: Septicemia.

Schock.Schock.

Emphysematous PyelonephritisEmphysematous Pyelonephritis

Definition:Definition: -Necrotizing renal infection characterized by gas within -Necrotizing renal infection characterized by gas within

the renal parenchyma or perinephric tissue.the renal parenchyma or perinephric tissue. -80-90% D.M.-80-90% D.M. -Urinary tract infection from stone or papillary necrosis in -Urinary tract infection from stone or papillary necrosis in

all cases.all cases. -Mortality 43%-Mortality 43% - E.coli most common.- E.coli most common. -Klebsiella and proteus less common.-Klebsiella and proteus less common.


Symptoms:Symptoms: Flank pain. Fever. Vomiting.Flank pain. Fever. Vomiting. Failed initial management.Failed initial management. Pneumaturia.Pneumaturia.

Signs: Signs: Tender flank . Sick patient.Tender flank . Sick patient.

Septic.Septic. Laboratory:Laboratory:

Urine and blood culture almost +ve. Urine and blood culture almost +ve. Radiological:Radiological:

Plain X-ray: gas shadow over the affected area. Plain X-ray: gas shadow over the affected area.


-U.S: Obstruction.-U.S: Obstruction.

-IVP of limited value.-IVP of limited value.

-C.T: presence of air inside the collecting system.-C.T: presence of air inside the collecting system.

Management:Management:

Fluids IV Antibiotics. Relieve obstruction.Fluids IV Antibiotics. Relieve obstruction.

Percutaneous drainage.Percutaneous drainage.

Nephrectomy. Nephrectomy.

Chronic PyelonephritisChronic Pyelonephritis

Definition:Definition:

Process of renal scarification and atrophy resulting in Process of renal scarification and atrophy resulting in renal insufficiency.renal insufficiency.

Cause:Cause:

Repeated infections in presence of urinary tract Repeated infections in presence of urinary tract

abnormalities either structural or functional:abnormalities either structural or functional:

D.M Calculi Analgesic nephropathy.D.M Calculi Analgesic nephropathy.

Obstructive nephropathy.Obstructive nephropathy.

In children VUR.In children VUR.


Symptoms:Symptoms: Acute infection.Acute infection. Asymptomatic.Asymptomatic. Hypertension.Hypertension. Renal failure.Renal failure.

Diagnosis:Diagnosis: Urinalysis:Pyuria,Bacteriuria,Proteinuria.Urinalysis:Pyuria,Bacteriuria,Proteinuria. Positive urine culture in acute attack.Positive urine culture in acute attack. IVU:IVU:

VCUG:VCUG:



Identifying the abnormality and correcting it.Identifying the abnormality and correcting it.

Preventing recurrence of UTIs.Preventing recurrence of UTIs.

Nephrectomy in unilateral atrophy causing hypertension.Nephrectomy in unilateral atrophy causing hypertension.

Renal AbscessRenal Abscess

Collection of purulent material confined to the renal Collection of purulent material confined to the renal parenchyma.parenchyma. Due to hematogenous seeding by Staphylococci or Due to hematogenous seeding by Staphylococci or

Gram-Negative organisms.Gram-Negative organisms. Symptoms: Fever. Chills. Abdominal pain. Vague Symptoms: Fever. Chills. Abdominal pain. Vague symptoms.symptoms.Laboratory:Leukocytosis,positive blood culture.Laboratory:Leukocytosis,positive blood culture.Radiological:U.S , CT.Radiological:U.S , CT.Management:Management:

Drainage.Drainage. Antimicrobial.Antimicrobial.

Perinephric AbscessPerinephric Abscess

Collections of purulent material within the perinephric Collections of purulent material within the perinephric space (between the kidney and Gerota's fascia).space (between the kidney and Gerota's fascia).

Paranephric if extend beyond Gerota‘s fascia.Paranephric if extend beyond Gerota‘s fascia.

Organism:Organism:

E.Coli by ascending infection.E.Coli by ascending infection.

Predisposing Factors:Predisposing Factors:

Urinary stasis. Obstruction,calculi, Urinary stasis. Obstruction,calculi,

Neurogenic bladders. DM. Neurogenic bladders. DM.

Diagnosis: same as Renal abscess.Diagnosis: same as Renal abscess.

Management: same as Renal abscess.Management: same as Renal abscess.

CystitisCystitis

Cystitis:Bladder infection.Cystitis:Bladder infection.Acute cystitis:Acute cystitis:

Common in females(20-40yrs old).Common in females(20-40yrs old). Uncomplicated occur with any anatomical or functional Uncomplicated occur with any anatomical or functional abnormalities.abnormalities. Mode of infection:Mode of infection: Ascending fecal-perineal urethral route.Ascending fecal-perineal urethral route. Causative organism:Causative organism: E.coliE.coli Staphylococcus.Staphylococcus.

CystitisCystitis

Symptoms:Symptoms:

Frequency, urgency, dysuria, occasionally hematuria.Frequency, urgency, dysuria, occasionally hematuria.

Diagnosis:Diagnosis:

Urinalysis:bacteruria,hematuria,pyuria.Urinalysis:bacteruria,hematuria,pyuria.

Urine culture:Urine culture:


TMP-SMX. Amoxacillin.TMP-SMX. Amoxacillin.

Cephalosporins. Fluroquinolones.Cephalosporins. Fluroquinolones.

CystitisCystitis

Reccurent infection:Reccurent infection:

Bacterial persistence: surgical removal of the infectiousBacterial persistence: surgical removal of the infectious

source(stones).source(stones).

Bacterial re infection: Fistulae between bladder andBacterial re infection: Fistulae between bladder and

bowel or vagina,pelvic surgey or irradiation.bowel or vagina,pelvic surgey or irradiation.


U.S IVU. Cystoscopy.U.S IVU. Cystoscopy.


ESWL. Correction of other abnormalities.ESWL. Correction of other abnormalities.

Antibiotics.Antibiotics.

ProstatitisProstatitis

Acute Prostatitis:Acute Prostatitis: Ascending infection.Ascending infection. Symptoms:Fever, chills, rectal, low back pain, Dysuria, Symptoms:Fever, chills, rectal, low back pain, Dysuria,

urgency,arthralgia,Malaise.urgency,arthralgia,Malaise. Diagnosis:Diagnosis: DRE extremely tender.DRE extremely tender. Urinalysis:pyuria,microscopic hematuria.Urinalysis:pyuria,microscopic hematuria. Urine culture.Urine culture. Management:Management: Hydration,bed rest, analgesic,antipyretics.Hydration,bed rest, analgesic,antipyretics. Fluouroquinolone,TMP-SMX(4-6 weeks).Fluouroquinolone,TMP-SMX(4-6 weeks).

Chronic ProstatitisChronic Prostatitis

Bacterial:Bacterial:

Same organisms as acute.Same organisms as acute.

Non bacterial:Non bacterial:

Chlamydial.Chlamydial.

EpidydmitisEpidydmitis

Inflamation of the epidydmis.Inflamation of the epidydmis.

Ascending infection.Ascending infection.

C.Trachomatis in men less than 40yrs.C.Trachomatis in men less than 40yrs.

E.coli in older men.E.coli in older men.

in severe epidydmitis may lead to epididymo-orchitis.in severe epidydmitis may lead to epididymo-orchitis.

SymptomsSymptoms::

Severe scrotal pain radiate to inguinal area and may beSevere scrotal pain radiate to inguinal area and may be

to the flank.to the flank.

O/EO/E tender swallowed epidydmis. tender swallowed epidydmis.

EpidydmitisEpidydmitis


CBC: Leukocytosis.CBC: Leukocytosis.

Urine analysis & C.S.Urine analysis & C.S.


Antibiotics. Antibiotics.

Epididymectomy.Epididymectomy.

Specific InfectionsSpecific Infections

Caused by specific organisms,each of which causesCaused by specific organisms,each of which causes

clinically unique disease that lead to specific clinically unique disease that lead to specific pathological tissue reaction such as:pathological tissue reaction such as:

-Tuberculosis.-Tuberculosis.

-Shistosomiasis.-Shistosomiasis.

-Filariasis.-Filariasis.

-Echinococcosis.-Echinococcosis.

TuberculosisTuberculosis

Caused by Mycobacterium tuberculosis.Caused by Mycobacterium tuberculosis.

Hematogenous from the lung.Hematogenous from the lung.

The kidney and the prostate are the 1ry site in G.U.tract.The kidney and the prostate are the 1ry site in G.U.tract.

Kidney infection decent to the ureter and bladder,Kidney infection decent to the ureter and bladder,

Prostate to epidydmis and epidydmis to testis.Prostate to epidydmis and epidydmis to testis.

Age: 20-40.Age: 20-40.

Sex: little common in male than females.Sex: little common in male than females.

Tuberculosis of the kidney may progress slowly(15-Tuberculosis of the kidney may progress slowly(15-20yrs). 20yrs).


Symptoms:Symptoms:

Asymptomatic.Asymptomatic.

Flank pain.Flank pain.

Vague generalized malaise,fatigability.Vague generalized malaise,fatigability.

Low grade persistent fever.night sweets.Low grade persistent fever.night sweets.

Symptoms of cystitis not responding to therapy.Symptoms of cystitis not responding to therapy.

Chronic draining scrotal sinus.Chronic draining scrotal sinus.

Gross or microscopic hematuria.Gross or microscopic hematuria.

Active T.B else were in the body in less than 50%.Active T.B else were in the body in less than 50%.


Signs:Signs:

- Evidence of Extragenital T.B(Lung,LNs,Tonsils,Intestine)- Evidence of Extragenital T.B(Lung,LNs,Tonsils,Intestine)

- Usually there is no enlarged or tenderness of the kidney.- Usually there is no enlarged or tenderness of the kidney.

- Thickened non tender or slightly tender epidydmis.- Thickened non tender or slightly tender epidydmis.

- Vas deferns is beaded and thickened.- Vas deferns is beaded and thickened.

- Chronic draining sinus through the scrotal skin.- Chronic draining sinus through the scrotal skin.

- Hydrocele.- Hydrocele.

- Nodular indurated prostate.- Nodular indurated prostate.

DiagnosisDiagnosis

Laboratory Findings: Laboratory Findings: Persistent Pyuria without organisms on culture.Persistent Pyuria without organisms on culture.

Acid fast stains positive in 60% of the patients.Acid fast stains positive in 60% of the patients.

1st morning urine culture.1st morning urine culture.

Anemia.Anemia.

High sedimentation rate.High sedimentation rate.

X-Ray findings:X-Ray findings:

Chest X-ray.Chest X-ray.

Abdominal X-R-ray:punctate calcification in the area of Abdominal X-R-ray:punctate calcification in the area of the kidney,may be calcification of ureter. the kidney,may be calcification of ureter.

IVPIVP

- Moth-eaten appearance of the involved ulcerated- Moth-eaten appearance of the involved ulcerated

calyces.calyces.

- Obliteration of one or more calyces.- Obliteration of one or more calyces.

- Dilatation of the calyces.- Dilatation of the calyces.

- Abscess cavity connect to the calyces.- Abscess cavity connect to the calyces.

- Single or multiple ureteral stricture.- Single or multiple ureteral stricture.

-Nonfunctioning kidney.-Nonfunctioning kidney.


Urethrocystoscopy:Urethrocystoscopy:

Ulcers, severe contracted bladder.Ulcers, severe contracted bladder.

Cystogram:VUR.Cystogram:VUR.

Medical treatment:Medical treatment:

Isoniazid 200-300mg daily.Isoniazid 200-300mg daily.

Rifampin 600 mg daily.Rifampin 600 mg daily.

Ethambutol 25mg/Kg daily for 2month then 15mg/kg.Ethambutol 25mg/Kg daily for 2month then 15mg/kg.

Streptomycin 1Gm IM daily.Streptomycin 1Gm IM daily.

Pyrazinamide 1.5-2 Gm daily.Pyrazinamide 1.5-2 Gm daily.

Treatment of the complications.Treatment of the complications.

Urinary Tract Infection Dr.Abdulmalik Tayib Consultant & Assistant Professor. Department of Urology.

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