2. DEFINITIONSDEFINITIONS
UTIUTI
Asymptomatic (subclinical infection) or symptomaticAsymptomatic (subclinical infection) or symptomatic
(disease)(disease)
Asymptomatic bacteriuria (ASB)Asymptomatic bacteriuria (ASB)
CystitisCystitis
ProstatitisProstatitis
PyelonephritisPyelonephritis
Catheter-associated bacteriuriaCatheter-associated bacteriuria
symptomatic (CAUTI) or asymptomaticsymptomatic (CAUTI) or asymptomatic
3. Asymptomatic bacteriuria (ASB)Asymptomatic bacteriuria (ASB)
Clinical criterionClinical criterion
No local or systemic symptoms or signs referable toNo local or systemic symptoms or signs referable to
the urinary tractthe urinary tract
Microbiologic criterionMicrobiologic criterion
≥≥10105
bacterial CFU/mLbacterial CFU/mL
except in catheter-associated disease, in which ≥10except in catheter-associated disease, in which ≥1022
CFU/mL is the cutoff.CFU/mL is the cutoff.
4. CystitisCystitis
Dysuria, urinary frequency, and urgencyDysuria, urinary frequency, and urgency
Nocturia, hesitancy, suprapubic discomfort, andNocturia, hesitancy, suprapubic discomfort, and
gross hematuriagross hematuria
Unilateral back or flank painUnilateral back or flank pain
upper urinary tractupper urinary tract
FeverFever
invasive infection of either the kidney or the prostateinvasive infection of either the kidney or the prostate
5. PyelonephritisPyelonephritis
Mild pyelonephritisMild pyelonephritis
low-grade feverlow-grade fever
with or without lower-back or costovertebral-angle painwith or without lower-back or costovertebral-angle pain
Severe pyelonephritisSevere pyelonephritis
high fever, rigors, nausea, vomiting, and flank and/or loinhigh fever, rigors, nausea, vomiting, and flank and/or loin
painpain
Symptoms are generally acute in onsetSymptoms are generally acute in onset
Symptoms of cystitis may not be presentSymptoms of cystitis may not be present
Fever of pyelonephritisFever of pyelonephritis
high spiking “picket-fence” pattern and resolves over 72 h of therapyhigh spiking “picket-fence” pattern and resolves over 72 h of therapy
Bacteremia develops in 20–30% of cases of pyelonephritis.Bacteremia develops in 20–30% of cases of pyelonephritis.
6. Pyelonephritis cont..Pyelonephritis cont..
DiabetesDiabetes
obstructive uropathy associated with acute papillaryobstructive uropathy associated with acute papillary
necrosisnecrosis
sloughed papillae obstruct the uretersloughed papillae obstruct the ureter
Papillary necrosis also evident inPapillary necrosis also evident in
pyelonephritis complicated by obstruction, sickle cellpyelonephritis complicated by obstruction, sickle cell
disease, analgesic nephropathy, or combinations of thesedisease, analgesic nephropathy, or combinations of these
conditionsconditions
Bilateral papillary necrosisBilateral papillary necrosis
Rapid rise in the serum creatinine levelRapid rise in the serum creatinine level
7. Pyelonephritis cont..Pyelonephritis cont..
EmphysematousEmphysematous
pyelonephritispyelonephritis
Production of gas inProduction of gas in
renal and perinephricrenal and perinephric
tissuestissues
Exclusively in diabeticExclusively in diabetic
patientspatients
8. Pyelonephritis cont..Pyelonephritis cont..
Xanthogranulomatous pyelonephritisXanthogranulomatous pyelonephritis
Chronic urinary obstruction (staghorn calculi), togetherChronic urinary obstruction (staghorn calculi), together
with chronic infection, leads to suppurative destruction ofwith chronic infection, leads to suppurative destruction of
renal tissuerenal tissue
On pathologic examinationOn pathologic examination
residual renal tissue frequently has a yellow coloration, withresidual renal tissue frequently has a yellow coloration, with
infiltration by lipid-laden macrophagesinfiltration by lipid-laden macrophages
Staghorn calculus, which has
been removed,
leaving a depression
Large staghorn
calculus
Areas of hemorrhage and necrosis with
collapse of cortical areas
10. ProstatitisProstatitis
Infectious and noninfectiousInfectious and noninfectious
InfectionsInfections
acute or chronicacute or chronic
almost always bacterialalmost always bacterial
less common than the noninfectious entity i.e.less common than the noninfectious entity i.e.
Chronic pelvic pain syndrome (formerly known asChronic pelvic pain syndrome (formerly known as
Chronic prostatitis)Chronic prostatitis)
11. Prostatitis cont..Prostatitis cont..
Acute bacterial prostatitisAcute bacterial prostatitis
Dysuria, frequency, and pain in the prostatic pelvic orDysuria, frequency, and pain in the prostatic pelvic or
perineal areaperineal area
Fever and chillsFever and chills
Symptoms of bladder outlet obstructionSymptoms of bladder outlet obstruction
Chronic bacterial prostatitisChronic bacterial prostatitis
more insidious onset as recurrent episodes of cystitismore insidious onset as recurrent episodes of cystitis
sometimes with associated pelvic and perineal painsometimes with associated pelvic and perineal pain
Men who present with recurrent cystitis should beMen who present with recurrent cystitis should be
evaluated for a prostatic focusevaluated for a prostatic focus
12. Complicated / Uncomplicated UTIComplicated / Uncomplicated UTI
Uncomplicated UTIUncomplicated UTI
acute cystitis or pyelonephritisacute cystitis or pyelonephritis
non-pregnant outpatient womennon-pregnant outpatient women
without anatomic abnormalities or instrumentation of thewithout anatomic abnormalities or instrumentation of the
urinary tracturinary tract
Complicated UTIComplicated UTI
symptomatic episode of cystitis or pyelonephritis in a man orsymptomatic episode of cystitis or pyelonephritis in a man or
womanwoman
with an anatomic predisposition to infection,with an anatomic predisposition to infection,
with a foreign body in the urinary tract, orwith a foreign body in the urinary tract, or
with factors predisposing to a delayed response to therapywith factors predisposing to a delayed response to therapy
13. EPIDEMIOLOGY ANDEPIDEMIOLOGY AND
RISK FACTORSRISK FACTORS
UTIUTI
More common in females than in malesMore common in females than in males
Except among infants and the elderlyExcept among infants and the elderly
Neonatal periodNeonatal period
Congenital urinary tract anomaliesCongenital urinary tract anomalies
After 50 years of ageAfter 50 years of age
Prostatic hypertrophyProstatic hypertrophy
Prevalence of ASBPrevalence of ASB
5% among women between ages 20 and 405% among women between ages 20 and 40
May be as high as 40–50% among elderly women and menMay be as high as 40–50% among elderly women and men
50–80% of women in the general population50–80% of women in the general population
at least one UTI during lifetime (uncomplicated cystitis)at least one UTI during lifetime (uncomplicated cystitis)
14. EPIDEMIOLOGY ANDEPIDEMIOLOGY AND
RISK FACTORS cont..RISK FACTORS cont..
Independent risk factors for acute cystitisIndependent risk factors for acute cystitis
Recent use of a diaphragm with spermicideRecent use of a diaphragm with spermicide
Frequent sexual intercourseFrequent sexual intercourse
History of UTIHistory of UTI
Diabetes mellitusDiabetes mellitus
IncontinenceIncontinence
15. EPIDEMIOLOGY ANDEPIDEMIOLOGY AND
RISK FACTORS cont..RISK FACTORS cont..
Many factors predisposing women to cystitis also
increase the risk of pyelonephritis
Factors independently associated with pyelonephritis in
young healthy women
Frequent sexual intercourse
New sexual partner
UTI in the previous 12 months
Maternal history of UTI
Diabetes
Incontinence
Pyelonephritis can occur without clear antecedent
cystitis
16. EPIDEMIOLOGY ANDEPIDEMIOLOGY AND
RISK FACTORS cont..RISK FACTORS cont..
About 20–30% of women who have had one
episode of UTI will have recurrent episodes
Early recurrence (within 2 weeks)
Regarded as relapse rather than reinfection
Need to evaluate the patient for a sequestered focus
17. EPIDEMIOLOGY ANDEPIDEMIOLOGY AND
RISK FACTORS cont..RISK FACTORS cont..
In pregnant womenIn pregnant women
ASB has clinical consequences, and both screeningASB has clinical consequences, and both screening
for and treatment of this condition are indicatedfor and treatment of this condition are indicated
Preterm birthPreterm birth
Perinatal death of the fetusPerinatal death of the fetus
Pyelonephritis in the motherPyelonephritis in the mother
Treatment of ASB in pregnant women decreases theTreatment of ASB in pregnant women decreases the
risk of pyelonephritis in mother by 75%risk of pyelonephritis in mother by 75%
18. EPIDEMIOLOGY ANDEPIDEMIOLOGY AND
RISK FACTORS cont..RISK FACTORS cont..
Men with UTIMen with UTI
Functional or anatomic abnormality of the urinaryFunctional or anatomic abnormality of the urinary
tracttract
Urinary obstruction secondary to prostatic hypertrophyUrinary obstruction secondary to prostatic hypertrophy
Lack of circumcisionLack of circumcision
19. EPIDEMIOLOGY ANDEPIDEMIOLOGY AND
RISK FACTORS cont..RISK FACTORS cont..
Women with DiabetesWomen with Diabetes
2-3 fold higher rate of ASB and UTI than women without2-3 fold higher rate of ASB and UTI than women without
diabetesdiabetes
There is insufficient evidence to make a correspondingThere is insufficient evidence to make a corresponding
statement about menstatement about men
Risk factors associated with UTI in women with diabetesRisk factors associated with UTI in women with diabetes
Increased duration of diabetesIncreased duration of diabetes
Use of insulin rather than oral medicationUse of insulin rather than oral medication
Poor bladder functionPoor bladder function
Obstruction in urinary flowObstruction in urinary flow
Incomplete voidingIncomplete voiding
Impaired cytokine secretionImpaired cytokine secretion
20. ETIOLOGYETIOLOGY
Uropathogens causing UTI vary by clinical syndromeUropathogens causing UTI vary by clinical syndrome
Enteric gram-negative rods predominateEnteric gram-negative rods predominate
Acute uncomplicated cystitisAcute uncomplicated cystitis
E. coliE. coli
75–90%75–90%
Staphylococcus saprophyticusStaphylococcus saprophyticus
5–15%5–15%
particularly frequent isolation from younger womenparticularly frequent isolation from younger women
Klebsiella, Proteus, Enterococcus, and Citrobacter species, along withKlebsiella, Proteus, Enterococcus, and Citrobacter species, along with
other organismsother organisms
5–10%5–10%
The spectrum of agents causing uncomplicated pyelonephritis isThe spectrum of agents causing uncomplicated pyelonephritis is
similar, with E. coli predominatingsimilar, with E. coli predominating
21. ETIOLOGY cont..ETIOLOGY cont..
In Complicated UTIIn Complicated UTI
E. coli remains the predominant organismE. coli remains the predominant organism
Aerobic gram-negative rodsAerobic gram-negative rods
Pseudomonas aeruginosa and Klebsiella, Proteus,Pseudomonas aeruginosa and Klebsiella, Proteus,
Citrobacter, Acinetobacter, and Morganella speciesCitrobacter, Acinetobacter, and Morganella species
Gram-positive bacteriaGram-positive bacteria
Enterococci and Staphylococcus aureusEnterococci and Staphylococcus aureus
YeastsYeasts
22. PATHOGENESISPATHOGENESIS
Ascending infection from the urethra to the bladder,Ascending infection from the urethra to the bladder,
continuing ascent up the ureter to the kidneycontinuing ascent up the ureter to the kidney
Any foreign body in the urinary tract, such as a urinaryAny foreign body in the urinary tract, such as a urinary
catheter or stone, provides an inert surface for bacterialcatheter or stone, provides an inert surface for bacterial
colonizationcolonization
Abnormal micturition and/or significant residual urineAbnormal micturition and/or significant residual urine
volume promotes true infectionvolume promotes true infection
In the simplest of terms, anything that increases theIn the simplest of terms, anything that increases the
likelihood of bacteria entering the bladder and staying therelikelihood of bacteria entering the bladder and staying there
increases the risk of UTI.increases the risk of UTI.
23. PATHOGENESIS cont..PATHOGENESIS cont..
Hematogenous spreadHematogenous spread
<2% of documented UTIs<2% of documented UTIs
Bacteremia caused by relatively virulent organismsBacteremia caused by relatively virulent organisms
Salmonella and S. aureusSalmonella and S. aureus
Focal abscesses or areas of pyelonephritis within a kidney andFocal abscesses or areas of pyelonephritis within a kidney and
result in positive urine culturesresult in positive urine cultures
Also the common route causing CandiduriaAlso the common route causing Candiduria
The presence of Candida in the urine of a non-instrumented-The presence of Candida in the urine of a non-instrumented-
immunocompetent patient impliesimmunocompetent patient implies
genital contaminationgenital contamination
potentially widespread visceral disseminationpotentially widespread visceral dissemination
25. Environmental FactorsEnvironmental Factors
Vaginal EcologyVaginal Ecology
Colonization of the vaginal introitus and periurethral areaColonization of the vaginal introitus and periurethral area
with organisms from the intestinal flora (usually E. coli)with organisms from the intestinal flora (usually E. coli)
Sexual intercourseSexual intercourse
Nonoxynol-9 in spermicideNonoxynol-9 in spermicide
toxic to the normal vaginal microfloratoxic to the normal vaginal microflora
increased risk of E. coli vaginal colonization and bacteriuriaincreased risk of E. coli vaginal colonization and bacteriuria
In postmenopausal womenIn postmenopausal women
previously predominant vaginal lactobacilli are replaced withpreviously predominant vaginal lactobacilli are replaced with
colonizing gram-negative bacteriacolonizing gram-negative bacteria
26. Environmental Factors cont..Environmental Factors cont..
Anatomic and Functional AbnormalitiesAnatomic and Functional Abnormalities
(Permits urinary stasis or obstruction)(Permits urinary stasis or obstruction)
Foreign bodiesForeign bodies
Stones, urinary cathetersStones, urinary catheters
Vesicoureteral refluxVesicoureteral reflux
Ureteral obstruction secondary to prostaticUreteral obstruction secondary to prostatic
hypertrophyhypertrophy
Neurogenic bladderNeurogenic bladder
Urinary diversion surgeryUrinary diversion surgery
27. Host FactorsHost Factors
Genetic backgroundGenetic background
Women with recurrent UTIWomen with recurrent UTI
first UTI before the age of 15 yearsfirst UTI before the age of 15 years
maternal history of UTImaternal history of UTI
Persistent vaginal colonization with E. coli, evenPersistent vaginal colonization with E. coli, even
during asymptomatic periods.during asymptomatic periods.
Vaginal and periurethral mucosal cells from suchVaginal and periurethral mucosal cells from such
women bind threefold more uropathogenic bacteriawomen bind threefold more uropathogenic bacteria
than do mucosal cells from other womenthan do mucosal cells from other women
28. Host Factors cont..Host Factors cont..
Mutations in host response genesMutations in host response genes
Toll-like receptors and IL-8 receptorToll-like receptors and IL-8 receptor
Linked to recurrent UTI and pyelonephritisLinked to recurrent UTI and pyelonephritis
Polymorphisms in the IL-8-specific receptor genePolymorphisms in the IL-8-specific receptor gene
CXCR1CXCR1
Increased susceptibility to pyelonephritisIncreased susceptibility to pyelonephritis
Lower-level expression of CXCR1 on the surface ofLower-level expression of CXCR1 on the surface of
neutrophils impairs neutrophil-dependent host defenseneutrophils impairs neutrophil-dependent host defense
against bacterial invasion of the renal parenchymaagainst bacterial invasion of the renal parenchyma
29. Microbial FactorsMicrobial Factors
Genetic virulence factorsGenetic virulence factors
Surface adhesinsSurface adhesins
P fimbriaeP fimbriae
Type 1 pilus (fimbria)Type 1 pilus (fimbria)
Mediate binding to specific receptors on the surfaceMediate binding to specific receptors on the surface
of uroepithelial cellsof uroepithelial cells
30. Microbial Factors cont..Microbial Factors cont..
P fimbriaeP fimbriae
Hair like protein structures that interact with a specificHair like protein structures that interact with a specific
receptor on renal epithelial cellsreceptor on renal epithelial cells
P denotes the ability of these fimbriae to bind to bloodP denotes the ability of these fimbriae to bind to blood
group antigen P, which contains a D-galactose-D-group antigen P, which contains a D-galactose-D-
galactose residuegalactose residue
Pyelonephritis and subsequent bloodstream invasion fromPyelonephritis and subsequent bloodstream invasion from
the kidneythe kidney
31. Microbial Factors cont..Microbial Factors cont..
Type 1 pilus (fimbria)Type 1 pilus (fimbria)
All E. coli strains possess but not all E. coli strains expressAll E. coli strains possess but not all E. coli strains express
Play a key role in initiating E. coli bladder infectionPlay a key role in initiating E. coli bladder infection
Mediate binding to uroplakins on the luminal surface ofMediate binding to uroplakins on the luminal surface of
bladder uroepithelial cellsbladder uroepithelial cells
initiates a complex series of signaling events that leads toinitiates a complex series of signaling events that leads to
apoptosis and exfoliation of uroepithelial cells, with the attachedapoptosis and exfoliation of uroepithelial cells, with the attached
E. coli organisms carried away in the urineE. coli organisms carried away in the urine
32. DIAGNOSTIC TOOLSDIAGNOSTIC TOOLS
HistoryHistory
High predictive value in uncomplicated cystitisHigh predictive value in uncomplicated cystitis
Women presenting with at least one symptom of UTIWomen presenting with at least one symptom of UTI
(dysuria, frequency, hematuria, or back pain) and without(dysuria, frequency, hematuria, or back pain) and without
complicating factorscomplicating factors
the probability of acute cystitis or pyelonephritis is 50%the probability of acute cystitis or pyelonephritis is 50%
If vaginal discharge and complicating factors are absent andIf vaginal discharge and complicating factors are absent and
risk factors for UTI are presentrisk factors for UTI are present
the probability of UTI is close to 90%, and no laboratory evaluationthe probability of UTI is close to 90%, and no laboratory evaluation
is neededis needed
Combination of dysuria and urinary frequency in the absenceCombination of dysuria and urinary frequency in the absence
of vaginal dischargeof vaginal discharge
increases the probability of UTI to 96%increases the probability of UTI to 96%
33. DIAGNOSTIC TOOLS cont..DIAGNOSTIC TOOLS cont..
Limitation of history alone as diagnostic toolLimitation of history alone as diagnostic tool
Did not enroll children, adolescents, pregnantDid not enroll children, adolescents, pregnant
women, men, or patients with complicated UTIwomen, men, or patients with complicated UTI
Sexually transmitted disease, caused by ChlamydiaSexually transmitted disease, caused by Chlamydia
trachomatis in particular, may be inappropriatelytrachomatis in particular, may be inappropriately
treated as UTItreated as UTI
Female patients under the age of 25Female patients under the age of 25
36. DIAGNOSTIC TOOLS cont..DIAGNOSTIC TOOLS cont..
Urine Dipstick TestUrine Dipstick Test
NitriteNitrite
Leukocyte esterase testLeukocyte esterase test
BloodBlood
Enterobacteriaceae convert nitrate to nitrite, and enough nitriteEnterobacteriaceae convert nitrate to nitrite, and enough nitrite
must accumulate in the urine to reach the threshold of detectionmust accumulate in the urine to reach the threshold of detection
If a woman with acute cystitis is forcing fluids and voiding frequently, theIf a woman with acute cystitis is forcing fluids and voiding frequently, the
dipstick test for nitrite is less likely to be positive, even when E. coli isdipstick test for nitrite is less likely to be positive, even when E. coli is
presentpresent
Leukocyte esterase testLeukocyte esterase test
detects this enzyme in the host’s polymorphonuclear leukocytes in thedetects this enzyme in the host’s polymorphonuclear leukocytes in the
urine, whether the cells are intact or lysedurine, whether the cells are intact or lysed
37. DIAGNOSTIC TOOLS cont..DIAGNOSTIC TOOLS cont..
Negative dipstick testNegative dipstick test
not sufficiently sensitive to rule out bacteriuria innot sufficiently sensitive to rule out bacteriuria in
pregnant womenpregnant women, in whom it is important to detect, in whom it is important to detect
all episodes of bacteriuriaall episodes of bacteriuria
Performance characteristics of the dipstick testPerformance characteristics of the dipstick test
MenMen
highly specifichighly specific
Non-catheterized nursing home residentsNon-catheterized nursing home residents
highly sensitivehighly sensitive
38. DIAGNOSTIC TOOLS cont..DIAGNOSTIC TOOLS cont..
Urine microscopyUrine microscopy
Pyuria in nearly all cases of cystitisPyuria in nearly all cases of cystitis
Hematuria in ~30% of casesHematuria in ~30% of cases
39. DIAGNOSTIC TOOLS cont..DIAGNOSTIC TOOLS cont..
Urine cultureUrine culture
Diagnostic “gold standard” for UTIDiagnostic “gold standard” for UTI
Women with symptoms of cystitisWomen with symptoms of cystitis
Colony count threshold of >102 bacteria/mL is moreColony count threshold of >102 bacteria/mL is more
sensitive (95%) and specific (85%) than a threshold ofsensitive (95%) and specific (85%) than a threshold of
105/mL105/mL
Acute cystitis in womenAcute cystitis in women
MenMen
Minimal level indicating infection appears to be 103/mLMinimal level indicating infection appears to be 103/mL
40.
41.
42.
43. TREATMENTTREATMENT
Antimicrobial therapy is warranted for any symptomaticAntimicrobial therapy is warranted for any symptomatic
UTIUTI
The choice of antimicrobial agent and the dose andThe choice of antimicrobial agent and the dose and
duration of therapy depend onduration of therapy depend on
Site of infectionSite of infection
Presence or absence of complicating conditionsPresence or absence of complicating conditions
Antimicrobial resistance patternAntimicrobial resistance pattern
E. coli ST131E. coli ST131
predominant multilocus sequence type found worldwide aspredominant multilocus sequence type found worldwide as
the cause of multidrug-resistant UTIthe cause of multidrug-resistant UTI
44. UNCOMPLICATED CYSTITIS INUNCOMPLICATED CYSTITIS IN
WOMENWOMEN
In 1999, TMP-SMX was recommended as the first-lineIn 1999, TMP-SMX was recommended as the first-line
agent for treatment of uncomplicated UTIagent for treatment of uncomplicated UTI
Collateral damageCollateral damage
Adverse ecologic effects of antimicrobial therapy, includingAdverse ecologic effects of antimicrobial therapy, including
killing of the normal flora and selection of drug-resistantkilling of the normal flora and selection of drug-resistant
organismsorganisms
Drugs with minimal effect on fecal floraDrugs with minimal effect on fecal flora
Pivmecillinam, Fosfomycin, and NitrofurantoinPivmecillinam, Fosfomycin, and Nitrofurantoin
Drugs that affect the fecal flora more significantlyDrugs that affect the fecal flora more significantly
Trimethoprim, TMP-SMX, quinolones, and ampicillinTrimethoprim, TMP-SMX, quinolones, and ampicillin
TREATMENTTREATMENT
45. UNCOMPLICATED CYSTITIS INUNCOMPLICATED CYSTITIS IN
WOMEN cont..WOMEN cont..
First-line agentsFirst-line agents
TMP-SMX and NitrofurantoinTMP-SMX and Nitrofurantoin
Second-line agentsSecond-line agents
Fluoroquinolone and β-lactamsFluoroquinolone and β-lactams
Optimal setting for empirical use of TMP-SMXOptimal setting for empirical use of TMP-SMX
uncomplicated UTI in a female patientuncomplicated UTI in a female patient
who has an established relationship with the practitionerwho has an established relationship with the practitioner
who can thus seek further care if her symptoms do notwho can thus seek further care if her symptoms do not
respond promptlyrespond promptly
TREATMENTTREATMENT
46. UNCOMPLICATED CYSTITIS INUNCOMPLICATED CYSTITIS IN
WOMEN cont..WOMEN cont..
NitrofurantoinNitrofurantoin
Resistance is lowResistance is low
Highly active against E. coli and most non–E. coliHighly active against E. coli and most non–E. coli
isolatesisolates
Proteus, Pseudomonas, Serratia, Enterobacter, andProteus, Pseudomonas, Serratia, Enterobacter, and
yeasts are all intrinsically resistant to this drugyeasts are all intrinsically resistant to this drug
Does not reach significant levels in tissue and cannotDoes not reach significant levels in tissue and cannot
be used to treat pyelonephritis.be used to treat pyelonephritis.
TREATMENTTREATMENT
47. UNCOMPLICATED CYSTITIS INUNCOMPLICATED CYSTITIS IN
WOMEN cont..WOMEN cont..
Most fluoroquinolones (ofloxacin, ciprofloxacin, andMost fluoroquinolones (ofloxacin, ciprofloxacin, and
levofloxacin)levofloxacin)
Highly effective as short-course therapy for cystitisHighly effective as short-course therapy for cystitis
ExceptionException
MoxifloxacinMoxifloxacin
may not reach adequate urinary levelsmay not reach adequate urinary levels
Fluoroquinolone resistanceFluoroquinolone resistance
Emergence of C. difficile outbreaks in hospital settingsEmergence of C. difficile outbreaks in hospital settings
Most experts now call for restricting fluoroquinolones to specificMost experts now call for restricting fluoroquinolones to specific
instancesinstances
uncomplicated cystitis in which other antimicrobial agents are not suitableuncomplicated cystitis in which other antimicrobial agents are not suitable
Use in adults >60 years of ageUse in adults >60 years of age
increased risk of Achilles tendon ruptureincreased risk of Achilles tendon rupture
TREATMENTTREATMENT
48. UNCOMPLICATED CYSTITIS INUNCOMPLICATED CYSTITIS IN
WOMEN cont..WOMEN cont..
Except for pivmecillinam, β-lactam agentsExcept for pivmecillinam, β-lactam agents
generally not preferred as TMP-SMX or fluoroquinolones ingenerally not preferred as TMP-SMX or fluoroquinolones in
acute cystitisacute cystitis
Urinary analgesicsUrinary analgesics
PhenazopyridinePhenazopyridine
NauseaNausea
Combination of analgesics withCombination of analgesics with
urinary antiseptics (methenamine, methylene blue)urinary antiseptics (methenamine, methylene blue)
urine-acidifying agent (sodium phosphate)urine-acidifying agent (sodium phosphate)
antispasmodic agent (hyoscyamine)antispasmodic agent (hyoscyamine)
TREATMENTTREATMENT
50. PYELONEPHRITISPYELONEPHRITIS
Acute uncomplicated pyelonephritisAcute uncomplicated pyelonephritis
FluoroquinolonesFluoroquinolones
First-line therapyFirst-line therapy
7-day course of therapy with oral ciprofloxacin (500 mg twice daily,7-day course of therapy with oral ciprofloxacin (500 mg twice daily,
with or without an initial IV 400-mg dose)with or without an initial IV 400-mg dose)
Oral TMP-SMX (one DS tablet twice daily for 14 days)Oral TMP-SMX (one DS tablet twice daily for 14 days)
If the pathogen’s susceptibility is not known and TMP-SMX is used,If the pathogen’s susceptibility is not known and TMP-SMX is used,
an initial IV 1-g dose of ceftriaxone is recommendedan initial IV 1-g dose of ceftriaxone is recommended
Options for parenteral therapyOptions for parenteral therapy
Fluoroquinolones, extended-spectrum cephalosporin with or withoutFluoroquinolones, extended-spectrum cephalosporin with or without
an aminoglycoside, or a carbapeneman aminoglycoside, or a carbapenem
TREATMENTTREATMENT
51. PYELONEPHRITIS cont..PYELONEPHRITIS cont..
Combinations of a β-lactam and a β-lactamase inhibitorCombinations of a β-lactam and a β-lactamase inhibitor
Ampicillin-sulbactamAmpicillin-sulbactam
Ticarcillin-clavulanateTicarcillin-clavulanate
Piperacillin-tazobactamPiperacillin-tazobactam
Imipenem-cilastatinImipenem-cilastatin
TREATMENTTREATMENT
More complicated historiesMore complicated histories
Previous episodes of pyelonephritisPrevious episodes of pyelonephritis
Recent urinary tract manipulationsRecent urinary tract manipulations
52. UTI IN PREGNANT WOMENUTI IN PREGNANT WOMEN
Nitrofurantoin, ampicillin, and cephalosporinsNitrofurantoin, ampicillin, and cephalosporins
Relatively safe in early pregnancyRelatively safe in early pregnancy
Sulfonamides should be avoided both inSulfonamides should be avoided both in
First trimesterFirst trimester
Possible teratogenic effectsPossible teratogenic effects
Near termNear term
KernicterusKernicterus
Fluoroquinolones are avoidedFluoroquinolones are avoided
Possible adverse effects on fetal cartilage developmentPossible adverse effects on fetal cartilage development
Asymptomatic or symptomatic UTIAsymptomatic or symptomatic UTI
Ampicillin and cephalosporinsAmpicillin and cephalosporins
Overt pyelonephritisOvert pyelonephritis
Parenteral β-lactam with or without aminoglycosidesParenteral β-lactam with or without aminoglycosides
TREATMENTTREATMENT
53. UTI IN MENUTI IN MEN
GoalGoal
To eradicate the prostatic infection as well as the bladderTo eradicate the prostatic infection as well as the bladder
infectioninfection
7-14 day course of a fluoroquinolone or TMP-SMX7-14 day course of a fluoroquinolone or TMP-SMX
Acute bacterial prostatitisAcute bacterial prostatitis
2-4 weeks course2-4 weeks course
Documented chronic bacterial prostatitisDocumented chronic bacterial prostatitis
4-6 weeks course4-6 weeks course
Recurrences (chronic prostatitis)Recurrences (chronic prostatitis)
12 weeks course12 weeks course
TREATMENTTREATMENT
54. COMPLICATED UTICOMPLICATED UTI
Therapy for complicated UTITherapy for complicated UTI
must be individualized and guided by urine culture resultsmust be individualized and guided by urine culture results
Xanthogranulomatous pyelonephritisXanthogranulomatous pyelonephritis
NephrectomyNephrectomy
Emphysematous pyelonephritisEmphysematous pyelonephritis
Percutaneous drainage can be used as the initial therapyPercutaneous drainage can be used as the initial therapy
followed by elective nephrectomy as needed.followed by elective nephrectomy as needed.
Papillary necrosis with obstructionPapillary necrosis with obstruction
intervention to relieve the obstruction and to preserve renalintervention to relieve the obstruction and to preserve renal
function.function.
TREATMENTTREATMENT
55. ASYMPTOMATIC BACTERIURIAASYMPTOMATIC BACTERIURIA
Treatment of ASBTreatment of ASB
Pregnant womenPregnant women
Persons undergoing urologic surgeryPersons undergoing urologic surgery
Neutropenic patientsNeutropenic patients
Renal transplant recipientsRenal transplant recipients
TREATMENTTREATMENT
56. CATHETER-ASSOCIATED UTICATHETER-ASSOCIATED UTI
CAUTICAUTI
Bacteriuria and symptoms in a catheterized patientBacteriuria and symptoms in a catheterized patient
Signs and symptomsSigns and symptoms
Localized to the urinary tractLocalized to the urinary tract
Unexplained systemic manifestations, such as feverUnexplained systemic manifestations, such as fever
Threshold for bacteriuria to meet the definition of CAUTI isThreshold for bacteriuria to meet the definition of CAUTI is
≥10≥1033
CFU/mLCFU/mL
Catheter changeCatheter change
7-14 day course of antibiotics is recommended7-14 day course of antibiotics is recommended
Intermittent catheterization may be preferable toIntermittent catheterization may be preferable to
certain populations (e.g., spinal cord-injured persons)certain populations (e.g., spinal cord-injured persons)
TREATMENTTREATMENT
57. CANDIDURIACANDIDURIA
Common complication of indwelling catheterizationCommon complication of indwelling catheterization
patients in the intensive care unitpatients in the intensive care unit
broad-spectrum antimicrobial drugsbroad-spectrum antimicrobial drugs
diabetes mellitusdiabetes mellitus
>50% of urinary Candida isolates>50% of urinary Candida isolates
non-albicans speciesnon-albicans species
Clinical presentationClinical presentation
asymptomatic laboratory finding to pyelonephritis and evenasymptomatic laboratory finding to pyelonephritis and even
sepsissepsis
Removal of the urethral catheter in asymptomatic casesRemoval of the urethral catheter in asymptomatic cases
TREATMENTTREATMENT
58. CANDIDURIACANDIDURIA
Treatment for candiduriaTreatment for candiduria
Symptomatic cystitis or pyelonephritisSymptomatic cystitis or pyelonephritis
High risk for disseminated diseaseHigh risk for disseminated disease
NeutropeniaNeutropenia
Undergoing urologic manipulationUndergoing urologic manipulation
Clinically unstableClinically unstable
Low-birth-weight infantsLow-birth-weight infants
Fluconazole (200–400 mg/d for 14 days)Fluconazole (200–400 mg/d for 14 days)
Candida isolates with high levels of resistance to fluconazoleCandida isolates with high levels of resistance to fluconazole
oral flucytosine and/ or parenteral amphotericin Boral flucytosine and/ or parenteral amphotericin B
Bladder irrigation with amphotericin B generally is not recommendedBladder irrigation with amphotericin B generally is not recommended
TREATMENTTREATMENT
59. PREVENTION OFPREVENTION OF
RECURRENT UTI INRECURRENT UTI IN
WOMENWOMEN Recurrence of uncomplicated cystitis inRecurrence of uncomplicated cystitis in
reproductive-age women is commonreproductive-age women is common
Preventive strategy is indicated if recurrent UTIsPreventive strategy is indicated if recurrent UTIs
are interfering with a patient’s lifestyleare interfering with a patient’s lifestyle
Three prophylactic strategies are available:Three prophylactic strategies are available:
ContinuousContinuous
PostcoitalPostcoital
Patient-initiated therapyPatient-initiated therapy
60. PREVENTION OF RECURRENTPREVENTION OF RECURRENT
UTI IN WOMEN cont..UTI IN WOMEN cont..
Continuous prophylaxis and post-coital prophylaxisContinuous prophylaxis and post-coital prophylaxis
Low doses of TMP-SMX, a fluoroquinolone, orLow doses of TMP-SMX, a fluoroquinolone, or
nitrofurantoinnitrofurantoin
Prescribed for 6 months and then discontinued, at whichPrescribed for 6 months and then discontinued, at which
point the rate of recurrent UTI often returns to baselinepoint the rate of recurrent UTI often returns to baseline
If bothersome infections recur, the prophylactic program canIf bothersome infections recur, the prophylactic program can
be reinstituted for a longer periodbe reinstituted for a longer period
Patient-initiated therapyPatient-initiated therapy
Supplying the patient with materials for urine cultureSupplying the patient with materials for urine culture
Course of antibiotics for self-medication at the firstCourse of antibiotics for self-medication at the first
symptoms of infectionsymptoms of infection
Urine culture is refrigerated and delivered to the physician’sUrine culture is refrigerated and delivered to the physician’s
office for confirmation of the diagnosisoffice for confirmation of the diagnosis
61. PROGNOSISPROGNOSIS
CystitisCystitis
Risk factor for recurrent cystitis and pyelonephritisRisk factor for recurrent cystitis and pyelonephritis
ASBASB
Common among elderly and catheterized patientsCommon among elderly and catheterized patients
Does not in itself increase the risk of deathDoes not in itself increase the risk of death
In the absence of anatomic abnormalitiesIn the absence of anatomic abnormalities
Recurrent infection in children and adults does not lead to chronic pyelonephritisRecurrent infection in children and adults does not lead to chronic pyelonephritis
or to renal failureor to renal failure
Chronic interstitial nephritisChronic interstitial nephritis
Analgesic abuse, obstruction, reflux, and toxin exposureAnalgesic abuse, obstruction, reflux, and toxin exposure
In the presence of underlying renal abnormalities (particularly obstructingIn the presence of underlying renal abnormalities (particularly obstructing
stones)stones)
Infection as a secondary factor can accelerate renal parenchymal damageInfection as a secondary factor can accelerate renal parenchymal damage
In spinal cord–injured patientsIn spinal cord–injured patients
Long term indwelling bladder catheter is a well-documented risk factor forLong term indwelling bladder catheter is a well-documented risk factor for
bladder cancerbladder cancer
62. THANK YOUTHANK YOU
REFERENCESREFERENCES
Harrison’s Principle of Internal Medicine 19Harrison’s Principle of Internal Medicine 19thth
ed.ed.
Kumar and Clarks clinical medicine 19Kumar and Clarks clinical medicine 19thth
eded
Davidson’s Principle and Practice of MedicineDavidson’s Principle and Practice of Medicine
2222ndnd
eded
Editor's Notes
Emphysematous pyelonephritis.
Infection of the right kidney of a diabetic man by Escherichia coli, a gas-forming, facultative anaerobic uropathogen, has led to destruction of the renal parenchyma (arrow) and tracking of gas through the retroperitoneal space (arrowhead).
Recurrent UTI is not necessarily complicated
Cystitis is temporally related to recent sexual intercourse in a dose-response manner, with an increased relative risk ranging from 1.4 with one episode of intercourse to 4.8 with five episodes of intercourse in the preceding week.
The implication of collateral damage in this context is that a drug that is highly efficacious for the treatment of UTI is not necessarily the optimal first-line agent if it also has pronounced secondary effects on the normal flora or is likely to change resistance patterns
β-lactams fail to eradicate uropathogens from the vaginal reservoir