4. Introduction
⢠Symptomatic
presence of micro
organisms within the
urinary tract
i.e., kidney, ureters,
bladder and urethra.
⢠Associated with
inflammation of
urinary tract.
5. ⢠Significant bacteriuria: presence of at least
105 bacteria/ml of urine.
⢠Asymptomatic bacteriuria : bacteriuria with
no
symptoms.
⢠Urethritis: infection of anterior urethral tract
*dysuria, urgency and frequency of urination.
⢠Cystitis: infection to urinary bladder
*dysuria, frequency and urgency, pyuria and
6. ⢠Acute pyelonephritis: infection of
one/both kidneys; sometimes lower tract
also.
*pyuria, fever, painful micturition
⢠Chronic pyelonephritis: particular type of
pathology of kidney; may/may not be
due to infection.
7. UTI - Terminology
⢠Uncomplicated: UTI without underlying renal or
neurologic disease.
⢠Complicated: UTI with underlying structural,
medical or neurologic disease.
⢠Recurrent : > 3 symptomatic UTIs within 12
months following clinical therapy.
⢠Reinfection: recurrent UTI caused by a different
pathogen at any time
⢠Relapse: recurrent UTI caused by same species
causing original UTI within 2 wks after therapy.
8. UTI
Upper Lower
â˘Acute pyleonephritis â˘Cystitis
â˘Chronic pyleonephriitis â˘Prostatitis
â˘Interstitial pyleonephritis â˘Urethritis
â˘Renal abscess
â˘Perirenal abscess
â˘Both upper & lower UTI are further divided into
complicated and uncomplicated.
9. Epidemiology
ď§ Seen in all age groups
ď§ Infants up to 6 months â 2/1000
ď§ More common in boys than girls
ď§ Women â at greater risk than men; prevalence
40-50% in women and 0.04% in men.
ď§ 10% women have recurrent UTI in their life
ď§ 7 million new cases of lower UTI / year
ď§ 1 million hospitalizations / year
ď§ Incidence of UTI increases in old age; 10% of
men and 20% of women are infected.
10. Etiology
⢠Acute uncomplicated UTI:
⢠Escherichia coli â cause about 80% of UTI
⢠20% of UTI caused by-
Gram negative enteric bacteria â Klebsiella,
Proteus
Gram positive cocci â Streptococcus
faecalis
Staphylococcus saprophyticus
⢠S.saprophyticus â restricted to infections in
young sexually active women.
11. Complicated UTI:
ď§ Pseudomonas aeruginosa, Enterobacter &
Serratia
ď§ Isolated in hospital acquired infections and
catheter associated UTI.
ď§ Viruses - Rubella, Mumps and HIV
ď§ Fungi - Candida, Histoplasma capsulatum
ď§ Protozoa - T. vaginalis, S. haematobium
12. 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
13. ⢠Ascending Infection:
ď§ most common route.
ď§ organisms ascend through urethra into
bladder.
organism
Colonize in
perineal and
periurethral areas
Ascend to
bladder,
kidneys
UTI
14. ⢠Hematogenous
spread:
ď§ Blood borne
spread to kidneys.
ď§ Occurs in
bacteraemia
mostly S.aureus.
15. ⢠Lymphatogenous spread:
ď§ Men- through rectal and colonic
lymphatic vessels to prostrate and
bladder.
ď§ Women- through periuterine lymphatics
to urinary tract.
⢠Direct extension from other organs:
ď§ Pelvic inflammatory diseases
ď§ Genito-urinary tract fistulas
16. ⢠The organism:
ď§ E.coli â many strains present but only few
cause infection.
ď§ Virulence factors:
1. fimbriae
2. resistance to serum bactericidal activity
; increased amounts of capsular K antigen
activity
3. toxin production
4. production of urease enzyme (proteus
sps)
23. ⢠Pyleonephritis:
ď§ Invasive nature
ď§ Suprapubic
tenderness
ď§ Fever and chills
ď§ White blood cell casts
in urine
ď§ Back pain
ď§ Nausea and vomiting
ďComplications include sepsis, septic shock
and death.
24. Clinical manifestations depending on age
⢠Babies and infants:
ď§ Failure to thrive
ď§ Fever
ď§ Apathy
ď§ Diarrhoea
⢠Children:
ď§ Dysuria, urgency, frequency
ď§ Haematuria
ď§ Acute abdominal pain
ď§ Vomiting
25. ⢠Adults:
ď§ Lower UTI- frequency, urgency,
dysuria,
haematuria
ď§ Upper UTI- fever, rigor and lion pain
and symptoms of lower UTI.
⢠Elderly patients:
ď§ Mostly asymptomatic
ď§ Not diagnostic as the symptoms are
common with age.
33. UTI
urinalysis
Urine microscopy and culture
Further investigation
pyelonephriti
Adult female Male s Children
Lower UTI Any UTI Complicated Any UTI
Treat without Blood
further Ultrasound cultures cystourethro
investigation cystoscopy CT scan graphy
Check renal
34. 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.
35. Anti-microbial therapy
⢠Goals of therapy:
ďź Elimination of infection
ďź Relief of acute symptoms
ďź Prevention of recurrence and long
term complications
⢠Decision to hospitalize ??
⢠Treatment considerations ??
36. ⢠Ideal antibiotic for UTI :
ď§ Adequate coverage over E.coli
ď§ Concentration in urine
ď§ Duration of therapy
ď§ Low resistance
ď§ Cost
ď§ Low adverse effect profile
37. Principles of anti microbial therapy
⢠Levels of antibiotic in urine but not in
blood
⢠Blood levels of antibiotic â important in
pyleonephritis
⢠Penicillins and cephalosporins â drugs of
choice for UTI with renal failure.
39. Single dose therapy
a. Trimethoprim- sulfamethaxole
bactrimâDS : TMPâ160mg + SMZâ800mg
co-trimoxazole-DS :TMP-160mg + SMZ-800mg
b. Amoxicillin- clavulnate 500mg
aceclav tab
acmox- AG tab
c. Amoxcillin 3gm
d. Ciprofloxacin 500mg â alquin tab
e. Norfloxacin 400mg â Actiflox-400 tab
40. ⢠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
41. 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
42. 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
47. Asymptomatic bacteriuria
⢠Children â treatment same as
symptomatic bacteriuria
⢠Adults â
treatment required in cases of
a. pregnancy
b. patient with obstructive structural
abnormalities
48. Bacteriuria in pregnancy
⢠To prevent risk of pyelonephritis
⢠7 day course with following antibiotics
ď§ Cephalaxin
ď§ Nitrofurantoin
ď§ Amoxicillin
⢠Therapy continued at regular intervals
of pregnancy.
49. Relapsing UTI
⢠7-10 day course
⢠If fails â 2week course / 6week course
⢠Structural abnormalities corrected by
surgery
⢠6week course â
a. children
b. adults with continuous symptoms
c. high risk of renal damage
50. Prophylaxis for UTI
⢠Single dose of trimethoprim 100mg /
nitrofurantion 50mg
⢠Long term low dose prophylaxis
beneficial
⢠Women- single dose of antibiotic after
sexual intercourse.
51. 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.
53. Sulfamethoxazole-trimethoprim
ď§ Adverse effects: Mechanism of action
o Steven Johnson's syndrome
o Dermatitis
o Angiodema
o GI disturbances
o Agranulocytosis
ď§ Contraindicated in
o Hypersensitivity to sulfa
drugs
o Infants
o Megaloblastic anaemia
54. nitrofurantoin
ď§ Damages bacterial DNA.
ď§ Reduced to reactive forms by bacterial
nitroreductase- damage DNA, ribosomes
ď§ Adverse effects:
o Hypersensitivity pneumonitis,GI
disturbances, haemolytic anaemia
ď§ Contraindications:
o Renal failure, neonates, pregnancy
55. Cefixime
ď§ 3rd generation cephalosporin
ď§ Disrupts synthesis of peptidoglycan of
bacterial cell wall
ď§ Adverse effects:
o Rash, utricaria
o Diarrhea
o Thrombocytopenia
o leucopenia
56. Amoxicillin
ď§ Penicillin class antibiotic
ď§ Inhibits cross linking of peptidoglycan
polymer chains which is the major
component of bacterial cell wall.
ď§ Adverse effects:
o Rash
o GI disturbances, renal dysfunction
o Antibiotic associated colitis, lethergy
ď§ Contraindications: penicillin
hypersensitivity
57. Ciprofloxacin
ď§ Fluoroquinoline antibiotic
ď§ Inhibits DNA gyrase and topisomerase 1V,
the enzymes necessary for separation of
bacterial DNA â inhibit cell division
ď§ Adverse effects:
o Peripheral neuropathy
o Rhabdomyolysis
o Steven Johnson's syndrome
o Hemolytic anaemia
58. Surgical treatment
a) Surgical removal of renal calculi,
bladder calculi
b) Ureteroplasty
c) Reimplatation of ureters if VUR
present
59. Conclusion
ď§ Urinary tract infections are the 2nd most
common bacterial infections.
ď§ Women are the most infected subjects in
the population.
ď§ Development of resistance to antibiotics
by the bacteria result in problems during
the treatment and lead to relapse or
recurrence.
ď§ Recent advances such as development of
immunologicals like intranasal vaccines
may result in life time cure of the infection
60. References
⢠Clinical pharmacy and therapeutics by
Roger Walker, Clive Edwards; 3rd edition;
page 503 â 511.
⢠Applied therapeutics the clinical use of
drugs by Mary Anne konda- kimble; 8th
edition; page456 â 465.