UTI Lecture 11 6 2014

1. INFECTIONS OF THE URINARY
TRACT
NOVEMBER 6, 2014
Ank Nijhawan, MD, MPH
Division of Infectious Diseases

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. Infections of the urinary tract
 Urethritis
 Prostatitis
 Cystitis
 Pyelonephritis
female
male

4. Outline
 Asymptomatic
bacteruria
 Urethritis
 Cystitis/Pyelonephrit
is
 Uncomplicated
 Complicated
 Epidemiology
 Pathogenesis
 Clinical presentation
 Microbiology
 Diagnosis
 Differential
diagnosis
 Treatment

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. Prevalence of Asymptomatic
Bacteruria
Nicholle et al, CID 2005, IDSA Guidelines

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. 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. 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. Cystitis, Pyelonephritis in
Women
 Epidemiology
 Pathogenesis
 Clinical presentation
 Microbiology
 Diagnosis
 Differential diagnosis
 Treatment

11. Epidemiology
 UTIs are a common occurrence in otherwise
healthy women
 Risk factors:
 History of UTI
 Sexual activity
 Spermicide use

12. Pathogenesis
 Colonization of vagina with fecal flora
 Cystitis: ascend urethra into bladder
 Pyelonephritis: pathogens ascend to kidneys
via ureters

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. 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. 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. Differential Diagnosis for
cysitis/pyelonephritis
 Vaginitis
 Urethritis
 Structural Urethral abnormalities (stricture)
 Painful bladder syndrome/interstitial cystitis
 Pelvic inflammatory disease
 Nephrolithiasis

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. 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. 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. 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. Interactions between mucosal surfaces and pathogens and
commensals during symptomatic UTI or asymptomatic bacterial
carriageIBC= intracellular bacterial community
Ragnarsdottir, Nature Reviews Urology, 2011

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. 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. 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. 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. 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. 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. 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. 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. Diagnosis
 Pyuria, WBC casts
 If no pyuira, consider alternate diagnosis or
obstruction
 Urine culture
 CT scan, Ultrasound if renal dysfunction

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. 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. What do you do if you see this?

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. 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. 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. What if you see this on CT?

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. 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. Results
 CXR with cavitary lesion
 HIV negative
 Urine AFB (collected at morning void, 20-
30cc):
 Mycobacterium Tuberculosis

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