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INFECTIONS OF THE URINARY 
TRACT 
NOVEMBER 6, 2014 
Ank Nijhawan, MD, MPH 
Division of Infectious Diseases
Case 1 
 A 23 yo woman presents to clinic reporting lower abdominal 
pain and dysuria for 3 days. 
 On exam she is afebr...
Infections of the urinary tract 
 Urethritis 
 Prostatitis 
 Cystitis 
 Pyelonephritis 
female 
male
Outline 
 Asymptomatic 
bacteruria 
 Urethritis 
 Cystitis/Pyelonephrit 
is 
 Uncomplicated 
 Complicated 
 Epidemio...
What is Asymptomatic 
Bacteruria? 
 Isolation of bacteria >= 100,000 CFU/mL 
 On 2 separate specimens in women, 1 in men...
Prevalence of Asymptomatic 
Bacteruria 
Nicholle et al, CID 2005, IDSA Guidelines
Who to screen and treat for 
Asymptomatic Bacteruria: 
 Pregnant women (at least once early on) 
 Prior to Trans-Urethra...
Who NOT to screen/treat for 
Asymptomatic Bacteruria 
 Premenopausal nonpregnant women 
 Diabetic women 
 Older persons...
What about Funguria? 
 Common diagnosis in inpatients, candida 
 Usually a benign process 
 May be difficult to disting...
Cystitis, Pyelonephritis in 
Women 
 Epidemiology 
 Pathogenesis 
 Clinical presentation 
 Microbiology 
 Diagnosis 
...
Epidemiology 
 UTIs are a common occurrence in otherwise 
healthy women 
 Risk factors: 
 History of UTI 
 Sexual acti...
Pathogenesis 
 Colonization of vagina with fecal flora 
 Cystitis: ascend urethra into bladder 
 Pyelonephritis: pathog...
Microbiology 
 75%-95% E. coli 
 Enterobacteriaceae: 
 Proteus 
 Klebsiella 
 Staph saprophyticus 
 Frequent contami...
Clinical presentation of 
uncomplicated UTI in women 
Cystitis Pyelonephritis 
 Dysuria 
 Urinary frequency 
 Urgency 
...
Urinalysis 
 WBCs: >10 WBCs/microL in urine= pyuria 
 WBC casts: indicate upper tract infection 
 RBCs: Hematuria is co...
Differential Diagnosis for 
cysitis/pyelonephritis 
 Vaginitis 
 Urethritis 
 Structural Urethral abnormalities (strict...
IDSA Treatment algorithm for 
cystitis 
Woman with acute uncomplicated 
cystitis 
Absence of fever, flank pain? 
Able to t...
Antibiogram at UTSW/St. Paul 
 E. coli, urine 
 Ampicillin 45% 
 Amp/sulbactam 
49% 
 Pip/Tazo 
96% 
 Cefuroxime 88% ...
Treatment for Pyelonephritis 
 Indication to get a urine culture 
 Only Fluoroquinolones are approved as oral 
therapy f...
Recurrent UTIs in Women 
 25% of women will have a recurrent UTI within 6 months 
 Defined as >=2 infections in 6 mo or ...
Interactions between mucosal surfaces and pathogens and 
commensals during symptomatic UTI or asymptomatic bacterial 
carr...
Considerations in Men 
 Men are less likely to get UTIs due to longer 
urethra, drier peri-urethral area and 
antibacteri...
Acute v. Chronic Bacterial 
Prostatitis 
Acute Chronic 
Micro Similar to UTIs, urethritis Same 
Clinical presentation Feve...
Complicated Cystitis/Pyelonephritis 
Clinical Anatomic 
 Male gender (?) 
 Diabetes 
 Pregnancy 
 Acute Pyelo in past ...
Catheter-associated UTI 
 Most common health care associated infection 
worldwide 
Definition: 
 Signs and symptoms of U...
Limiting Unnecessary 
Catheterization 
 Incontinence, convenience not an indication 
 Remove catheters as soon as they a...
Catheter awareness survey 
 469 patients, 117 had a catheter 
 Providers were unaware of catheter 28% of 
time 
 21% st...
Microbiology of complicated UTI 
 E. coli, Proteus, Klebsiella, Staph 
saprophyticus 
 Pseudomonas, Serratia, and Provid...
Clinical presentation of 
complicated Pyelonephritis 
 Fever (>38ºC), chills, flank pain, costovertebral 
angle tendernes...
Diagnosis 
 Pyuria, WBC casts 
 If no pyuira, consider alternate diagnosis or 
obstruction 
 Urine culture 
 CT scan, ...
Treatment of complicated UTI 
 Cystitis: 
 Fluroquinolones, not moxifloxacin 
 Do not use Bactrim, fosfomycin, nitrofur...
Treatment of complicated UTI 
 Pyelonephritis 
 Initial treatment should be inpatient 
 If Mild-moderate: 
 Ceftriaxon...
What do you do if you see this?
Emphysematous UTI 
 Cystitis, Pyelitis, Pyelonephritis 
 Over 80% are in Diabetics; often women in 
60s 
 Abdominal pai...
Emphysematous UTI, 
management 
 Classification 
 Class 1- Pyelitis without obstruction or abscess– 
IV anbx 
 Class 2-...
Renal and Perinephric Abscess 
 Ascending infection (renal abscess) or 
hematogenous spread (perinephric abscess) 
 Trea...
What if you see this on CT?
Xanthogranulomatous 
Pyelonephritis 
 Unusual variant of chronic pyelonephritis 
 Destruction of the kidney from lipid l...
Case #2 
 18 yo man from Mexico 
 4 months of urinary urgency, incomplete 
emptying 
 3 months ago dysuria, hematuria 
...
Results 
 CXR with cavitary lesion 
 HIV negative 
 Urine AFB (collected at morning void, 20- 
30cc): 
 Mycobacterium ...
Summary 
 Urinary Tract Infections encompass infections of 
urethra, bladder, prostate, ureters and kidneys 
 Wide range...
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Uti

UTI Lecture 11 6 2014

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Uti

  1. 1. INFECTIONS OF THE URINARY TRACT NOVEMBER 6, 2014 Ank Nijhawan, MD, MPH Division of Infectious Diseases
  2. 2. Case 1  A 23 yo woman presents to clinic reporting lower abdominal pain and dysuria for 3 days.  On exam she is afebrile but has suprapubic discomfort.  A urinalysis is sent and shows positive leukocyte esterase, positive nitrite, 30 WBCs, no epis  Urine culture pending  What other questions do you want to ask?  Vaginal discharge? Sexually active? Back pain? Fever? N/V? History of PID?  Other exam findings?  CVA tenderness? Pelvic exam?  Other testing?  Consider pregnancy test, urine GC/CT, trichomonas testing, candida,Bacterial vaginosis, other STIs  Treatment? For how long?
  3. 3. Infections of the urinary tract  Urethritis  Prostatitis  Cystitis  Pyelonephritis female male
  4. 4. Outline  Asymptomatic bacteruria  Urethritis  Cystitis/Pyelonephrit is  Uncomplicated  Complicated  Epidemiology  Pathogenesis  Clinical presentation  Microbiology  Diagnosis  Differential diagnosis  Treatment
  5. 5. What is Asymptomatic Bacteruria?  Isolation of bacteria >= 100,000 CFU/mL  On 2 separate specimens in women, 1 in men  Appropriately collected urine sample  Absence of signs or symptoms of UTI  May or may not have pyuria
  6. 6. Prevalence of Asymptomatic Bacteruria Nicholle et al, CID 2005, IDSA Guidelines
  7. 7. Who to screen and treat for Asymptomatic Bacteruria:  Pregnant women (at least once early on)  Prior to Trans-Urethral Resection of the Prostate (TURP)  If positive, start treatment just prior to procedure  Stop after procedure unless catheter to remain in place  Prior to urologic procedures where mucosal bleeding is anticipated  Consider in women with catheter-associated bacteruria, if bacteruria persists after catheter removed
  8. 8. Who NOT to screen/treat for Asymptomatic Bacteruria  Premenopausal nonpregnant women  Diabetic women  Older persons living in community  Elderly institutionalized subjects  Persons with spinal cord injury  Catheterized patients where catheter remains in situ  *Pyuria with asymptomatic bacteruria is not a reason to treat
  9. 9. What about Funguria?  Common diagnosis in inpatients, candida  Usually a benign process  May be difficult to distinguish infection from colonization, pyuria and colony counts not helpful  Rarely develops into disseminated infection  If catheter in place, consider removal and repeat U/A and culture  If symptomatic, start antifungal treatment, fluconazole preferred if susceptible  Amphotericin bladder washes no longer recommended
  10. 10. Cystitis, Pyelonephritis in Women  Epidemiology  Pathogenesis  Clinical presentation  Microbiology  Diagnosis  Differential diagnosis  Treatment
  11. 11. Epidemiology  UTIs are a common occurrence in otherwise healthy women  Risk factors:  History of UTI  Sexual activity  Spermicide use
  12. 12. Pathogenesis  Colonization of vagina with fecal flora  Cystitis: ascend urethra into bladder  Pyelonephritis: pathogens ascend to kidneys via ureters
  13. 13. Microbiology  75%-95% E. coli  Enterobacteriaceae:  Proteus  Klebsiella  Staph saprophyticus  Frequent contaminants:*  Coag negative staph (other than S. saprophyticus)  Group B strep  Enterococci  Lactobacilli
  14. 14. Clinical presentation of uncomplicated UTI in women Cystitis Pyelonephritis  Dysuria  Urinary frequency  Urgency  Suprapubic pain  Fevers  Chills  Flank pain  CVA tenderness  Nausea, vomiting Why are symptoms important? 50% of women with 1 or more UTI symptoms will have a UTI 90% of women with dysuria/frequency but without vaginal irritation or discharge have a UTI Bent, JAMA, 2002
  15. 15. Urinalysis  WBCs: >10 WBCs/microL in urine= pyuria  WBC casts: indicate upper tract infection  RBCs: Hematuria is common in UTI, not vaginitis  Leukocyte esterase: used to detect >10WBCs/hpf  Nitrite: indicate >105 Enterobacteriaceae infection (which convert urinary nitrate to nitrite); can get false positives with pyridium or eating beets
  16. 16. Differential Diagnosis for cysitis/pyelonephritis  Vaginitis  Urethritis  Structural Urethral abnormalities (stricture)  Painful bladder syndrome/interstitial cystitis  Pelvic inflammatory disease  Nephrolithiasis
  17. 17. IDSA Treatment algorithm for cystitis Woman with acute uncomplicated cystitis Absence of fever, flank pain? Able to take oral medications? Consider Pyelonephritis or complicated UTI YES NO Nitrofurantoin 100mg bid x 5 d OR Bactrim DS po bid x 3 d OR Fosfomycin 3gm single dose OR Pivmecillinam •If none of these treatments are an option due to allergy, compliance, tolerability, may consider •Fluoroquinolones •Select Betalactams
  18. 18. Antibiogram at UTSW/St. Paul  E. coli, urine  Ampicillin 45%  Amp/sulbactam 49%  Pip/Tazo 96%  Cefuroxime 88%  Cefotaxime 95%  Ceftriaxone 95%  Ceftazidime 95%  Cefepime 95%  Ertapenem 99%  Meropenem 100%  Gentamicin 88%  Amikacin 99%  Tobramycin 87%  Ciprofloxacin 68%  Levofloxacin 69%  TMP/SMX 65%  Nitrofurantoin 96%
  19. 19. Treatment for Pyelonephritis  Indication to get a urine culture  Only Fluoroquinolones are approved as oral therapy for this  Consider possibility of resistance (e.g. ESBL)  If >10% resistance locally, consider broad spectrum antibiotics  May require admission/IV antibiotics
  20. 20. Recurrent UTIs in Women  25% of women will have a recurrent UTI within 6 months  Defined as >=2 infections in 6 mo or >=3 infections/1 year  Reinfection v. Relapse  Risk factors:  Genetic: nonsecretor uroepithelial cell; decreased IL-8 receptor/CXCR-1  Behavioral: spermicide, diaphragm, history of UTI  Pelvic anatomy: shorter distance between anus and urethra  Post-menopausal women, incontinence  Prophylaxis:  Post-coital voiding, discontinue spermicide/diaphragm  Cranberry juice (?)  Probiotics (suppository better)  Antibiotics  Estrogen cream
  21. 21. Interactions between mucosal surfaces and pathogens and commensals during symptomatic UTI or asymptomatic bacterial carriageIBC= intracellular bacterial community Ragnarsdottir, Nature Reviews Urology, 2011
  22. 22. Considerations in Men  Men are less likely to get UTIs due to longer urethra, drier peri-urethral area and antibacterial secretions from prostate  Some consider all UTIs in men to be complicated  Differential includes  prostatitis,  epididymitis,  urethritis
  23. 23. Acute v. Chronic Bacterial Prostatitis Acute Chronic Micro Similar to UTIs, urethritis Same Clinical presentation Fevers, chills, dysuria, pelvic, perineal pain, cloudy urine, obstructive symptoms, dribbling of urine Milder symptoms Exam Tender prostate, do not do vigorous prostatic massage BPH, edema, may have nontender prostate Diagnosis Urine culture Urine and prostate secretion culture Treatment FQ, Bactrim FQ Special considerations More common in HIV patients If presentation consistent, but cultures negative, consider Chlamydia
  24. 24. Complicated Cystitis/Pyelonephritis Clinical Anatomic  Male gender (?)  Diabetes  Pregnancy  Acute Pyelo in past year  Symptoms for >7 d PTA  Hospital Acquired Infection  Multiple drug resistance  Renal failure  Renal transplantation  Immunosuppression  Catheter, stent, nephrostomy  Recent urinary instrumentation  Obstruction  Anatomic abnormality  Urologic dysfunction
  25. 25. Catheter-associated UTI  Most common health care associated infection worldwide Definition:  Signs and symptoms of UTI in patient with indwelling catheter:  new onset or worsening of fever, rigors,  altered mental status, malaise, or lethargy with no other identified cause;  flank pain; costovertebral angle tenderness;  acute hematuria; pelvic discomfort;  >= 103 CFU of a single bacteria isolated from urine
  26. 26. Limiting Unnecessary Catheterization  Incontinence, convenience not an indication  Remove catheters as soon as they are no longer needed  Automatic discontinuation orders, Reminders  Use condom catheters in men when possible  Use a closed catheter system
  27. 27. Catheter awareness survey  469 patients, 117 had a catheter  Providers were unaware of catheter 28% of time  21% students  22% interns  27% residents  37% attendings  Catheter use was inappropriate 31% of patients  Catheter more likely to be appropriate if team aware of it (OR 3.7) Saint, AM J Med, 20000
  28. 28. Microbiology of complicated UTI  E. coli, Proteus, Klebsiella, Staph saprophyticus  Pseudomonas, Serratia, and Providencia species,  Enterococci  Staphylococci  Fungi  More likely to have resistant organisms
  29. 29. Clinical presentation of complicated Pyelonephritis  Fever (>38ºC), chills, flank pain, costovertebral angle tenderness, and nausea/vomiting  Sepsis, multiple system organ dysfunction  Shock, acute renal failure  May develop emphysematous UTI- cystitis, pyelitis, pyelonephritis or Perinephric abscess
  30. 30. Diagnosis  Pyuria, WBC casts  If no pyuira, consider alternate diagnosis or obstruction  Urine culture  CT scan, Ultrasound if renal dysfunction
  31. 31. Treatment of complicated UTI  Cystitis:  Fluroquinolones, not moxifloxacin  Do not use Bactrim, fosfomycin, nitrofurantoin unless known to be susceptible  May need IV treatment, Ceftriaxone, carbapenems, aminoglycosides  For enterococci, use Ampicillin
  32. 32. Treatment of complicated UTI  Pyelonephritis  Initial treatment should be inpatient  If Mild-moderate:  Ceftriaxone, Cefepime, Fluoroquinolones, Aztreonam  If Severe:  Carbapenem, Betalactam/betalactamase inhibitor such as Ampicillin/Sulbactam and Pipercillin/Tazobactam
  33. 33. What do you do if you see this?
  34. 34. Emphysematous UTI  Cystitis, Pyelitis, Pyelonephritis  Over 80% are in Diabetics; often women in 60s  Abdominal pain (rather than dysuria), most common presenting sign  Diagnosis made on imaging/CT scan
  35. 35. Emphysematous UTI, management  Classification  Class 1- Pyelitis without obstruction or abscess– IV anbx  Class 2- with disease limited to renal parenchyma- IV anbx with percutaneous drainage  Class 3- extension of gas into perinephric space  If AKI, thrombocytopenia, Shock, Altered mental status- nephrectomy and IV anbx  If only 1 or less of the above, can consider percutaneous drainage and IV anbx, nephrectomy if not improving  Class 4- bilateral disease or in solitary kidney  Percutaneous drainage and IV anbx, relief of obstruction
  36. 36. Renal and Perinephric Abscess  Ascending infection (renal abscess) or hematogenous spread (perinephric abscess)  Treat with IV Antibiotics, consider staph coverage if hematogenous spread  Renal abscess need percutaneous drainage if > 5 cm  Perinephric abscesses require drainage
  37. 37. What if you see this on CT?
  38. 38. Xanthogranulomatous Pyelonephritis  Unusual variant of chronic pyelonephritis  Destruction of the kidney from lipid laden macrophages (defect in microbial processing)  Most common in middle-aged women with recurrent UTIs  Micro: Escherichia coli, Proteus mirabilis, Pseudomonas aeruginosa, Enterococcus faecalis, and Klebsiella species  Treatment: IV Anbx, Partial or total nephrectomy  Consider Renal Cell CA
  39. 39. Case #2  18 yo man from Mexico  4 months of urinary urgency, incomplete emptying  3 months ago dysuria, hematuria  Also with cough, fever, night sweats  CT scan show asymmetric bladder wall thickening, hydronephrosis
  40. 40. Results  CXR with cavitary lesion  HIV negative  Urine AFB (collected at morning void, 20- 30cc):  Mycobacterium Tuberculosis
  41. 41. Summary  Urinary Tract Infections encompass infections of urethra, bladder, prostate, ureters and kidneys  Wide range of severity and clinical presentations from asymptomatic bacteriuria to complicated pyelonephritis  Consider urethritis, vaginitis, PID in women; prostatitis, epididymitis in men  Clinical presentation should guide management  Do not treat a urinalysis, treat the patient  Prudent use of fluoroquinolones  Get Urology involved early in complicated infections

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