Urinary Tract Infections
Dr. Sughosh Kulkarni
MBBS, MD, FDFSI
Case 1
• 73-year-old female with history of HTN and DM
• She was hypothermic with a temperature of 35.6O C and
tachycardic with a heart rate of 103
• Laboratory results showed significant leukocytosis with
increased white blood cell count
• Urine was cloudy in appearance,
• Positive for leukocyte esterase
• Microscopy > 50 WBC/HPF
Urinary Tract Infection
• Definition
Disease caused by microbial invasion of the urinary tract
that extends from the renal cortex of the kidney to the
urethral meatus
• Bacteriuria - presence of detectable bacteria in urine
• Pyuria - Presence of pus cells in urine
Epidemiology of UTI
• Second most common infection after respiratory tract infections in the
community
• Most common HAIs 35% of total HAIs
• ™
Prevalence: About 10% of humans develop UTI in some part of their life
• Leading cause of gram-negative sepsis (urosepsis)
• Urinary catheters 50% of nosocomial UTIs
Urinary Tract Infection Classification
Both ascending (common) Ascending route
and descending route
Local manifestations:
Local and systemic dysuria, urgency,
manifestations (fever, frequency
vomiting, abdominal pain)
Essentials of Medical Microbiology
Predisposing Factors
• Gender: Higher prevalence in
females
- Short urethra
- Close proximity of urethral meatus to
anus
• A™ge: Incidence increases with age
• „During first year of life prevalence
same in both females and males
Etiology
• Escherichia coli (uropathogenic E. coli)
– Commonest cause (70%) of all forms of UTIs - community acquired
& nosocomial UTI and upper & lower UTI
– Other endogenous flora - gram-negative bacilli (E.coli, Klebsiella,
Proteus, etc.) & Enterococci
• ™
Hospital acquired UTIs - Enterobacteriaceae and
Staphylococci, Pseudomonas, Acinetobacter. Multidrug
resistant
Essentials of Medical Microbiology
Common microorganisms causing UTIs
Bacterial agents Other agents
Gram-negative bacilli: Fungus:
Escherichia coli: Most common Candida albicans
Klebsiella pneumoniae, Proteus mirabilis
Pseudomonas aeruginosa Parasites:
Acinetobacter Spp, Enterobacter Spp, Serratia Spp Schistosoma hematobium
Trichomonas vaginalis
Gram-positive cocci: Viruses:
Staphylococcus saprophyticus Herpes simplex virus
Staphylococcus aureus Adenovirus
Staphylococcus epidermidis JC and BK virus
Enterococcus Spp Cytomegalovirus
Clinical Manifestations
1. Asymptomatic bacteriuria
2. Lower UTI: Cystitis & acute urethral syndrome
3. Upper UTI (pyelonephritis)
Essentials of Medical Microbiology
Laboratory Diagnosis – Sample collection
Clean catch midstream urine in females
Laboratory Diagnosis – Sample collection
Clean catch midstream urine in males
Laboratory Diagnosis
• Direct examination:
- Wet mount examination - pus cells
- Leukocyte esterase test
- Nitrate reduction test (Griess test)
- Catalase test
- Gram-staining
• ™
Culture: MacConkey agar and blood agar or CLED agar
• ≥105 colony forming units (CFU)/mL of urine – significant
‘significant bacteriuria’ (Infection)
Gram-staining
Wet mount
URINE DIPSTICK CHEMICAL ANALYSIS
How to Calculate the Number of Bacteria in Urine?
Let’s say you used a 0.001 mL loop, and after
incubation, you see:
👉 100 colonies on the agar plate
Then:
👉 100 colonies × 1000 (dilution factor) = 1,00,000 CFU/mL
Finding Interpretation
Significant → likely true
≥10⁵ CFU/mL
infection
Doubtful → repeat test or
10⁴–10⁵ CFU/mL
correlate clinically
<10⁴ CFU/mL Contamination likely
Asymptomatic Bacteriuria
• Asymptomatic Bacteriuria –
– Significant number of bacteria in urine >10^5 CFU/ml with no symptoms
– Common in females and incidence increases with age
• Clinically significant in –
– Pregnant women, people undergoing prostatic surgery or any urologic
procedure where bleeding is anticipated
– Routine screening & treatment for asymptomatic UTI is highly recommended
• ™
Clinically not significant –
– In non-pregnant, pre-menopausal women, old age, catheterized patient, or
patients with spinal injury
– Neither screening nor treatment of asymptomatic UTI is needed
Treatment Urinary tract infections
• Based on antimicrobial susceptibility testing report
• Preferred Drugs: Quinolones (e.g. norfloxacin),
nitrofurantoin, cephalosporins, and aminoglycosides
• Hopsital acquired UTIs with MDR strains: carbapenem
(e.g. meropenem), beta lactam-beta lactam inhibitor
combinations (e.g. piperacillintazobactam) or fosfomycin
Essentials of Medical Microbiology
Feature Cystitis Pyelonephritis Urethritis
Renal pelvis and
Site involved Urinary bladder Urethra
parenchyma
Dysuria, urgency, Flank pain, fever, Dysuria, urethral
Symptoms
frequency nausea, vomiting discharge
Present (high-grade
Fever Usually absent Sometimes present
with chills)
Flank pain Absent Present Absent
N. gonorrhoeae,
E. coli, Klebsiella, E. coli (90%), Proteus,
Common organisms Chlamydia,
Proteus Pseudomonas
Mycoplasma
Urine culture, blood Gram stain of urethral
Diagnostic tests Urine routine, culture
culture, imaging smear, NAAT
IV antibiotics (up to 5
Syndromic
Oral antibiotics (up to 7 days followed by Oral
Treatment management, partner
days) antibiotics for 10 days)
treatment
hydration
