1. Prof. M.C.Bansal
Founder Principal & Controller Jhalawar Medical College &
Hospital Jhalawar.
Ex. Principal & controller Mahatma Gandhi Medical College and
Hospital , Sitapura ; Jaipur.

3.  Urinary tract infections have been described since ancient
times.
 First documented description in the Ebers Papyrus dated to
c. 1550 BC. It was described by the Egyptians as "sending
forth heat from the bladder". Effective treatment did not
occur until the development and availability of antibiotics in
the 1930s before which time herbs, bloodletting and rest
were recommended.

4.  Urinary tract infection (UTI) is an infection of
urethra, bladder, ureters, or the kidneys, which comprise the
urinary tract.
 Urethritis (urethral infection), cystitis (bladder
infection), ureter infection, and pyelonephritis (kidney
infection).

5.  Between 1 year and ~50 years of age, UTI and recurrent UTI are predominantly diseases of females.
Are 10 times more common among women than men. as 50–80% of women in the general
population acquire at least once atime; UTI during their lifetime—uncomplicated cystitis in most
cases
 The urethra is much shorter (4cm) and closer to the anus. . Colonization of the vaginal introitus and
perirurethral area with organisms from the intestinal flora (usually E. coli) is the critical initial step in
the pathogenesis of UTI.
 Escherichia coli is more likely to colonize the glans and prepuce of clitoris; and subsequently migrate
into the urinary tract . Sexual intercourse is associated with an increased risk of vaginal colonization
with E. coli and thereby increases the risk of UTI . Honey moon Cystitis may persist as chronic UTI.
 As a woman's estrogen levels decrease with menopause, her risk of urinary tract infections increases
due to the loss of protective effect of estrogen .

6.  The genetic background of the host influences the
individual's susceptibility to recurrent UTI, at least
among women . A familial disposition to UTI and to
pyelonephritis is well documented.
 Women with recurrent UTI are more likely to have
had their first UTI before age 15 years and to have a
maternal history of
UTI.

7.  A new sex partner or multiple partners
 More frequent or intense intercourse
 Use of irritating contraceptives, such as diaphragms and spermicide
 Episode of UTI in the previous 12 months, diabetes, and pregnancy
 Maternal h/o UTI
 Any condition that permits urinary stasis or obstruction predisposes
the individual to UTI. .
 Foreign bodies such as stones or urinary catheters provide an inert
surface for bacterial colonization and formation of a persistent
biofilm.
 Vesico ureteral reflux, ureteral obstruction , neurogenic bladder ,
incomplete voiding, spinal cord injury, Anterior vaginal prolapse (
cysto –urthrocele)and urinary diversion surgery create an
environment favorable to UTI.

8.  The most common causes of UTI infections (75-90%) are E. coli
, a gram negetive bacteria that usually inhabit the colon.
 Staphylococcus saprophyticus for 5–15%,
 Klebsiella, Pseudomonas, Enterobacter, Proteus, Staphylococcu
s, Mycoplasma, Chlamydia, Serratia and Neisseria spp.).-5-10%
 Fungi (Candida and Cryptococcus spp.) and
 Parasites (Trichomonas and Schistosoma)
 Klebsiella and group B streptococcus infections are relatively
more common in patients with diabetes, and Pseudomonas
infections are relatively more common in patients with chronic
catheterization. Proteus mirabilis i s a c common uropathogen
in patients with indwelling catheters, spinal cord injuries, or
structural abnormalities of the urinary tract.

9.  Asymptomatic Bacteriuria:-- patient does not have local or
systemic symptoms referable to the urinary tract.
screening urine culture:--bacteriuria
 Cystitis
 The typical symptoms of cystitis are dysuria, urinary frequency,
and urgency. Nocturia, hesitancy, supra pubic discomfort, and
gross hematuria .
 Unilateral back(lumber/ renal angle ) or flank pain is generally an
indication that the upper urinary tract is involved. Fever is also an
indication of invasive infection of either the kidney ,
Pyelonephritis.

10.  Mild pyelonephritis :-low-grade fever with or without lower-back or
costo vertebral-angle pain.
 severe pyelonephritis :--High fever--resolves over 72 hrs of therapy
 Rigors, nausea, vomiting, and flank and/or loin pain. Symptoms are
generally acute in onset . Altered mental status.
 Bacteremia develops in 20–30% of cases of pyelonephritis
 Emphysematous pyelonephritis is a particularly severe form of the
disease that is associated with the production of gas in renal and peri
nephric tissues and occurs almost exclusively in diabetic patients
 Xanthogranulomatous pyelonephritis occurs when chronic urinary
obstruction (often by stag horn calculi), together with chronic
infection, leads to suppurative destruction of renal tissue

11.  Uncomplicated UTI refers to acute cystitis or pyelonephritis in non
pregnant outpatient women without anatomic abnormalities or
instrumentation of the urinary tract
 Complicated UTI presents as a symptomatic episode of cystitis or
pyelonephritis in a man or woman with an anatomic predisposition
to infection, with a foreign body in the urinary tract, or with factors
predisposing to a delayed response to therapy.

12.  urine test:-presence of urinary nitrites, white blood cells (leukocytes),
or leukocyte esterase. Mid stream urine sample should be collected
after cleaning the Vulva with soap and water / catheter spaceman .
 urine microscopy, looks for the presence of red blood cells, white
blood cells, or bacteria.
 Urine culture is positive; if it shows a bacterial colony count of greater
than or equal to 103 colony-forming units per ml of a typical urinary
tract organism in symptomatic pt / > 1lack bacteria count /ml.
 105 colony-forming units per mL is consistent with a diagnosis of UTI
in asymptomatic patients.
 Antibiotic sensitivity can also be tested with these cultures, making
them useful in the selection of antibiotic treatment. However, women
with negative cultures may still improve with antibiotic treatment.

13.  For uncomplicated UTI :--
 ANTIBIOTICS:--Nitrofurantoin—100 mg bad -5 days
 TMP-SMX DS(160/800) --1 bad ----3 days
 Fluoroquinolones—Norflox 400-800mg /day
 Pylonephritis:--IV ciprofloxacin / oral ciprofloxacin 500mg bd –7 days.
 Oral TMP-SMX (one double-strength tablet twice daily for 14 days.
 Blactam +b lactamase inhibitor---ampicillin+sulbactum,ticarcillin
+clavulanate,piperacillin+tazobactum – are prescribed in complicated
cases
 IV ceftriaxone

14.  Drug should be present in (high bacteriolethal concentration as an blood ) all fluids of urinary tract e.g.
Glomerular filtrate, interstitial space, Intra cellular space , extra cellular space ,affernt and efferent blood
vessels of glomerular capsule . So that its effctive against all bacteri present in any part of renal system. No
residual infection persists even after caesation of antibiotic therapy.
 Drug should not be altered in its efficacy / detoxified by liver and kidney it self.
 Drug shold not be nephrotoxic.
 Drug should be present in same bacterio lethal concentration in urine when passing down in ureters and
stored in bladder for variable time (4-6hrs ) before it bring voided.
 Drug should be broadly effective against all common bacteria cuasing urinary tract infection .
 The efficacy of drug should not be much influenced / altered by change in PH of blood as well as that of urine .
 Drug should not cause crystalization / nidus formation for development of calculus .
 Drug should have wide marhin of safety ---its bacterio lethal effect and toxicity to patient perticularly
pregnant women and fetus in utero.
 Easy to administer -----Oral or/ and parentral
 Dose schedule should be simple ---od / bid ..
 Bactria should not be able to develop their resistance too early and too frequently.

15.  Catheter-Associated UTI;--bactriuria & symptoms in a cathetarised
pt.,either localized or to UTI or systemic such as fever
 Bacteriuria:-10 3-10 5 cfu/ml.
 Candiduria:--The appearance of Candida in the urine is an increasingly
common complication of indwelling catheterization, particularly for
patients in the intensive care unit, those taking broad-spectrum
antimicrobial drugs, and those with underlying diabetes mellitus.
 C. albicans is still the most common isolate, although C. glabrata and
other non-albicans species are also isolated frequently.
 The clinical presentation varies from an asymptomatic laboratory
finding to pyelonephritis and even sepsis. In asymptomatic patients,
removal of the urethral catheter results in resolution of candiduria in
more than one-third of cases.

16.  Treatment is recommended for patients who have symptomatic cystitis or
pyelonephritis and for those who are at high risk for disseminated disease.
 High-risk patients include those with neutropenia, those who are
undergoing urologic manipulation, and low-birth-weight infants.
 Fluconazole (200–400 mg/d for 14 days) achieves high levels in urine and
is the first-line regimen for Candida infections of the urinary tract
 oral flucytosine and/or parenteral amphotericin B are preferably given
toresistance cases.

17. Causative agent:--Neisseria gonorrhoeae ; a Gram neg. Inra cellular
diplococci .
Sites of infection:--endocervix ,urethra , skenes gland , bartholines
gland,
Symptoms:--urinary symptoms—dysuria , frequency of micturition and
PID .
SIGNS:-Externa urethral meatus –congested
On squeezing the urethra—purulent discharge present .
Diagnosis:--secretions—Grahm staining & culture:--Grahm negetive,
intracellular diplococcic.
Culture:--Thayer martin medium:-definitive

18.  Single dose treatment---
 Drugs:- inj. Ceftriaxone , ciproflox:--500 mg , oflox:-400
mg , cefixime -400 mg , levoflox—250 mg , Kenamycin /
streptomycin 2gm injection / 5gm single injection of
spiramycin .
 Note ---Simultaneous treatment of sex partner is must.


19.  One of the common causes of urethritis.
 T/T:--Azithromycin:--1 gm single dose.
 Doxycycline:--100 mg bd -7 days.
 Ofloxacin:--200 mg bd –7 days.
 Erythromycin:-500 mg—7 days.
 Sexual partner should be treated at the same time.

20.  Recurrent UTIs:--Are symptomatic UTIs that follow resolution of
an earlier episode, usually after appropriate treatment.
 Recurrent UTIs include relapses (i.e., symptomatic recurrent
UTIs with the same organism following adequate therapy) and
 Reinfection (i.e., recurrent UTIs with previously isolated bacteria
after treatment and with a negative intervening urine culture, or
 A recurrent UTI caused by a second bacterial isolate).
 Most recurrent UTIs are thought to represent reinfection with
the same organism.
 Recurrent UTIs are common among otherwise healthy young
women with anatomically and physiologically normal urinary
tracts.

21.  Risk Factors
 The strongest risk factor for recurrent UTIs in young women is frequency of sexual intercourse.
 Antimicrobial prophylaxis has proved effective in reducing the risk of recurrent UTIs in women
with two episodes of infection in the previous year. Continuous prophylaxis for six to 12 months
reduces the rate of UTIs during the prophylaxis period
 Postcoital prophylaxis may be preferable in women with UTIs temporally related to intercourse.
 Cranberry products seem to notably reduce the recurrence of symptomatic cystitis.
 Use of topical estrogen may reduce the incidence of recurrent UTIs in postmenopausal women.
 Treatment of complicated UTIs should begin with broad-spectrum antibiotic coverage, with
adjustment of antimicrobial coverage guided by culture results.

22.  urinary tract disorders- commonly encountered in pregnancy.
 Some precede pregnancy— example nephrolithiasis.
 pregnancy-induced changes may predispose to development
or worsening of urinary tract disorders- There is the markedly
increased risk of pyelonephritis.
 complications are unique to pregnancy such as pre
eclampsia. Prmaturity, PROM.

23.  With good prenatal control / erradication of UTI or early
detection in ANC followed by complete and appropriate
therapy, most women with these disorders will be least likely
to develop any long-term serious consequences.

24.  Significant changes in both structure and function Urinary tract
during pregnancy.
 The kidneys become larger.
 dilatation of the renal calyces and ureters –Urine content increases >
10ml.
Dilatation develops before 14 weeks and likely is due to
progesterone-induced relaxation of the muscular layers.
More marked dilatation is apparent beginning in mid pregnancy
because of ureteric compression, especially on the right side (dextra
rotation of uterus ) .
There is also some increased vesicoureteral reflux during pregnancy.
*all these changes predisposes pregnant women to UTI

25.  refers to persistent, actively multiplying bacteria within the urinary tract in an
asymptomatic women.
 Its prevalence in non pregnant women is 5 to 6 percent and depends on parity, race, and
socioeconomic status
 The highest incidence is in African-American multi paras with sickle-cell trait, and the
lowest incidence is in affluent white women of low parity..
 The incidence during pregnancy is similar to that in non pregnant women and varies from
2 to 7 percent.
 Bacteriuria is typically present at the time of the first prenatal visit, and if an initial
positive urine culture is treated, fewer than 1 percent of women develop urinary infection
.
 A clean-voided specimen containing more than 100,000 organisms per ml is diagnostic
 . It may be prudent to treat when lower concentrations are identified, because
pyelonephritis develops in some women with colony counts of 20,000 to 50,000
organisms/ml.

26.  If not treated, approximately 25 percent of infected women will
develop symptomatic infection during pregnancy.
 overt bacteriuria has been reported to be associated with preterm or
low-birth weight infants .
 Bacteriuria that persists or recurs after delivery has been associated
with pyelographic evidence of chronic infection, obstructive lesions,
and congenital abnormalities.
 The American Academy of Pediatrics and the American College of
Obstetricians and Gynaecologists (2007), as well as a U.S. Preventative
Task Force (2006), recommends screening for bacteriuria at the first
Anenatal visit,

27.  Cap.Amoxicillin 3 g
 Cap.Ampicillin 2 g
 Cap. Cephalosporin 2 g
 Tab. Nitrofurantoin 200 mg
 Tab.Trimethoprim-sulfamethoxazole 320/1600 mg

28.  Amoxicillin 500 mg three times daily
 Ampicillin 250 mg four times daily
 Cephalosporin 250 mg four times daily
 Ciprofloxacin 250 mg twice daily
 Levofloxacin 250 mg daily
 Nitrofurantoin 50 to 100 mg four times daily; 100 mg
twice daily
 Trimethoprim-sulfamethoxazole 160/800 mg two
times daily

29.  Nitrofurantoin 100 mg four times daily for 10 days
 Nirofurantoin 100 mg twice daily fo 7 days
 Nitrofurantoin 100 mg at bedtime for 10 days

30.  Treatment failures
Nitrofurantoin 100 mg four times daily for 21 days
 Suppression for bacterial persistence or recurrence
Nitrofurantoin 100 mg at bedtime for remainder of pregnancy

31.  Bacteriuria responds to empirical treatment with any of several
antimicrobial .
 selection based on in vitro susceptibilities,
 empirical oral treatment for 10 days with nitrofurantoin
macrocrystals, 100 mg at bedtime, is usually effective.
 regardless of regimen given, the recurrence rate is approximately
30 percent.
 For recurrences, nitrofurantoin, 100 mg orally at bedtime for 21
days
 For women with persistent or frequent bacteriuria recurrences,
suppressive therapy for the remainder of pregnancy can be given.

32. most common bacterial infections during pregnancy
Organisms that cause urinary infections are those from the
normal perineal flora.
Most Common bacteria:--E .coli.

33.  puerperium-several risk factors exist that predispose a woman to
urinary infections.
 Bladder sensitivity to intravesical fluid tension is decreased as a
consequence of the trauma of labor as well as conduction analgesia
 Sensation of bladder distension diminishes by discomfort caused by
an episiotomy, periurethral lacerations, or vaginal wall hematomas.
 Normal postpartum diuresis may worsen bladder over distension.
 Catheterization to relieve retention and distension commonly leads
to urinary infection (usually no long-term sequelae )
 Operative and instrumental delivery delays early mobilization of
patient.
 Retention of urine is also common as in pearly pregnancy .

34.  Cystitis is characterized by dysuria, urgency, and frequency, but
with few associated systemic findings.
 Pyuria and bacteriuria are usually found.
 Microscopic hematuria is common, and occasionally there is gross
hematuria from hemorrhagic cystitis .
 usually uncomplicated, but the upper urinary tract may become
involved by ascending infection
 Lower urinary tract symptoms with pyouria accompanied by a
sterile urine culture may be from urethritis caused by Chlamydia
trachomatis.

35.  Women with cystitis respond readily to any of several
regimens.
 Most of the three-day regimens listed previously are usually
90-percent effective .
 Single-dose therapy is less effective, and if it is used,
concomitant pyelonephritis must be confidently excluded.
 Mucopurulent cervicitis usually coexists- erythromycin
therapy is effective

36.  Renal infection is the most common serious medical
complication of pregnancy
 Increased risk in second trimester, nullipara and young age
 It is usually unilateral in most of cases .
 Right-sided in more than half of cases.
 Bilateral in one fourth cases.

37.  pyelonephritis - one of the leading cause of septic shock
during pregnancy
 urosepsis may be related to an increased incidence of
cerebral palsy in preterm infants(prematurity and birth
trauma to prmature head , asphyxia are the contributory
factors ) .
 Fortunately, there are no serious long-term maternal
sequelae .

38.  abrupt onset of fever
 shaking chills
 aching pain in one or both lumbar regions.
 Anorexia
 nausea and vomiting(leads to dehydration).
 Tenderness in one or both costovertebral angles.

39.  respiratory insufficiency from endotoxin-induced alveolar
injury(may lead to)
 frank pulmonary) edema
 In some cases, pulmonary injury may be so severe that it
causes acute respiratory distress syndrome (ARDS)

40.  Bacteraemia demonstrated in 15 to 20 percent patients.
 Incidence-E. Coli( isolated from urine or blood) in 70 to 80
percent of infections.
 Klebsiella pneumoniae in 3 to 5 percent
 Enterobacter or Proteus in 3 to 5 percent
 gram-positive organisms including group B Streptococcus in
up to 10 percent of cases.

41.  Hospitalize the patient.
 Obtain mid stream catch of urine for culture and sensitivity. Send blood also for
culture.
 Evaluate hemogram, serum creatinine, and Serum electrolytes.
 Monitor vital signs frequently, including urinary output—consider indwelling
catheterization.
 Establish urinary output to 50 mL/hr with intravenous crystalloid.
 Administer intravenous antimicrobial therapy .
 Obtain chest radiograph if there is dyspnea or tachypnea.
 Repeat hematology and blood chemistry studies after 48 hours.
 Change to oral antimicrobials when patient becomes afebrile.
 Discharge when patient remain afebrile for 24 hours, continue same
antimicrobial therapy for 7 to 10 days
 Repeat urine culture 1 to 2 weeks after antimicrobial therapy is completed.

42.  To start with antimicrobial therapy is usually
empirical, ampicillin 500-100mg IV 6hrly plus gentamycin
80mg IM bid / cefazolin or ceftriaxone or an extended-
spectrum antibiotics give response in 95-percent cases.

43.  If there is no clinical improvement by 48 to 72 hours, then USG is done to look
for urinary tract obstruction indicate by presence of abnormal ureteric or
pyelocaliceal dilatation .
 some women may have calculi.
 If stones are strongly suspected despite a non diagnostic USG examination, a
plain abdominal radiograph should be performed ; it identifies nearly 90
percent stones, single X-Ray exposure is usually not hazardous to fetus.
 others-Intravenous pyelography . The modified one-shot pyelogram—a single
radiograph obtained 30 minutes after contrast injection—almost always
provides adequate imaging .It is to be done after discussing the pross and cons
of benefit to mother and Xray exposure hazard to fetus ----as exposuredoes and
duration both are > simple Xray.
 Magnetic resonance urography may be used safely .
 Other causes of persistent infection are an intra renal or peri nephric abscess or
phlegmon

44.  Obstruction can be relieved by cystoscopic placement of a
double-J ureteral stent .
 these stents tend to become encrusted, percutaneous
nephrostomy - a better option as the stents are easier to
replace.
 Surgical removal of stones may be required in some cases.

45.  Recurrent infection—either covert or symptomatic—is
common and develops in 30 to 40 percent of women
following completion of treatment for pyelonephritis
 Nitrofurantoin, 100 mg orally at bedtime, is given for
the remainder of the pregnancy.

 this regimen reduces recurrence of bacteriuria.

46.  chronic interstitial nephritis that classically was thought to be due
chronic pyelonephritis.
 radiologicaly identified scarring is frequently accompanied by
ureteric reflux with voiding-hence it is termed reflux nephropathy.
 Long-term complications include hypertension, which may be
quite severe if there is demonstrable renal damage.
 After surgical correction, half of these women have bacteriuria
when pregnant .
 Maternal and fetal prognosis depends on the extent of renal
destruction.