The document discusses urinary tract infections, including the spectrum of organisms that cause infections and their antibiotic resistance patterns in both inpatient and outpatient settings. It analyzes data from a study of 200 patients which found that Escherichia coli and extended-spectrum beta-lactamase producing Klebsiella were the most common organisms, and that resistance to fluoroquinolones was high. The document also provides an overview of different types of urinary tract infections and their treatments.

1. URINARY TRACT INFECTIONS
Dr.Sudhanshu Mishra
Co-ordinator : Dr.V.P.Mandora
PG GUIDE : DR.A.V.Mulay

3. “When I woke up just after dawn on September
28, 1928, I certainly didn't plan to revolutionize all
medicine by discovering the world's first antibiotic, or
bacteria killer. But I suppose that was exactly what I
did.”
–Alexander Fleming

4. “URINARY TRACT INFECTIONS: SPECTRUM OF ORGANISMS ALONG
WITH THEIR ANTIBIOTIC SENSITIVITY IN INPATIENT AND OUTPATIENT
SET-UPS”
Total Number of Cases Studied(n) = 200
 INCLUSION CRITERIA:
This study will include all those patients in whom Urinary
Tract Infections are suspected and their Urine Culture and
Antibiotic sensitivity pattern have been sent.
Both pediatric and adults of both sexes included .
Both Inpatients and Outpatients Included.
 EXCLUSION CRITERIA:
Patients in whom Urine Culture and/or Antibiotic Sensitivity
Pattern have not been done.

5.  MATERIALS AND METHODS
 This study will be a cross-sectional study of all patients of
suspected Urinary Tract Infections in whom Urine Culture and
Antibiotic Sensitivity patterns have been done.
 All patients who are diagnosed to have urinary tract infections
will be thoroughly studied regarding the organism isolated
from urine culture as well as their sensitivity pattern to
antibiotics.
 All the study subjects will be evaluated using the proforma
attached along with their Urine Culture reports and Antibiotic
sensitivity pattern.

6. URINARY TRACT INFECTIONS
 Leadingcause of morbidity and health
care expenditures in persons of all ages.
 An estimated 50 % of women report
having had a UTI at some point in their
lives.
 8.3million office visits and more than 1
million hospitalizations, for an overall
annual cost > $1 billion in USA (2010)

7. ANATOMY

9. URINE CULTURE SAMPLES
38 46
Culture Positive
Culture Negative
116 Contaminated
Sample

10. DEMOGRAPHY OF UTI
25 23
20
15
Males
10 Females
7
5 5
5
2 2
1 1
0 0 0 0
0
0-10 10-20 20-30 30-40 40-50 Above
Y 50

11. PROFILE OF CULTURE POSITIVE
PATIENTS
00
INPATIENT 18
OUTPATIENT
28

12. DISTRIBUTION OF INPATIENTS
NO.OF PATIENTS
ICCU 5
DELUXE 0
GENERAL 1
PAED 0
GYNAEC 2 NO.OF PATIENTS
NEW ONCO 6
B WARD 9
A WARD 5
0 2 4 6 8 10

13. SPECTRUM OF ORGANISMS
Outpatients
Citrobacter 1
ESBL E.Coli 2
Acinetobacter Wolfii 3
Outpatients
Psedumonas Aeruginosa 2
E.Coli 10
0 5 10 15

14. Inpatients
Providencia Retigens 1
Non Albicans Candida 1
Entrococcus Faecalis 4
Psedumonas Aeruginosa 6 Inpatients
ESBL Kleibsella 3
ESBL E.Coli 9
0 2 4 6 8 10

15. ANTIBIOTIC RESISTANCE
OUTPATIENTS
TMP-SMX 11.11%
Nitrofurantoin 5.55%
Cephalosporins 16.66%
OUTPATIENTS
FQs 44.40%
0 0.1 0.2 0.3 0.4 0.5

16. RESISTANCE PATTERN
INPATIENTS
Colistin 0%
71.43%
FQs 57.14%
17.86%
Cotrimoxazole 32.14% INPATIENTS
Amikacin 21.43%
10.71%
Cefoperazone+Sulba… 21.43%
46.43%
Ampicillin+Sulbactam 28.57%
0.00%20.00%40.00%60.00%80.00%

17. ACUTE UNCOMPLICATED CYSTITIS
 Sexually active young
women.
 Causes: anatomy and
certain behavioral
factors, including delays in
micturition, sexual
activity, and the use of
diaphragms and spermicides
tract.
 Aggressive diagnostic work-
ups are unwarranted in
young women presenting
with an uncomplicated
episode of cystitis.

18. ACUTE UNCOMPLICATED CYSTITIS
 The microbiology is limited
to a few pathogens.
 70%- 85% are caused by
Escherichia coli
 5-20%are caused by
coagulase-negative
Staphylococcus
saprophyticus
 5-12% are caused by other
Enterobacteriaceae such as
Klebsiella and Proteus.

19. ACUTE UNCOMPLICATED CYSTITIS
 Clinical
Features:
dysuria, frequency, urgency,
suprapubic pain, hematuria.
 Fever >38C, flank
pain, costovertebral angle
tenderness, and nausea or
vomiting suggest upper tract
infection.

20. ACUTE UNCOMPLICATED CYSTITIS
 Diagnosis: direct history and PE
 PE: Temperature, abdominal exam, assessment of
CVA tenderness, pelvic exam.
 H/o STD’s, new sexual partner, partner with urethral
symptoms, gradual onset.

21. ACUTE UNCOMPLICATED CYSTITIS
 Guidelines for tx of acute cystitis recommend
empiric antibiotic tx.
 Unnecessary antibiotic use??
 Clinical criteria for Dx:
Dysuria, presence of > trace urine
leukocytes, and presence of nitrites or...
Dysuria and frequency in the absence of
vaginal discharge.

22. ACUTE UNCOMPLICATED CYSTITIS
 UA:Evaluation of midstream urine for
pyuria.
 White blood cell casts in the urine are Dx of
upper tract infection.
 Urine Culture: Not necessary
 Warranted in: Suspected complicated
infection, persistent symptoms following
tx, symptoms recur < 1 mo after tx.

23. ACUTE UNCOMPLICATED CYSTITIS
 Urine dipsticks:
 Leukocyte esterase (pyuria), sensitivity 75-
90%, specificity 95%
 Nitrite (Enterobacteriacea), sensitivity 35-
85%, specificity 95%, false positive with
phenazopyridine, beets.
 Microscopic evaluation for pyuria or a culture is
indicated in pt with negative leukocyte esterase
that have urinary symptoms.

24. ACUTE UNCOMPLICATED CYSTITIS
 Susceptibility:
 E.coli
 30% isolates resistance to ampicillin and sulfonamides
 Increasing of resistance to TMP-SMX
 Resistance to nitrofurantoin is <5%
 Resistance to fluoroquinolones <5%
 S.saprophyticus
 3% resistant to TMP-SMX
 0% resistant to nitrofurantoin
 0.4% resistant to ciprofloxacin

25. ACUTE UNCOMPLICATED CYSTITIS
 Treatment:
 Short course vs. prolonged tx
 Short course preferred except with beta-lactam agents
 TMP-SMX (160/800mg BID x 3) first-line tx if: no
allergy to the drug, no antibiotics in the past 3
mo, no recent hospitalization.
 Nitrofurantoin (100mg BID x 5 days)
 Analgesia: Phenazopyridine 200mg TIDx2

26. ACUTE COMPLICATED CYSTITIS
 UTI when/with structural, functional or metabolic
abnormalities (polycystic, solitary, transplant
kidney;DM, CRF, indwelling cath, neurogenic
bladder) or elderly, male, child, pregnant or h/o
recurrent UTI)
 E.coli accounts for fewer than one third of
complicated cases.
 Clinically, the spectrum of complicated UTIs may
range from cystitis to urosepsis with septic shock.

27. ACUTE COMPLICATED CYSTITIS
 Urine culture and susceptibility are necessary.
 These infections are usually associated with high-
count bacteriuria (> 10(5) CFU/mL).
 MO:
Proteus, Klebsiella, Pseudomonas, Serratia, and
Providencia, enterococci, staphylococci and fungi
AND E.coli

28. ACUTE COMPLICATED CYSTITIS
 Empiric therapy for these patients should include an
agent with a broad spectrum of activity against the
expected uropathogens:
fluoroquinolone, ceftazidime, cefepime, aztreon
am, imipenem-cilastatin. (Obtain Ucx prior to
Tx)
 Tx x 7-14 days
 Follow-up urine culture should be performed
within 14 days after treatment???

29. RECURRENT CYSTITIS
 Up to 27% of young women with acute
cystitis develop recurrent UTIs.
 The causative organism should be identified
by urine culture.
 Relapse: infection with the same organism
(multiple relapses = complicated UTIs).
 Recurrence: infection with different
organisms.

30. RECURRENT CYSTITIS
 >3 UTI recurrences documented by urine Cx within
one year can be managed using one of three
preventive strategies:
1. Acute self-treatment with a three-day course of
standard therapy.
2. Postcoital prophylaxis with one-half of a TMP-
SMX double-strength tablet (80/400 mg).
3. Continuous daily prophylaxis TMP-SMX one-half
tablet per day (40/200 mg); nitrofurantoin 50 to 100
mg per day; norfloxacin 200 mg per day.

31. UNCOMPLICATED PYELONEPHRITIS
 Suspect if:
 Cystitis-like illness and accompanying flank pain
 Severe illness with
fever, chills, nausea, vomiting, abdominal pain
 Gram-negative bacteremia.

32. UNCOMPLICATED PYELONEPHRITIS
 DX: Clinical, confirm with:
 UA: pyuria and/or WBC casts
 UCx with > 10 (5) CFU/mL (80%)
 Tx: 14 days total
 Oral: TMP/SMX, fluoroquinolones
 IV: 3rd gen
cephalosporin, aztreonam, quinolones, aminoglycoside

33. UNCOMPLICATED PYELONEPHRITIS
 Pt with symptoms after 3 days of appropriate
antimicrobial tx should be evaluated by renal US or
CT for obstruction or abscess.

34. UTI IN MEN
 At risk: Older men with prostatic disease, UT
instrumentation, anal sex, or partner colonized with
uropathogens.
 UCx: 10 (3) CFU/mL sensitivity and specificity 97%.
 Additional studies?
 Not necessary in young healthy men who have a single
episode.

35. UTI IN MEN
 Tx:
 Uncomplicated cystitis:
 TMP/SMX or fluoroquinolones x 7 days
 Complicated cystitis:
 Fluoroquinolones x 7-14 days
 Bacterial prostatitis:
 Fluoroquinolone x 6-12 weeks

36. CATHETER-ASSOCIATED UTI
 Risk of bacteriuria is ~ 5%/day (long term catheter
bacteriuria is inevitable).
 40% of nosocomial infections
 Most common source of gram-negative bacteremia.
 Dx: Ucx 10 (2) CFU/mL
 MO:
E.coli, Proteus, Enterococcus, Pseudomona, Enterobacter,
Serratia, Candida

37. CATHETER-ASSOCIATED UTI
 Mild to mod: oral quinolones10-14days
 Severe infection: IV/oral 14-21days
 Asymptomatic bacteriuria in pt with an indwelling
Foley should not be Tx unless they are
immunosuppressed, have risk of bacterial
endocarditis or pt who are about to undergo urinary
tract instrumentation.

38. ASYMPTOMATIC BACTERIURIA
 UCx: > 10(5)CFU/mL with no symptoms
 Three groups of pt with asymptomatic bacteruria
have been shown to benefit from tx:
 Pregnant
 Renal transplant
 Pt who are about to undergo urinary tract procedures.

39. PREGNANT PATIENTS
 Asymptomatic bacteriuria: two consecutive voided
urine specimens with isolation of the same bacterial
strain >10(5) or a single cath urine specimen.
 Nitrofurantoin 100mg BID x 5-7 days
 Amoxi/Clav 500mg BID or 250 TID x 7days
 Fosfomycin 3g PO x 1

40. URINARY CATHETER
• Developed in the 1920s by Dr. Frederick
Foley
• The urinary catheter was originally an open
system with the urethral tube draining into an
open container.
• In the 1950s, a closed system was developed
in which the urine flowed through a catheter
into a closed bag.
40

41. Urinary Catheter Utilization
• About 25% of patients during their
hospitalization
• Almost all of them are placed the same
admission
• A large number is placed in ED
• Intensive care medical-surgical units
41

42. Urinary catheters are not
harmless…
• Urinary tract infection
• Mechanical trauma to urethra and bladder
• Immobility (restraining patient)*
Prolonged stay?
Pressure Ulcers? Falls?
*Saint S, Ann Intern Med 2002; 137: 125-7
42

43. HOSPITAL-ACQUIRED UTI:
PREVALENCE
• 600,000 patients develop hospital-acquired UTI’s
per year
• Catheter-associated infections (CAUTI) comprise
80% of these cases
• UTIs account for 40% of all hospital-acquired
infections
43

44. CATHETER ASSOCIATED UTI (CAUTI)
 Catheter-risk of bacteriuria increases each day of
use:
• Per day: 5%
• 1 week: 25%
• 1 month: 100%
44

45. BIOFILM: EXTRACELLULAR POLYMERS
(DONLAN, CID 2001; 33:1387–92, LIEDL, CURR OPINION UROL 2001;11:
75-9)
 Organisms attach to
and grow on a surface
and produce
extracellular polymers
 Intraluminal ascent
(48hours) of bacteria
faster than extraluminal
(72-168 hours)
 Most catheters used >1
week have biofilms Staphylococcus aureus biofilm on
an indwelling catheter.
 Extraluminal more
CDC Public Health Image Library
important in women
45

46. Usually females
Usually males
46
Maki, Emerg Infect Dis 2001; 7: 1-6

47. 47
Maki, Emerg Infect Dis 2001; 7: 1-6

48. BACTERIOLOGIC MONITORING
• Not recommended for asymptomatic patients.
• Only culture the urine if the patient has symptoms
of an UTI such as fever, chills, and abdominal pain
• Cloudy urine ≠infection
• Sediment in urine ≠infection
48

49. ASYMPTOMATIC BACTERIURIA
 No benefit from treatment
 Increased risk of resistance and C. difficile
disease with treating asymptomatic
bacteriuria
 Pyuria does not equate infection when
catheter present
 Avoid urine cultures unless patient is
symptomatic or if it is a part of sepsis
workup in a catheterized patient
49

50. ACCEPTABLE INDICATIONS FOR
URINARY CATHETER PLACEMENT
 Acute urinary retention or obstruction
 Perioperative use in selected surgeries
 Assist healing of perineal and sacral wounds
in incontinent patients
 Hospice/comfort/ palliative care
 Required immobilization for trauma or
surgery
 Chronic indwelling on admission
50 50

51. ACUTE URINARY RETENTION OR
OBSTRUCTION
 Outflow obstruction: examples include prostatic
hypertrophy with obstruction, urethral obstruction
related to severe anasarca, urinary blood clots with
obstruction
 Acute urinary retention: this may be medication
induced, medical (neurogenic bladder) or trauma to
spinal cord.
51 51

52. PERIOPERATIVE USE IN SELECTED
SURGERIES
 Urologic surgery or other surgery on
contiguous structures of the genitourinary
tract
 Anticipated prolonged duration of
surgery, large volume infusions during
surgery, or need for intraoperative urinary
output monitoring
 Spinalor epidural anesthesia may lead to
urinary retention; prompt discontinuation of this
type of anesthesia should prevent need for
urinary catheter placement
52 52

53. ASSIST HEALING OF PERINEAL AND SACRAL
WOUNDS IN INCONTINENT PATIENTS
 Thisis a relative indication when there is
concern that incontinence is leading to
worsening skin integrity in areas where
there is skin breakdown
53 53

54. HOSPICE/ COMFORT CARE/ PALLIATIVE
CARE
 Thisis a relative indication. In end-of-life
situations, it is reasonable to accommodate
the patient’s wishes on what provides them
with the best comfort
54 54

55. REQUIRED IMMOBILIZATION FOR
TRAUMA OR SURGERY
 This includes:
1. unstable thoracic or lumbar spine
2. multiple traumatic injuries such as pelvic
fractures
3. Acute hip fracture is risk for dislocation
55 55

56. CHRONIC INDWELLING URINARY CATHETER
UPON ADMISSION
 Patientsfrom home or extended care facility
with a chronic urinary catheter
56 56

57. UNACCEPTABLE REASONS FOR
PLACEMENT
 Urine output monitoring OUTSIDE intensive care
 Incontinence
 Morbid obesity
 Immobility
 Confusion or dementia
 Patient request
57 57

58. URINE OUTPUT MONITORING OUTSIDE
INTENSIVE CARE
 This includes:
1. Close urinary output monitoring by nephrology in
patients with renal failure
2. Monitoring of urine output in patients with congestive
heart failure on diuretics
 Potential solutions:
1. Use urinals for men and hats for women (to
monitor output)
2. Accurate daily weights.
58 58

59. URINE OUTPUT MONITORING OUTSIDE
INTENSIVE CARE
 For patients with congestive heart failure, consider
involving the patient
 Provide patients with information regarding how to
document their output and daily weights (consider
pamphlets)
 This will also help the patient learn to accurately
measure their output.
59

60. INCONTINENCE
 Incontinence should not be a reason for urinary
catheter placement. Patients admitted from home
or from extended care facilities with incontinence
managed their incontinence without problems prior
to admission. Mechanisms to keep the skin intact
need to be in place and avoid urinary catheter
placement in that population.
60 60

61. INCONTINENCE: POTENTIAL
SOLUTIONS
 Use Skin Barrier Creams for protection
 Start Toilet Training:
 Offer use of bedpan or assist patient up to commode
regularly
 Evaluate for any wet bed linen and change if wet
at the time patient is being turned in bed
61 61

62. PATIENTS TRANSFERRED FROM
INTENSIVE CARE TO FLOOR
 The intensive care is an area where high
prevalence of urinary catheter utilization is present.
 Evaluating those who are transferred to non-
intensive care units for need of urinary catheter and
discontinuation of those not needed may
significantly reduce unnecessary utilization
62 62

63. MORBID OBESITY AND IMMOBILITY
 Morbid obesity should not be a trigger for
urinary catheter placement. Patients that are
morbidly obese have functioned without a
urinary catheter prior to admission. The
association of immobility and morbid obesity
may lead to more inappropriate catheter
placement. This may result in more
immobility with the urinary catheter being a
“one point restraint”
63 63

64. IMMOBILITY: POTENTIAL SOLUTIONS
 Start toilet training every 2 hours
 Offer bedpan, urinal or assist patient out
of bed
 Of 145 hospitalized patients with a high
risk for pressure ulcers, urinary catheter
presence was associated with 1.8 times
risk of pressure ulcer compared to those
without urinary catheter (p=0.03). The most
significant association was between
urinary catheter catheter use and stage 2
pressure ulcer.
64 64

65. CONFUSION OR DEMENTIA
 Patients with confusion or dementia should not
have a urinary catheter placed unless there is an
indication for placement
65 65

66. THE VERY ELDERLY PATIENTS
 Disproportionate use inappropriately in the very
elderly.
 It may be a marker of immobility, incontinence, and
dementia?
66

67. PATIENT REQUEST
 Although healthcare workers may report
that patients want the urinary catheter in, this
is infrequently documented. The only
exception is in patients that are end of life or
palliative care.
 Patient’s Convenience:
- Example: patient on diuretics and does not want
to move out of bed multiple times
- Education is key! Provide reasons to patient of
increased risk of urinary catheter : urine
infection, skin breakdown, deep venous
thrombosis and/or pneumonia due to immobility
67 67

68. INCREASED WORK LOAD FOR
HEALTHCARE WORKERS (HCW)
 Increased acuity of patients or reduction
of the nurse to patient ratio
 e.g., patient is incontinent and immobile
and requires multiple changes of sheets
 Potential solution: link it to other initiatives
(eg. pressure ulcer prevention requires
frequent repositioning of
patients), evaluate the nurse to patient
ratio, shift resources to support the HCW
that has more responsibilities
68

69. WHAT NEEDS TO BE DONE
 Both nurses and physicians should evaluate the
indications for urinary catheter utilization.
 Physicians should promptly discontinue catheters
that are no longer needed.
 Nurses evaluating catheters and finding no
indication should contact physician to promptly
discontinue catheter.
69

70.  THANK YOU