Urinary tract infections full topic

1. •UTIs
Submitted To :
Dr. KANCHAN VOHRA
Assistant Professor
Submitted By :
Mohd. Rafi Bhat
Department of pharmaceutical
science & Drug Research

2. Introduction
A urinary tract infection (UTI) is an infection in any part of your
urinary system.
Urinary tract is made up of your kidneys, ureters, bladder, urethra
, and Prostate gland ( in males ).
Most UTIs only involve the urethra and bladder,( Prostate gland in
males ) in the lower tract.
 However, UTIs can involve the ureters and kidneys, in the upper
tract.
Although upper tract UTIs are more rare than lower tract UTIs,
they’re also usually more severe.
Infection may occur in the kidneys (pyelonephritis), bladder
(cystitis) or urethra (urethritis) or a combination of these.

3. UTI may be evident solely by the presence of
bacteria in the urine (bacteriuria) or signs and
symptoms of bacterial invasion of one or more
components of the tract .
Once any component of the tract is invaded , the
entire tract is at risk for infection.
UTIs can be designed as asymptomatic or
symptomatic, complicated or uncomplicated , and
acute , chronic , or recurrent .

4. Uncomplicated : UTI without underlying renal (structural )or
neurologic disease/ abnormalities .
Complicated : UTI with underlying structural ( a stone, indwelling
catheter , enlarged prostate gland ) ,medical or neurologic disease.
Recurrent : > 3 symptomatic UTIs within 12 months following
clinical therapy. ( futher categorized into relapse & reinfection ).
Reinfection: recurrent UTI caused by a different pathogen at any
time ( occurs weeks to months after successful treatment ).
Relapse : recurrent UTI caused by same species causing original
UTI within 2 wks after therapy.

5. Some groups are at increased risk of having urinary tract
infections:
women are vulnerable because the urethra is only 4cm long and
bacteria only have to travel this short distance from outside the
body to the inside of the bladder
people with urinary catheters, such as the critically ill, who cannot
empty their own bladder
people with diabetes have altered immune systems and are more
vulnerable to infection
men with prostate problems, since an enlarged prostate gland can
cause the bladder to only partially empty.
babies, especially those born with congenital abnormalities of the
urinary system.

6. Symptoms of a UTI depend on what part of the urinary
tract is infected.
Lower tract UTIs affect the urethra and bladder.
Symptoms of a lower tract UTI include:
 burning with urination (Dysuria)
 increased frequency of urination without passing much urine
 increased urgency of urination
 bloody urine (Hematuria)
 cloudy urine
 urine that looks like cola or tea
 urine that has a strong odor
 pelvic pain in women
 rectal pain in men

7. Upper tract UTIs affect the kidneys. These can be potentially life
threatening if bacteria move from the infected kidney into the
blood. This condition, called urosepsis, can cause dangerously low
blood pressure, shock, and death.
Symptoms of an upper tract UTI include:
pain and tenderness in the upper back and sides (Flank
Pain )
chills
fever
nausea
vomiting

8. An infection occurs when bacteria get into the urine and begin to
grow. The bacterial infection usually starts at the opening of the
urethra where the urine leaves the body and moves upward into
the urinary tract.
The culprit in at least 90% of uncomplicated infections is a type of
bacteria called Escherichia coli, better known as E. coli. These
bacteria normally live in the bowel (colon) and around the anus.
However, sometimes other bacteria are responsible.
Gram- negative
Enterobacter
Enterococcus
Pseudomonas
Klebsiella
Proteus
Gram – Positive
Enterococcus species
Staphylococcus species
ETIOLOGY

9. Urinary Tract Infection (UTI)
Normal mechanisms that maintain sterility of urine
• a. Adequate urine volume
• b. Free-flow from kidneys through urinary meatus
• c. Complete bladder emptying
• d. Normal acidity of urine
• e. Peristaltic activity of ureters and competent
ureterovesical junction
• f. Increased intravesicular pressure preventing reflux
• g. In males, antibacterial effect of zinc in prostatic fluid

10. Pathogenesis
4 routes of bacterial entry to urinary Tract :
1. Ascending infection
2. Blood borne spread
3. Lymphatogenous spread
4. Direct extension from other organs

11. • Ascending Infection:
 most common route.
 organisms ascend through urethra
into bladder.
Organism Colonize in perineal and
periurethral areas
Ascend to bladder, kidneys UTI

12. Lymphatogenous spread:
 Men- through rectal and colonic lymphatic vessels
to prostrate and bladder.
Women- through periuterine lymphatics to urinary
tract.
Direct extension from other organs:
Pelvic inflammatory diseases
Genito-urinary tract fistulas

13. • Hematogenous
spread:
 Blood borne
spread to kidneys.
 Occurs in
bacteraemia
mostly S.aureus.

14. UTI- DIAGNOSIS
• Microscopic examination of urine
• Urinalysis
• Urine culture
• Imaging techniques – CT scan and MRI

15. Findings on Exam in UTI
• Physical Exam:
– CVA tenderness (pyelonephritis)
– Urethral discharge (urethritis)
– Tender prostate on DRE (prostatitis)
• Labs: Urinalysis
– + leukocyte esterase
– + nitrites
• More likely gram-negative rods
– + WBCs
– + RBCs
Dipstick test

16. Laboratory findings
Normal Findings
• pH - 4.6 – 8.0
•Appearance- clear
Color – pale to amber
yellow
•Odor – aromatic
•Blood – none
•Leukocyte esterase –
none
•WBC- absent
•Bacteria- absent
Abnormal findings
•pH – Alkaline ( increases)
•Appearance – cloudy
•Color - deep amber
•Odor – foul smelling
•Blood – maybe present
•Leukocyte esterase –
present
•WBC- present
•Bacteria- present

17. Culture in UTI
• Positive Urine Culture = >105 CFU/mL
• Most common pathogen for cystitis, prostatitis,
pyelonephritis:
– Escherichia coli
– Staphylococcus saprophyticus
– Proteus mirabilis
– Klebsiella
– Enterococcus
• Most common pathogen for urethritis
• Chlamydia trachomatis
• Neisseria Gonorrhea

18. Diagnostic tests for adults with recurrent UTI
Intravenous pyelography / excretory
urography
An intravenous pyelogram (IVP) is an x-ray examination of the kidneys, ureters and
urinary bladder that uses iodinated contrast material injected into veins.
When contrast material is injected
into a vein in the patient's arm, it
travels through the blood stream and
collects in the kidneys and urinary
tract, turning these areas bright white
on the x-ray images. An IVP allows
the radiologist to view and assess the
anatomy and function of the kidneys,
ureters and the bladder.

19. The exam is used to help diagnose
symptoms such as blood in the urine or
pain in the side or lower back.
The IVP exam can enable the radiologist
to detect problems within the urinary
tract resulting from:
kidney stones
enlarged prostate
tumors in the kidney, ureters or urinary
bladder
scarring from urinary tract infection
surgery on the urinary tract
congenital anomalies of the urinary tract

20. UTI - management
• Symptomatic UTI- antibiotic therapy
• Asymptomatic UTI- no treatment required
except in special situations.
• Non- specific therapy:
• more water intake.
• Maintaining acidity of urine by fluids like
canberry juice.

21. Anti-microbial therapy
•Goals of therapy:
-Elimination of infection.
-Relief of acute symptoms.
-Prevention of recurrence and long
term complications.

22. • Ideal antibiotic for UTI :
• Adequate coverage over E.coli
• Concentration in urine
• Duration of therapy
• Low resistance
• Cost
• Low adverse effect profile

23. Principles of anti microbial therapy
• Levels of antibiotic in urine but not in blood
• Blood levels of antibiotic – important in
pyleonephritis
• Penicillins and cephalosporins – drugs of
choice for UTI with renal failure.

24. treatment duration
• Single dose therapy
• 3 day course
• 7 day course
• 10 – 14 day course

25. Single dose therapy
a. Trimethoprim- sulfamethaxole
bactrim–DS : TMP–160mg + SMZ–800mg
co-trimoxazole-DS : TMP-160mg + SMZ-800mg
b. Amoxicillin- clavulnate 500mg
aceclav tab , acmox- AG tab
c. Ciprofloxacin 500mg – alquin tab
d. Norfloxacin 400mg – Actiflox-400 tab

26. • for uncomplicated UTI
• Not for patients with
1. past history of complicated UTI
2. history of antibiotic resistance
3. history of relapse with single dose
• advantages: compliance, cost, less side
effects, less resistance
• Disadvantages: increased recurrence or
relapse

27. 3 day therapy
• Efficacy same as 7 day therapy with less
adverse effects
• Drugs used include
1. quinolines
2. TMP-SMZ
3. betalactam antibiotics
• Extended release ciprofloxacin 500mg
for uncomplicated UTI 1000mg for
complicated UTI

28. 7 day therapy
• Used less for uncomplicated UTI
• Useful in :-1. recurrent cases
2. pregnancy
3. UTI with other risk factors
14 day therapy
• For complicated UTI
• High risk of mortality and morbidity

29. Pathogen specific treatment
Pathogen Treatment options
Escherichia coli Ceftriaxone 50mg/kg i.v
/I.M Qday
Pseudomonas
aeroginosa
Gentamycin 6-7.5mg /kg
i.v Q8hr / Qday
Klebsiella sps
Enterobacter sps
Proteus sps
Ceftadizine 100-
150mg/kg/day i.v Q8hr
Enterococcus sps Ampicillin 100-
200mg/kg/day Q6hr

30. Infection specific treatment
Lower
UTI
 3day therapy preferred
*Trimethoprim Cephalaxin
*Nitrofurantion *ciprofloxacin
Amoxicillin *Co-amoxiclav
Norfloxacin

31. Acute pyelonephritis
• Parenteral antibiotics
• Cefuroxime – 750mg i.v. Q8h
Gentamycin - 80-120g i.v. Q12h
Ciprofloxacin – 200mg i.v. Q12h
• 10-14 days treatment
• Ceftazimide, imipenam, ciprofloxacin –
for hospital acquired pyelonephritis

32. Asymptomatic bacteriuria
• Children – treatment same as
symptomatic bacteriuria
• Adults –
treatment required in cases of
a. pregnancy
b. patient with obstructive structural
abnormalities

33. Bacteriuria in pregnancy
• To prevent risk of pyelonephritis
• 7 day course with following antibiotics
 Cephalaxin
Nitrofurantoin
Amoxicillin
• Therapy continued at regular intervals
of pregnancy.

34. Relapsing
UTI• 7-10 day course
• If fails – 2week course / 6week course
• Structural abnormalities corrected by
surgery
• 6week course – children
a. adults with continuous symptoms
b. high risk of renal damage

35. Prophylaxis for UTI
• Single dose of trimethoprim 100mg /
nitrofurantion 50mg
• Long term low dose prophylaxis
beneficial
• Women- single dose of antibiotic after
sexual intercourse.

36. Catheter associated UTI
• Asymptomatic UTI develop in
catheterized patients after 10-14 days.
• Antibiotic treatment - eradicate
organism but high chance of relapse.
• Catheter removal before treatment is
beneficial.

37. Uncomplicated (simple) Cystitis
• Definition
– Healthy adult woman (over age 12)
– Non-pregnant
– No fever, nausea, vomiting, flank pain
• Diagnosis
– Dipstick urinalysis (no culture or lab tests needed)
• Treatment
– Trimethroprim/Sulfamethoxazole for 3 days
– May use fluoroquinolone (ciprofoxacin or levofloxacin)
in patient with sulfa allergy, areas with high rates of
bactrim-resistance
• Risk factors:
– Sexual intercourse
• May recommend post-coital voiding or prophylactic antibiotic
use.

38. Complicated Cystitis
• Definition
– Females with comorbid medical conditions
– All male patients
– Indwelling foley catheters
– Urosepsis/hospitalization
• Diagnosis
– Urinalysis, Urine culture
– Further labs, if appropriate.
• Treatment
– Fluoroquinolone (or other broad spectrum antibiotic)
– 7-14 days of treatment (depending on severity)
– May treat even longer (2-4 weeks) in males with UTI

39. Special cases of Complicated cystitis
• Indwelling foley catheter
– Try to get rid of foley if possible!
– Only treat patient when symptomatic (fever, dysuria)
• Leukocytes on urinalysis
• Patient’s with indwelling catheters are frequently colonized with
great deal of bacteria.
– Should change foley before obtaining culture, if possible
• Candiduria
– Frequently occurs in patients with indwelling foley.
– If grows in urine, try to get rid of foley!
– Treat only if symptomatic.
– If need to treat, give fluconazole (amphotericin if
resistance)

40. Pyelonephritis
• Infection of the kidney
• Associated with constitutional symptoms – fever, nausea,
vomiting, headache
• Diagnosis:
• Urinalysis, urine culture, CBC, Chemistry
• Treatment:
• 2-weeks of Trimethroprim/sulfamethoxazole or fluoroquinolone
• Hospitalization and IV antibiotics if patient unable to take po.
• Complications:
– Perinephric/Renal abscess:
• Suspect in patient who is not improving on antibiotic therapy.
• Diagnosis: CT with contrast, renal ultrasound
• May need surgical drainage.
– Nephrolithiasis with UTI
• Suspect in patient with severe flank pain
• Need urology consult for treatment of kidney stone

41. Prostatitis
• Symptoms:
– Pain in the perineum, lower abdomen, testicles, penis, and with ejaculation,
bladder irritation, bladder outlet obstruction, and sometimes blood in the
semen
• Diagnosis:
– Typical clinical history (fevers, chills, dysuria, malaise, myalgias,
pelvic/perineal pain, cloudy urine)
– The finding of an edematous and tender prostate on physical examination
– Will have an increased PSA
– Urinalysis, urine culture
• Treatment:
– Trimethoprim/sulfamethoxazole, fluroquinolone or other broad spectrum
antibiotic
– 4-6 weeks of treatment
• Risk Factors:
– Trauma
– Sexual abstinence
– Dehydration

42. Urethritis
• Chlamydia trachomatis
– Frequently asymptomatic in females, but can present with dysuria, discharge or
pelvic inflammatory disease.
– Send UA, Urine culture (if pyuria seen, but no bacteria, suspect Chlamydia)
– Pelvic exam – send discharge from cervical or urethral os for chlamydia PCR
– Chlamydia screening is now recommended for all females ≤ 25 years
– Treatment:
• Azithromycin – 1 g po x 1
• Doxycycline – 100 mg po BID x 7 days
• Neisseria gonorrhoeae
– May present with dysuria, discharge, PID
– Send UA, urine culture
– Pelvic exam – send discharge samples for gram stain, culture, PCR
– Treatment:
• Ceftriaxone – 125 mg IM x 1
• Cipro – 500 mg po x 1
• Levofloxacin – 250 mg po x 1
• Ofloxacin – 400 mg po x 1
• Spectinomycin – 2 g IM x 1
– You should always also treat for chlamydia when treating for gonnorhea!

43. Antibiotics used in treatment

44. Sulfamethoxazole-trimethoprim
 Adverse effects:
o Steven Johnson's syndro
o Dermatitis
o Angiodema
o GI disturbances
o Agranulocytosis
 Contraindicated in
o Hypersensitivity to sulfa
drugs
o Infants
o Megaloblastic anaemia
• me
Mechanism of action

45. nitrofurantoin
 Damages bacterial DNA.
 Reduced to reactive forms by bacterial
nitroreductase- damage DNA, ribosomes
 Adverse effects:
o Hypersensitivity pneumonitis,GI
disturbances, haemolytic anaemia
 Contraindications:
o Renal failure, neonates, pregnancy

46. Cefixime
3rd generation cephalosporin
Disrupts synthesis of peptidoglycan of
bacterial cell wall
Adverse effects: o Rash, utricaria
 o Diarrhea
o Thrombocytopenia
o leucopenia

47. Amoxicillin
 class --Penicillin antibiotic
 Inhibits cross linking of peptidoglycan
polymer chains which is the major
component of bacterial cell wall.
 Adverse effects:
o Rash
o GI disturbances, renal dysfunction
o Antibiotic associated colitis, lethergy
 Contraindications: penicillin
hypersensitivity

48. Ciprofloxacin
 Fluoroquinoline antibiotic
 Inhibits DNA gyrase and topisomerase 1V, the
enzymes necessary for separation of bacterial
DNA – inhibit cell division
 Adverse effects:
o Peripheral neuropathy
o Rhabdomyolysis
o Steven Johnson's syndrome
o Hemolytic anaemia

49. Reference
s• Clinical pharmacy and therapeutics by
Roger Walker, Clive Edwards; 3rd edition;
page 503 – 511.
• Applied therapeutics the clinical use of
drugs by Mary Anne konda- kimble; 8th
edition; page456 – 465.