Urinarytractinfections 120301095907-phpapp01

P.Bindu
M.Pharmacy 1st year
EVALUATION SEMINAR ON
PRESENTED TO
Dr. Santhrani Thaakur

Contents
 Introduction
 Terminology
 Classification of UTI
 Epidemiology
 Etiology
 Pathogenesis
 Risk factors
 Clinical presentation
 Diagnosis
 Treatment
 Conclusion
 References

Introduction
• Symptomatic
presence of micro
organisms within the
urinary tract
i.e., kidney, ureters,
bladder and urethra.
• Associated with
inflammation of
urinary tract.

• 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

• 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.

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.

UTI
Upper
•Acute pyleonephritis
•Chronic pyleonephriitis
•Interstitial pyleonephritis
•Renal abscess
•Perirenal abscess
Lower
•Cystitis
•Prostatitis
•Urethritis
•Both upper & lower UTI are further divided into
complicated and uncomplicated.

Epidemiology
 Seen in all age groups
 Infants up to 6 months – 2/1000
 More common in boys than girls
 Women – at greater risk than men; prevalence
40-50% in women and 0.04% in men.
 10% women have recurrent UTI in their life
 7 million new cases of lower UTI / year
 1 million hospitalizations / year
 Incidence of UTI increases in old age; 10% of
men and 20% of women are infected.

Etiology
• Acute uncomplicated UTI:
• Escherichia coli – cause about 80% of UTI
• 20% of UTI caused by-
Gram negative enteric bacteria – Klebsiella,
Proteus
Gram positive cocci – Streptococcus
faecalis
Staphylococcus saprophyticus
• S.saprophyticus – restricted to infections in
young sexually active women.

Complicated UTI:
 Pseudomonas aeruginosa, Enterobacter &
Serratia
 Isolated in hospital acquired infections and
catheter associated UTI.
 Viruses - Rubella, Mumps and HIV
 Fungi - Candida, Histoplasma capsulatum
 Protozoa - T. vaginalis, S. haematobium

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

• Ascending Infection:
 most common route.
organisms ascend through urethra into
bladder.
organism
Colonize in
perineal and
periurethral areas
UTI
Ascend to
bladder,
kidneys

• Hematogenous
spread:
 Blood borne
spread to kidneys.
 Occurs in
bacteraemia
mostly S.aureus.

• Lymphatogenous spread:
Men- through rectal and colonic
lymphatic vessels to prostrate and
bladder.
Women- through periuterine lymphatics
to urinary tract.
• Direct extension from other organs:
Pelvic inflammatory diseases
Genito-urinary tract fistulas

• The organism:
 E.coli – many strains present but only few
cause infection.
 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)

UTI – RISK FACTORS
1. Aging: diabetes mellitus
urine retention
impaired immune system
2. Females: shorter urethra
sexual intercourse
contraceptives
incomplete bladder emptying with age
3. Males: prostatic hypertrophy
bacterial prostatis
age

UTI-CLINICAL PRESENTATION
• Clinical manifestations depending on
site of infection
• Clinical manifestations depending on
age of patient

Clinical manifestations depending on site
of infection
• Urethritis:
 Discomfort in voiding
 Dysuria
 Urgency
 frequency

• Cystitis:
 dysuria, urgency and frequent
urination
 Pelvic discomfort
 Abdominal pain
 Pyuria
• Hemorrhagic cystitis:
 Visible blood in urine.
 Irritating voiding symptoms

• Pyleonephritis:
 Invasive nature
 Suprapubic
tenderness
 Fever and chills
 White blood cell casts
in urine
 Back pain
 Nausea and vomiting
Complications include sepsis, septic shock
and death.

Clinical manifestations depending on age
• Babies and infants:
Failure to thrive
Fever
Apathy
Diarrhoea
• Children:
Dysuria, urgency, frequency
Haematuria
Acute abdominal pain
Vomiting

• Adults:
 Lower UTI- frequency, urgency,
dysuria,
haematuria
 Upper UTI- fever, rigor and lion pain
and symptoms of lower UTI.
• Elderly patients:
 Mostly asymptomatic
 Not diagnostic as the symptoms are
common with age.

UTI- DIAGNOSIS
• Microscopic examination of urine
• Urinalysis
• Urine culture
• Imaging techniques – CT scan and MRI

Laboratory examination
• Uncontaminated, midstream urine sample
used.
• Methods for urine collection:
1. stick on bags
2. catheterization
3. suprapubic aspiration(SPA) –
gold standard for urine collection

Laboratory findings
Normal Findings
• pH - 4.6 – 8.0
• Appearance- clear
• Color – pale to amber
yellow
• Odor – aromatic
• Blood – none
• Leukocyte esterase –
none
• WBC- absent
• Bacteria- absent
Abnormal findings
•pH – Alkaline (
increases)
• Appearance – cloudy
• Color - deep amber
• Odor – foul smelling
•Blood – maybe present
•Leukocyte esterase -
present
•WBC- present
•Bacteria- present

Urinalysis :
• Presence of pus, white
blood cells, red blood
cells
• Bacterial count > 105 /ml –
significant bacteriuria
• Leukocyte esterase
dipstick test – WBC in
urine
• Nitrite dipstick test- pink
colour

Urine culture :
 For pyelonephritis
 Not a rapid diagnostic tool
 >105 bacteria /ml
 Differential leukocyte count-
increased neutrophils
Urine culture

Diagnostic tests for adults with recurrent
UTI
• Intravenous pyelography / excretory
urography

• Voiding cystourethrography
• Cystoscopy
• Manual pelvic and
prostrate
examination

UTI
urinalysis
Urine microscopy and culture
Male
Any UTI
Ultrasound
cystoscopy
Adult female
Lower UTI
Treat without
further
investigation
Children
Any UTI
cystourethro
graphy
pyelonephriti
s
Complicated
Blood
cultures
CT scan
Check renal
Further investigation

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.

Anti-microbial therapy
• Goals of therapy:
 Elimination of infection
 Relief of acute symptoms
 Prevention of recurrence and long
term complications
• Decision to hospitalize ??
• Treatment considerations ??

• Ideal antibiotic for UTI :
Adequate coverage over E.coli
Concentration in urine
Duration of therapy
Low resistance
Cost
Low adverse effect profile

Principles of anti microbial therapy
• Levels of antibiotic in urine but not in
blood
• Blood levels of antibiotic – important in
pyleonephritis
• Penicillins and cephalosporins – drugs of
choice for UTI with renal failure.

treatment duration
• Single dose therapy
• 3 day course
• 7 day course
• 10 – 14 day course

Single dose therapy
a. Trimethoprim- sulfamethaxole
bactrim–DS : TMP–160mg + SMZ–800mg
co-trimoxazole-DS :TMP-160mg + SMZ-800mg
b. Amoxicillin- clavulnate 500mg
aceclav tab
acmox- AG tab
c. Amoxcillin 3gm
d. Ciprofloxacin 500mg – alquin tab
e. Norfloxacin 400mg – Actiflox-400 tab

• 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

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

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

Pathogen specific treatment
Pathogen Treatment options
Escherichia coli Ceftriaxone 50mg/kg i.v
/I.M Qday
Pseudomonas
aeroginosa
Gentamycin 6-7.5mg /kg
i.v Q8hr / Qday
Klebsiella sps
Enterobacter sps
Proteus sps
Ceftadizine 100-
150mg/kg/day i.v Q8hr
Enterococcus sps Ampicillin 100-
200mg/kg/day Q6hr

Infection specific treatment
Lower UTI
 3day therapy preferred
*Trimethoprim Cephalaxin
*Nitrofurantion *ciprofloxacin
Amoxicillin *Co-amoxiclav
Norfloxacin

Antibiotic Dose Side effects contraindications
Co-amoxiclav 375mg
every
8hr
nausea, diarrhea,
rashes, hepatitis
Penicillin
hypersensitivity
Trimethoprim 200mg
every
12hr
Nausea, vomiting,
pruritis, rashes
Severe renal
failure, neonates
Ciprofloxacin 250mg
every
12hr
Nausea, vomiting,
dizziness,
convulsions,
hallucinations,
hepatitis, blood
disorders,
photosensitivity
CNS disorders
Pregnancy
Children
G6PD deficiency
Nitrofurantoin 100mg
every
12hr
Nausea, vomiting,
peripheral
neuropathy,
pulmonary
reactions
Renal failure
Neonates
Porphyria
G6PD deficiency

Acute pyelonephritis
• Paranteral antibiotics
• Cefuroxime – 750mg i.v. Q8h
Gentamycin - 80-120g i.v. Q12h
Ciprofloxacin – 200mg i.v. Q12h
• 10-14 days treatment
• Ceftazimide, imipenam, ciprofloxacin –
for hospital acquired pyelonephritis

Asymptomatic bacteriuria
• Children – treatment same as
symptomatic bacteriuria
• Adults –
treatment required in cases of
a. pregnancy
b. patient with obstructive structural
abnormalities

Bacteriuria in pregnancy
• To prevent risk of pyelonephritis
• 7 day course with following antibiotics
 Cephalaxin
Nitrofurantoin
Amoxicillin
• Therapy continued at regular intervals
of pregnancy.

Relapsing UTI
• 7-10 day course
• If fails – 2week course / 6week course
• Structural abnormalities corrected by
surgery
• 6week course –
a. children
b. adults with continuous symptoms
c. high risk of renal damage

Prophylaxis for UTI
• Single dose of trimethoprim 100mg /
nitrofurantion 50mg
• Long term low dose prophylaxis
beneficial
• Women- single dose of antibiotic after
sexual intercourse.

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.

Sulfamethoxazole-trimethoprim
 Adverse effects:
o Steven Johnson's syndrome
o Dermatitis
o Angiodema
o GI disturbances
o Agranulocytosis
 Contraindicated in
o Hypersensitivity to sulfa
drugs
o Infants
o Megaloblastic anaemia
Mechanism of action

nitrofurantoin
 Damages bacterial DNA.
 Reduced to reactive forms by bacterial
nitroreductase- damage DNA, ribosomes
o Hypersensitivity pneumonitis,GI
disturbances, haemolytic anaemia
 Contraindications:
o Renal failure, neonates, pregnancy

Cefixime
 3rd generation cephalosporin
 Disrupts synthesis of peptidoglycan of
bacterial cell wall
o Rash, utricaria
o Diarrhea
o Thrombocytopenia
o leucopenia

Amoxicillin
 Penicillin class antibiotic
 Inhibits cross linking of peptidoglycan
polymer chains which is the major
component of bacterial cell wall.
o Rash
o GI disturbances, renal dysfunction
o Antibiotic associated colitis, lethergy
 Contraindications: penicillin
hypersensitivity

Ciprofloxacin
 Fluoroquinoline antibiotic
 Inhibits DNA gyrase and topisomerase 1V,
the enzymes necessary for separation of
bacterial DNA – inhibit cell division
o Peripheral neuropathy
o Rhabdomyolysis
o Steven Johnson's syndrome
o Hemolytic anaemia

Surgical treatment
a) Surgical removal of renal calculi,
bladder calculi
b) Ureteroplasty
c) Reimplatation of ureters if VUR
present

Conclusion
 Urinary tract infections are the 2nd most
common bacterial infections.
 Women are the most infected subjects in
the population.
 Development of resistance to antibiotics
by the bacteria result in problems during
the treatment and lead to relapse or
recurrence.
 Recent advances such as development of
immunologicals like intranasal vaccines
may result in life time cure of the infection

References
• Clinical pharmacy and therapeutics by
Roger Walker, Clive Edwards; 3rd edition;
page 503 – 511.
• Applied therapeutics the clinical use of
drugs by Mary Anne konda- kimble; 8th
edition; page456 – 465.

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