Presentation notes about UTI in female for medical students, undergraduate doctors and other health allied courses. It was prepared by medical doctor at Free Medicine.

1. UTI
URINARY TRACT INFECTION IN FEMALE
Free Medicine

2. OUTLINE
1. Introduction
2. Terminology
3. Epidemiology
4. Classification
5. Risk Factors
6. Etiology
7. Pathophysiology
8. Clinical Presentation
9. Differential Diagnosis
10. Investigation
11. Treatment
12. Complication
13. Prevention
14. Conclusion
15. Reference

3. FEMALE URINARY TRACT SYSTEM
COMPONENTS:
1. Urethra
2. Bladder
3. Ureters
• Right
• Left
4. Kidneys
• Right
• Left

4. 1. INTRODUCTION
• Urinary Tract Infections (UTI) is an infection in any part
of the urinary system (i.e. urethra, bladder, ureter, and
kidney).
• UTI is caused by pathogenic invasion of the urinary tract,
which leads to an inflammatory response of the
urothelium.
• The prevalence and incidence of UTI is higher in women
than in men. 1 out of 5 women has UTI.
• Signs and symptoms may include fever, chills, dysuria,
urinary urgency, frequency, pelvic pain and cloudy or
malodorous urine.
• UTI is treated by antibiotics accordance to severity.

5. 2. TERMINOLOGY
• Significant bacteriuria – presence of more than 500,000
CFU/mL of urine.
• Asymptomatic bacteriuria – bacteriuria without
symptoms.
• Uropathogens – bacteria with specific virulence factors
that facilitates invasion of the urinary tract.
• Urethritis – infection of urethra.
• Cystitis – infection of urinary bladder.
• Pyelonephritis – infection of one or both kidneys.
• Uncomplicated UTI – UTI which involves urinary bladder
without underlying metabolic, structural, neurological, or
immunological disorders.

6. 2. TERMINOLOGY CONT.
• Uncomplicated UTI – UTI which involves urinary bladder
with underlying metabolic, structural, neurological, or
immunological disorders.
• Recurrent UTI – presence of more than 3 UTIs within 12
months, or more than 2 UTIs in 6 months.
• Reinfection UTI – Recurrent UTI caused by different
uropathogens at any time, after 2 weeks of antibiotic
therapy.
• Relapse UTI – Recurrent UTI caused by same
uropathogens within 2 weeks after antibiotic therapy.
• Candiduria – presence of yeast (candida species) in the
urine.

7. 2. TERMINOLOGY CONT.
Primary UTI
Recurrent UTI
(same uropathogen)
Relapse UTI
Recurrent UTI
(different uropathogen)
Reinfection UTI

8. 3. CLASSIFICATION OF UTI
• UTI can be classified based on the site of infection, level
of complexity, duration and clinical presentation.
UTI
Symptoms
Asymptomatic
Symptomatic
Complexity
Uncomplicated
Complicated
Site
Lower
UTI
Upper
UTI
Duration
Acute
Chronic

9. 3. CLASSIFICATION OF UTI CONT.
Based on the site of infection:
1. Lower Tract Infection
a) Urethritis
b) Prostatitis (in men)
c) Cystitis
2. Upper Tract Infection
a) Acute Pyelonephritis (mild, moderate, severe)
b) Chronic Pyelonephritis (mild, moderate, severe)
c) Interstitial Pyelonephritis
d) Renal abscess
e) Urosepsis  SIRS

10. 3. CLASSIFICATION OF UTI CONT.
Urethritis
Cystitis
Pyelonephritis
Pyelonephrosis
Renal abscess
UPPER
UTI
LOWER
UTI

11. 3. CLASSIFICATION OF UTI CONT.
Based on the level of complexity:
1. Uncomplicated UTI
– Non pregnant woman without underlying anatomical,
functional, metabolic, neurological, or immunological
disorders.
2. Complicated UTI
 Structural Abnormalities includes calculi, congenital or
acquired tract abnormalities, tract obstruction, permanent or
indwelling catheter, and pregnancy.
 Metabolic disease includes Diabetes, renal insufficiency.
 Neurological disorder includes spinal injury, quadriplegia.
 Impaired host defences includes HIV infection, current
chemotherapy, active cancer, and concomitant
immunocompromising diseases.

12. 3. CLASSIFICATION OF UTI CONT.
Based on clinic presentation:
1. Asymptomatic Bacteriuria
2. Symptomatic UTI
– Uncomplicated UTI
– Complicated UTI
Based on duration/type of infection:
1. Acute Pyelonephritis (mild, moderate, severe)
– Usually single uropathogen and takes a short period of time.
2. Chronic Pyelonephritis (mild, moderate, severe)
– Usually polymicrobial involving more than one uropathogen
and also it is usually prolonged or recurring infection following
treatment.

13. 3. CLASSIFICATION OF UTI COT.
SEVERITY GRADIENT OF SEVERITY
SX
No
Symptoms
Local
Symptoms
General
Symptoms
SIRS SIRS + MOSF
SITE LOWER UTI UPPER UTI
DX ABU CY-1 PN-2 PN-3 US-4 US-5 US-6
INX
Dipstick
MSU Culture + S, if
required
Dipstick
MSU Culture + S
Renal USS
IV Pyelogram or
Renal CT
Dipstick
MSU Culture + S
Blood Culture
Renal USS
Renal and Abdominal CT, if required
RISK
ORENUC - No RF, Recurrent UTI RF, Extra urogenital RF,
Nephropathic RF, Urological RF, and Catheter RF
RX NO
Empirical
3 – 5d
Empirical + Directed
7 – 14d
Empirical + Directed
7 – 14d
Combine 2 antibiotics

14. 4. EPIDEMIOLOGY
• UTIs are among the most common bacterial disease,
affecting 150 million people worldwide annually,
resulting in more than 6 billion dollar expenditures.
• Approximately 50% of women will experience at least
one UTIs during their lifetime.
• Despite antibiotic therapy, 20 – 30% of women with an
initial UTI will experience recurrent UTIs within 3 – 4
months of the initial treatment.
• In 2019, more than 404.6 million incident cases of UTI
occurred worldwide, and more than 230,000 people died
of UTI.
• Prevalence of UTI increases with age

15. 5. RISK FACTORS
Risk Factors in young and premenopausal women:
1. Sexual intercourse
2. Spermicide, spermicide-coated condoms and caps
3. A new sexual partner
4. Previous history of UTI
5. Poor hygiene
6. Pregnancy
7. Urinary tract obstruction e.g. calculi
8. Small volume of urine
9. Frequent antibiotic use
10. Familial tendency

16. 5. RISK FACTORS CONT.
Risk Factors in menopausal women:
1. Previous history of UTI
2. Urinary incontinence
3. Atrophic Vaginitis due to estrogen deficiency
4. Cystocoele
5. Increased post-void urine volume
6. Urine catheterization
7. Functional deterioration
– Voiding dysfunction
– Vesicoureteral reflux

17. TYPE CATEGORY OF RISK FACTOR EAMPLES OF RISK FACTORS
O NO known/associated RF Health premenopausal women
R
Recurrent UTI RF,
but no risk of severe outcome
Sexual behaviour
Contraceptive devices
Secretory type of certain blood groups
Controlled diabetes mellitus
E
Extra-urogenital RF,
with risk of more severe outcome
Pregnancy
Male gender
Badly controlled diabetes mellitus
Relevant immunosuppression
Connective tissue diseases
Prematurity, new born
N
Nephropathic disease,
with risk of more severe outcome
Relevant renal insufficiency
Polycystic nephropathy
U
Urological RF,
with risk of more severe outcome,
which can be resolved during therapy
Ureteral obstruction (i.e. stone, stricture)
Transient short-term urinary tract catheter
Asymptomatic bacteriuria
Controlled neurogenic bladder dysfunction
Urological surgery
C
Permanent urinary Catheter and
non-resolvable urological RF,
with risk of more severe outcome
Long-term urinary catheter
Non-resolvable urinary obstruction
Badly controlled neurogenic bladder

18. 5. RISK FACTORS CONT.
Factors that make women more prone to UTI than men:
BECAUSE OF FEMALE ANATOMY.
1. Short urethra (2 – 3 cm)
2. More sensitive skin around urethral meatus
3. Proximity of urethral meatus and rectum
4. Warmness from perineum
5. Sexual penetration
6. Use of spermicide
7. Menstrual health
8. Menopause
9. Pregnancy

19. 6. ETIOLOGY
• Causative agents of UTI are:
1. Escherichia coli (75 – 95%)
2. Klebsiella pneumoniae
3. Proteus mirabilis
4. Staphylococcus saprophyticus
 In sexually active women
5. Streptococcus faecalis
6. Pseudomonas aeuruginosa
 Hospital acquired infections and catheter associated UTI
• Other causative agents apart from bacteria:
1. Viruses – HIV, Rubella, Mumps
2. Fungi – Candida, Hisptoplasma capsulatum
3. Protozoa – T. Vaginalis, S. haematobium

20. 6. ETIOLOGY CONT.
75%
6%
6%
5%
3%
2%
1%
1% 1%
Uncomplicated UTI
E. coli
K. Pneumoniae
S. Saprophyticus
Enterococcus spp.
GBS
P. Mirabilis
P. Auroginosa
S. Aureus
Candida spp.

21. 6. ETIOLOGY CONT.
65%
8%
0%
11%
2%
2%
2% 3%
7%
Complicated UTI
E. coli
K. Pneumoniae
S. Saprophyticus
Enterococcus spp.
GBS
P. Mirabilis
P. Auroginosa
S. Aureus
Candida spp.

22. 7. PATHOPHYSIOLOGY
• The urinary tract is normally sterile.
• In general, there are 4 main mechanism responsible for
UTIs:
1. Ascending spread
2. Haematogenous spread
3. Lymphatic spread
4. Periurogenital spread (direct expansion)
• Ascending spread is the most common mechanism.
• Uropathogenic bacteria, derived from a subset of fecal
flora, have tracts of adherence, growth, and resistance
to host defence mechanisms.
• Host defence plays important role.

23. 7. PATHOPHYSIOLOGY CONT.
HEMATOGENOUS ROUTE
It starts with primary infection
which manifest into
bacteraemia, and then spread
to urinary system.
ASCENDING ROUTE
It starts with colonization of
lower urinary tract, which
manifest into penetration and
ascension of pathogens, then
spread to bladder, ureter and
kidneys.

24. 7. PATHOPHYSIOLOGY CONT.
1. ASCENDING SPREAD:
• Uropathogens that have reached periurethral area, ascends
toward the bladder, in female, the ascend is usually short due
to short urethra.
• Fimbria allow bacteria to adhere and penetrate urotheal
mucosal surface.
• Sexual intercourse may promote ascension. Frequent voiding,
voiding before and after sex, and empty bladder lower risk of
ascension.
• Bacteria uses urine as media for replication. Acidic urine (pH <
5), the presence of organic acids, and high urea levels are less
favourable for bacterial replication.
• Premenopausal women have a large concentration of
lactobacilli in the vagina and an acidic PH, preventing
colonization.

25. 7. PATHOPHYSIOLOGY CONT.
1. ASCENDING SPREAD:
• After penetration bacteria replicate and form biofilms.
• Bladder mucosal invasion, result into inflammation and causes
cystitis.
• When defence system of lower urinary tract fails, bacteria
ascend from bladder to kidney through ureter.
• Inside ureter, bacteria produce toxin which inhibit peristalsis
and reduce urine flow.
• In kidney, host defence mechanism is local leucocytes.
• Infection of renal parenchyma causes inflammatory response
called pyelonephritis.
• Inflammation continue causing tubular obstruction and
damage leading to interstitial oedema.
• Interstitial nephritis causes Acute Kidney Injury.

26. • If the inflammatory cascade causes tubular obstruction and damage occur, leading to interstitial oedema.
• This may lead to interstitial nephritis, causing AKI.
Acute kidney Injury
• Infection of the renal parenchyma causes inflammatory response called pyelonephritis.
• While infection of the renal parenchyma is usually the result of bacterial ascension, it can also be
haematogenous spread.
Pyelonephritis
• Once sufficient bacterial colonization occurs, bacteria may ascend on the ureter towards the kidney.
• Fimbria may aid in ascension process. Bacterial toxins may also play a role by inhibiting peristalsis
(reducing the flow of urine)
Ascension
• Fimbria allow bladder epitheal cell attachment and penetration.
• Following penetration, bacteria continue to replicate and form biofilms.
Uroepthelium penetration
• Uropathogen colonizes the periurethral area and ascends though the urethra upwards towards the
bladder.
Colonization
ASCENDING
SPREAD

27. 7. PATHOPHYSIOLOGY CONT.
2. HAEMATOGENOUS SPREAD:
• Haematogenous spread is restricted to few relatively
uncommon microbes such as:
– Staphycoccus aureus
– Candida spp
– Salmonella spp
– Mycobacterium tuberculosis
• These bacteria or fungi usually cause primary infections
elsewhere, and causes bacteraemia or fungaemia.
• During circulation, bacteria in blood can reach renal
parenchyma and causes upper UTI.
• Haematogenous spread is uncommon in healthy
individuals.

28. • If the inflammatory cascade causes tubular obstruction and damage occur, leading
to interstitial oedema.
• This may lead to interstitial nephritis, causing AKI.
AKI
• Infection of the renal parenchyma causes inflammatory response called
pyelonephritis.
• While infection of the renal parenchyma is usually the result of bacterial ascension,
it can also be haematogenous spread.
Pyelonephritis
• In circulatory system, bacteria are carried by blood around the body.
• In immunosuppressed patient, renal parenchyma can be breech by bacteria.
Bacteraemia
• Bacteria invasion other organs and systems such as respiratory system,
gastrointestinal system, or cardiovascular system.
• In immunosuppressed patient, bacterial replication is high and can cause bacteria
to enter the circulatory system
Primary Infection
HAEMATOGENOUS
SPREAD

29. 7. PATHOPHYSIOLOGY CONT.
3. LYMPHATIC SPREAD
• In women, periuterine lymphatic vessels aid spread of
bacteria towards urinary tract.
• In men, rectal and colonic lymphatic vessels aid spread of
bacteria toward urinary tract.
4. DIRECT EXPANSION (PERIUROGENITAL SPREAD)
• Infections and abnormalities of pelvic organs can cause
direct spread of bacteria to urinary tract.
• For examples of diseases:
– Pelvic Inflammatory Diseases (PID)
– Genito-urinary tract fistulas.

30. 7. PATHOPHYSIOLOGY CONT.
URINARY TRACT HOST DEFENSE MECHANISMS:
URINE MUCOSAL IMMUNITY
1. Acidic pH: intolerable by pathogens
2. High urine osmolality
3. Urinary inhibitors of bacterial
adherence
4. Competitive inhibitors of
attachment of uroepithelial cells
5. Mechanical flushing of urine flow
6. Unidirectional flow of urine
1. Urothelial secretion of cytokines
and chemokines
2. Mucopolysaccharide lining:
increases difficulty of bacterial
penetration
3. Mucosal IgA
4. In men: prostatic secretions
contain bactericidal zinc and
urethra is longer

31. 7. PATHOPHYSIOLOGY CONT.
BACTERIAL VIRULENCE FACTORS IN UTI:
1. Bacterial adherence and invasion
– Fimbria, pilli, and adhesive membrane glycoprotein (curli)
2. Bacterial motility and chemotaxis
– Flagella
3. Production of toxin
– Hemolysin, CNF, LPS, and SPATES
4. Immune evasion and biofilm formation
– Capsular polysaccharides, O-antigen, cellulose, and salmochellin
5. Iron acquisition
– Haem receptors, siderophores (aerobactin, entrobactin,
yersiniabactin)
6. Swaming
– Express of specific genes for movements in the surfaces such as
catheter by P. Mirabilis.

32. 7. PATHOPHYSIOLOGY CONT.
BACTERIAL VIRULENCE FACTORS IN UTI

33. 8. CLINICAL PRESENTATION
• Clinical manifestations depend on site of infection,
severity and age of patient.
• Asymptomatic Bacteriuria can only be diagnozed by
laboratory work, not clinically.
SYMPTOMS OF URETHRITIS:
1. Discomfort in voiding or burning sensation
2. Dysuria
3. Urinary Urgency
4. Urinary Frequency
5. Urethral Discharge ()

34. 8. CLINICAL PRESENTATION CONT.
SYMPTOMS OF CYSTITIS:
1. Dysuria  Nycturia
2. Urinary Urgency
3. Urinary Frequency
4. Suprapubic pain or LAP
5. Pelvic pressure
6. Foul smell, turbid urine
SYMPTOMS OF HEMORRHAGIC CYSTITIS:
1. Hematuria
2. Irritating voiding symptoms

35. 8. CLINICAL PRESENTATION CONT.
SYMPTOMS OF PYELONEPHRITIS:
1. High grade fever, chills and malaise
2. Nausea and Vomiting
3. Flank pain or lion tenderness
4. Back pain
5. Costovertebral tenderness
COMPLICATIONS OF PYELONEPHRITIS:
1. Urosepsis
2. Septic Shock
3. SIRS and MOSF

36. 8. CLINICAL PRESENTATION - SITE.
Clinical presentation of UTI depending on Site of Infection:
SITE OF INFECTION CLINICAL PRESENTATION
URETHRITIS
-Dysuria
-Burning sensation
-Discomfort while voiding
-Urinary Frequency
-Urinary Urgency
-Urethral discharge (rarely)
CYSTITIS
-Symptoms of Urethritis PLUS
-Suprapubic pain or LAP
-Back pain
-Pelvic pressure
-Costovertebral angle tenderness
-Hematuria
PYELONEPHRITIS
-Symptoms of Cystitis PLUS
-Flank pain
-Loin tenderness
-Fever, chills and malaise
-Nausea and vomiting

37. 8. CLINICAL PRESENTATION - AGE.
Clinical presentation of UTI depending on Site of Infection:
SITE OF INFECTION CLINICAL PRESENTATION
BABIES AND INFANTS
-Failure to thrive
-Fever
-Apathy
-Diarrhoea
CHILDREN
-Dysuria, urinary frequency and urgency
-Hematuria
-Acute abdominal pain
-Nausea and vomiting
ADULTS
Lower UTI – dysuria, frequency, urgency, suprapubic
pain or LAP, pelvic pressure, costovertebral angle
tenderness
Upper UTI – Flank pain, loin tenderness, high grade
fever, malaise, nausea, vomiting PLUS symptoms of
lower UTI
ELDERS
--Mostly asymptomatic
-Not diagnostic as symptoms are common with age
-Urinary incontinence maybe present in UTI

38. 9. DIFFERENTIAL DIAGNOSIS
Infectious DDX:
1. Acute Pyelonephritis
2. Chlamydial Genitourinary Infections
3. Nonbacterial Cystitis
4. Herpes Simplex
5. Interstitial Cystitis
6. Pelvic Inflammatory Diseases
7. Urethriris
8. Vaginitis
9. Renal and Perirenal Abscess
10. Fungal Infection
11. Papillary Necrosis

39. 9. DIFFERENTIAL DIAGNOSIS CONT.
Non-infectious DDX:
1. Uric Acid and Hypercalcemic Nephropathy
2. Lithium and Heavy Metal Toxicity
3. Sarcoidosis and Other Granulomatous Diseases (e.g. TB)
4. Interstitial Cystitis
5. Polycystic Kidney Disease
6. Genitourinary Malignancy
7. Renal Transplant Rejection
8. Periurethral Disease
9. Bladder Cancer

40. 10. INVESTIGATION
SPECIMEN COLLECTION:
• Suprapubic aspiration (SPA) is the golden standard
method of urine sample collection. It is only used when
indicated because it is invasive and uncomfortable.
• Urine specimen is commonly collected via clean-catch
midstream urine (MSU).
• It is sometimes recommended to clean the perineum
and vulva prior collection, and to split the labia during
collection to avoid contamination.
• Other method of collecting urine specimen is
Transurethral Catheterization (TUC)

41. 10. INVESTIGATION CONT.
The following are investigations:
1. Urinalysis
A. Macroscopic examination of urine
B. Microscopic examination of urine
C. Urine dipstick
2. Urine culture and sensitivity
3. Full blood picture
4. Imaging
A. KUB Ultrasound sound/KUB X-ray
B. Abdominal CT scan
C. MRI
D. IV Pyelography or IV Urography (IVU)
E. Micturation Cystourethrogram (MCUG)

42. 10. INVESTIGATION CONT.
1. Macroscopic Examination of Urine:
 Cloudy, turbid urine
 Possible blood-tinged colour (pink, red, brown)
 Possible green from rare Pseudomonas infections
 Strong offensive smell
 Frothy urine indicate presence of protein
2. Dip Sticks
The presence of the following parameters suggest UTI:
1. Leukocytes – presence of WBCs (pyuria)
2. Nitrites – Suggest E. coli
3. Protein – Not confirmatory
4. Blood – Marker of Inflammation (hematuria)
5. Glucose - Not specific

43. 10. INVESTIGATION CONT.
3. Urine microscopy
 UTI diagnosed when >100,000
CFU/mL were detected by grain
stained microscopy.
 WBCs indicating pyuria, RBCs
indicating hematuria, microorgasms
indicating bacteriuria, leukocyte casts
and other cellular elements.
4. Full Blood Picture
 Leucocytosis – Elevated absolute neutrophils
 Elevated ESR
 Elevated CPR
 Elevated Platelets
 Anaemia in 40% of patient with perinephric abscesses

44. 5. Urine Culture
 Urine culture remains the criterion standard for the diagnosis
of UTI. Two culture techniques (dip slide, agar) are widely
used and accurate.
 INDICATION OF URINE CULTURE AND SENSITIVITY:
1) Immunosuppression
2) Recurrent UTI, Relapse UTI, and Chronic UTI
3) Recent Instrumentation
4) Advanced age
5) Recent exposure to antibiotics
6) Complicated UTI with pyelonephritis
7) Transplant patient
8) Pregnancy
9) Men
10) Hospitalized patient
10. INVESTIGATION CONT.

45. 10. INVESTIGATION CONT.
5. Urine Culture Cont.
 An uncomplicated UTI (cystitis) does not require a urine
culture unless the woman has experienced a failure of empiric
therapy.
 UTI is diagnosed by urine culture depend on colony forming
and method of specimen collection.
METHOD COLONY COUNT (CFU/Ml)
SPA Any
TUC  10,000
MSU
 100,000
10,000 – 50,000 PLUS
high clinical suspicion of UTI (fever, dysuria, pyuria)

46. 10. INVESTIGATION CONT.
6. Imaging
– Imaging in UTI is reserve for complicated UTI
– INDICATION OF IMAGING IN UTI:
1. Clinical suspicion of obstruction, calculi, abdominal mass,
VUR, posterior urethral valves, renal injury, abscess, and
anatomical abnormalities.
2. Recurrent UTI
3. Reduced renal function, renal impairment
4. Concurrent bacteraemia
5. UTI in less than 3 years
6. No or inadequate response to 48hrs of IV antibiotocs
7. Abnormal voiding, anuria
8. Significant electrolyte derangement
9. Pregnancy
10. Pyonephritis, hydronephrosis, renal scarring

47. 10. INVESTIGATION CONT.
The following are imaging used:
1. KUB X-ray
– To detect calculi and gas.
2. Intravenous Pyelogram
– To assess upper urinary tract for anatomical abnormalities and
obstruction.
3. Voiding Cystourethrogram (VCUG)
– It is also called Micturating Cystourethrogram (MCUG)
– To assess urethra and bladder size, shape, and capacity. Also
to detect VUR reflux or posterior urethral valves.
4. KUB Ultrasound
– To detect hydronephrosis, pylonephrosis, abscess, and to
assess post-void residual urine

48. 10. INVESTIGATION CONT.
5. CT Scan (with or without contrast)
– Best for detecting anatomic abnormalities
– It is more effective than MRI
6. MRI
– It is good because of no radiation
– It is recommended pregnant women and baby
7. Nuclear Scans DMSA and MAG3
– DMSA is gold standard for renal scan detection
– To detect and localize abscess and other abnormalities
8. Endoscopy
– Cystourethroscopy – Upper UTI
– Ureterorenoscopy – Lower UTI

49. 10. INVESTIGATION CONT.
A B
C
A. KUB X-Ray showing calculi, B. IV Pyelogram – normal findings,
C – KUB USS showing renal abscess

50. 10. INVESTIGATION CONT.
MCUG or VCUG showing urethral stricture

51. 10. INVESTIGATION CONT.

52. 11. TREATMENT
• Symptomatic UTIs are treated using antibiotic therapy,
while asymptomatic UTIs do not require antibiotic
therapy except in special situations.
• Other treatment can be included to relieve symptoms
and manage complications.
• Goal of therapy:
1. Elimination of infection
2. Relief of acute symptoms
3. Prevention of recurrence
4. Prevention of long term complications

53. 11. TREATMENT
• Treatment of UTI is based on the following:
1. Disease severity
2. Drug sensitivity
3. Drug side effects
4. Culture and sensitivity
5. Chronicity of the disease
6. Economic status of the patient
7. Local resistance patterns
• Many uncomplicated UTI and lower UTI patients are
treated as outpatients.
• Depending on indications, many complicated UTI and
upper UTI patients are treated as inpatients.

54. 11. TREATMENT
• Absolute Indication of Hospitalization:
1. Inability to maintain hydration (persistent vomiting)
2. Progression of an uncomplicated UTI
3. Urosepsis is suspected
4. Urinary tract obstruction
5. Diagnosis uncertainty
• Relative Indication of Hospitalization:
1. Age greater than 60 years
2. Anatomical abnormalities
3. Immunocompromised state
• DM, malignancy, SCD, transplantation
4. General medical frailty

55. 11. TREATMENT
• Ideal Antibiotic for UTI:
1. Adequate coverage over E.coli
2. Concentration in urine
3. Duration of therapy
4. Low resistance
5. Cost
6. Low adverse effect
• There are two ways to select antibiotics:
1. Empiric Antibiotic Selection
Doesn’t require urine culture and sensitivity
2. Specific Antibiotic Selection
Require urine culture and sensitivity

56. 11. EMPIRICAL TREATMENT – UNCOMPLICATED UTI
FIRST LINE
Trimethprim/Sulfamethoxazole 160/800mg PO BID for 3 days
Nitrofurantoin 100mg PO BID for 5 – 7 days
Fosfomycin 3g PO single dose with 100mls of water
SECOND LINE
Ciprofloxacin 500mg PO BID for 5 – 7 days
Levofloxacin 250mg PO OD for 3 days
Ofloxacin 200mg PO BID for 3 days
Trimethoprim/Sulfamethoxazole a.k.a Bactrim, Septrin, Co-trimoxazole

57. 11. EMPIRICAL TREATMENT – UNCOMPLICATED UTI
ALTERNATIVE THERAPHY
Amoxicillin-clavulanate 500mg/125mg PO BID for 5 – 7 days
Cefpodoxine 100mg PO BID for 5 – 7 days
Cefuroxime 250mg PO BID for 5 – 7 days
Cephalexin 250mg PO QID for 5 – 7 days
Cefadroxil 500mg PO BID for 5 – 7 days
Pivmecillinam 400mg TID for 3 – 5 days

58. 11. EMPIRICAL TREATMENT – COMPLICATED UTI
FIRST LINE
Ciprofloxacin 500mg PO BID for 7 - 14 days
Ciprofloxacin extended release 1g PO OD for 7 - 14 days
Levofloxacin 750mg PO OD for 5 days

59. 11. EMPIRICAL TREATMENT – COMPLICATED UTI
PARENTERAL THERAPY
Ciprofloxacin 400 mg IV BID for 7 - 14 days
Levofloxacin 750 mg IV OD for 5 days
Ampicillin 1 – 2g IV QID PLUS
Gentamicin 2mg/Kg IV TID for 7 – 14 days
Piperacillin-tazobactam 3.375 mg IV QID for 10 days
Doripenem 500 mg IV BID for 10 days
Imipenem-cilastatin 500 mg IV QID for 10 days
Meropenem 1g IV TID for 7 – 14 days

60. 11. EMPIRICAL TREATMENT – PREGNANT WOMEN
PREGNANT WOMEN
Nitrofurantoin 100 mg PO BID for 5 – 7 days
Amoxicillin 500 mg PO BID for 5 – 7 days
Amoxicillin-clavulanate 500mg/125mg PO BID for 5 – 7 days
Cephalexin 500 mg PO QID for 5 – 7 days

61. 11. EMPIRICAL TREATMENT PER TZ STG
UNCOMPLICATED UTI
Nitrofurantoin 100mg PO BID for 5 days
Flucloxacillin-amoxicillin 500g PO TID for 5 days
COMPLICATED UTI
Ciprofloxacin 500mg PO BID for 5 – 7 days
Levofloxacin 250mg PO OD for 3 days

62. 11. EMPIRICAL TREATMENT PER TZ STG
PREGNANT WOMEN
Nitrofurantoin 100mg PO BID for 5 days
Amoxicillin-clavulanate 500mg/125mg PO BID for 7 days
CHILDREN
Nitrofurantoin 50mg PO BID for 5 days
Amoxicillin-clavulanate (40mg/Kg of amoxicillin) PO TID for 7 days

63. 11. EMPIRICAL TREATMENT PER TZ STG
PARENTERAL THERAPY FOR ADULTS
Ceftriaxone 1g IV OD for 5 days
Gentamicin 120mg IV OD for 7 days
Ceftriaxone-sulbactam 1g IV OD for 5 days
Piperacillin-tazobactam 4.5 mg IV QID for 10 days
PARENTERAL THERAPY FOR CHILDREN
Ceftriaxone 80mg/Kg IV OD for 5 days
Gentamicin 7.5mg/Kg IV OD for 7 days
Ceftriaxone-sulbactam (80mg/Kg of Ceftriaxone) IV OD for 5 days

64. 11. TREATMENT OF OTHER SYMPTOMS
SYMPTOM TREATMENT
Excess
Vomiting
Antiemetic medication:
Metoclopramide or Promethazine
Fever and Pain
Antipyretic and Analgesic medication:
Paracetamol or Ibuprofen
Dehydration
Intravenous Fluids (IV Ringer’s Lactate)
Oral Rehydration Solution (ORS)
Monitor all vital signs (Temperature, BP, RR, and PR)
Other symptoms are managed when they are severe and
worsening patient conditions.

65. 11. SURGICAL TREATMENT
• Surgical therapy is used when there are anatomical
anomalies or obstruction.
• The folowing are surgical therapy in UTI:
1. Surgical removal of renal or bladder calculi
2. Reimplantation of ureters if VUR present
3. Ureteroplasty
4. Vesicostomy
5. Ureterostomies
6. Cystoplasty
7. Percutanoues drainange
8. Nephrectomy
• Surgical therapy will be selected depending on the
anomalies found on diagnosis and imaging.

66. 11. ASYMPTOMATIC UTI TREATMENT
• INDICATION OF ASYMPTOMATIC UTI TREATMENTS:
1. Babies and Children
2. Pregnancy
3. Urologic Procedure
4. Obstructive nephropathy
• Treatment is usually empirical using appropriate
medication as mentioned previous.
• Some patient may need surgical therapy depending on
their abnormalities.
• Treatment is recommended to other patient at risk of
developing pyelonephritis.

67. 12. COMPLICATION
The following are complications of UTI:
1. Recurrent UTI
2. Permanent kidney damage
3. Urethral narrowing (stricture)
– More common in male with recurrent gonococcal urethritis
4. Urosepsis
– Life threatening complication, require emergency
management.
5. Low Birth Weight and Premature delivery in pregnancy

68. 12. COMPLICATION - UROSEPSIS
• Any of features of cystitis or pyelonephritis plus two or
more of the following:
1. Temperature > 38°C or < 36°C
2. Tachycardia PR > 90 beats per minute
3. Tachypnoea RR > 20/minute
4. WBC count > 12,000/mm3 or < 4000/mm3
5. Confusion
6. Hypotension
7. Other evidence of organ dysfunction as a sequalae of UTI
complications.

69. 13. PREVENTION
1. Empty bladder fully when urinating
2. Urinate after sexual intercourse
3. Wipe from front to back
4. Drink plenty of water daily
5. Drink cranberry juice
6. Avoid frequent use of diaphragms and spermicide
7. Do not delay urinating when the need arises
8. Avoid irritation of the vagina with feminine hygiene products
such a douches or sprays, strong soaps, or scented
pantyliners
9. Use topical estrogen in postmenopausal women
10. Use antibiotics in cases of recurrent infections
– Continuous use, postcoital use, and self-treatment.
11. Use of lactobacillus probiotics

70. 14. CONCLUSION
• UTI is the second most bacterial infection.
• Women are more at risk to get UTI than men.
• Symptoms and signs of UTI are easy to access, however
there is difficulties in treatment because of recurrence
and resistance to antibiotics.
• Patient should be consulted to use antibiotics as
prescribed and follow preventive measures to avoid
recurrence, chronic UTI, and complications.
• Recently there is effort to develop intranasal vaccines
which may reduce the prevalence of UTI.
• Complicated UTI should be treated properly and correct
of the complication or any abnormalities.

71. 15. REFERENCES
1. Williams Gynaecology – Third Edition
2. Uptodate.com – Acute Cystitis in Females
3. Medscape.com – UTI in Females
4. Google Images – UTI images
5. Standard Treatment Guidelines and National Essential
Medicines List for Tanzania Mainland
6. UTI: Etiology and Antimicrobial Resistance with
Reference to Adhesive Organelles – Navir Kumar
Chaudhary, S Mahadeva Murthy

72. Dear Medicine, my love for you burns
stronger than any urinary tract infection.
THANKS FOR LISTENING. ANY QUESTION?