This lecture was conducted during the Nephrology Unit Grand Ground by Medical Student under Nephrology Division under the supervision and administration of Prof. Jamal Al Wakeel, Head of Nephrology Unit, Department of Medicine and Dr. Abdulkareem Al Suwaida, Chairman of Department of Medicine and Nephrology Consultant. Nephrology Division is not responsible for the content of the presentation for it is intended for learning and /or education purpose only.

Urinary tract infection An overview Presented By: Dr. Nasser Al Faqih Medical Student 2009

Definitions UTI : is currently defined as the inflammatory response of the urothelium to bacterial invasion it is usually associated with lower or upper urinary tract infection symptoms Bacteriuria: is the presence of the bacteria in the urine Pyuria : is the presence of white blood cell (pus cell) in urine Uncomplicated UTI: is the one occurring in a patient with a structurally and functionally normal urinary tract Complicated UTI: is the one occurring in the presence of an underling anatomical or functional abnormality UTI may be isolated , recurrent or unresolved

Prevalence of urinary tract infections (UTI) Females are much more affected than males It is estimated that half of all women will have at least one UTI in their live. the risk of UTI in women increases after menopause after a UTI 20 - 40 % will have a recurrence the recurring infections are usually reinfections. asymptomatic bacteriuria in women occurs in 2.7% of 15 - 24 years old 9.3% of over 65 years old and 20 - 50% of over 80 years old

Prevalence of UTIs UTI is rare in young and middle-aged men UTI in men is often associated with : underlying pathology catheterisation urological procedures. urinary catheter increases the risk of UTI - because it may introduce infection or the bacteria colonise the catheter - pseudomonas is commonly encountered organism

Route of infection Ascending infection Haematogenous infection Bacteria in perineal area ascends through the urethra, enters the urinary bladder and multiplies This is the most common route of infection e.g. E.coli to the bladder Haematogenous infection In a patient with bacteremia, bacteria may be “seeded” into the kidneys from the blood e.g. staph .aureus , T.B

Causative agents of UTIs

Risk factor Women in general Pregnant women Sexually active women abnormality of normal flow of urine Enlarged prostate Kidney stones Vesicoureteral reflux Neurogenic bladder indwelling urinary catheters compromised immune function diabetes immunosuppressive drugs

Clinical features of UTI Cystitis Frequency Urgency Dysuria – painful voiding suprapubic Pain Cloudy or foul-smelling urine

Clinical features of UTI Acute pyelonephritis Loin pain and tenderness High Fever and chills Nausea and vomiting malaise

microscopy for WBCs & RBCs INVESTIGATION OF UTI Midstream urine (MSU) for: dipstick for nitrite microscopy for WBCs & RBCs urine culture If sterile pyuria is detected then T.B has to be considered in the differential diagnosis

INVESTIGATION OF UTI cnt .. Further investigation if underlying cause is suspected : - symptoms of upper UTI - recurrent infection - pregnant women - unusual infected organism e.g. proteus

INVESTIGATION OF UTI cnt .. Further investigations include , as indicated by the clinical condition of the patient ,the following: - CBC - Blood culture - Plain KUB - Ultrasound - IVU or CT urogram - Cystoscopy

Treatment of UTI Antimicrobials are the mainstay of treatment The choice of antimicrobial depend on the diagnosis, the clinical condition of the patient and the organism isolated . Dose , route and duration of antimicrobial depend on the diagnosis and severity of infection Treatment of underlying cause if present - e.g. stones , obstruction , reflux ….etc

Treatment of UTI Commonly used antimicrobials include : - trimethoprim - cotrimoxazole - quinolones - nitrofurantoin - cephalosporin - ampicillin , amoxicillin - aminoglycosides - fluconazole for fungi

Treatment of UTI Acute uncomplicated cystitis: trimethoprim for 3 days Cotrimoxazole for 3 days Quinolones for 3 days nitrofurantoin for 7 days Acute Uncomplicated pyelonephritis: Ciprofloxacin for 7- 10 days Cephalosporin for 7- 10 days Amoxicillin for 7-10 days Aminoglycosides 7-10 days

UTI IN CHILDERN A common pediatric problem Girls are more affected than boys May indicate an underlying cause Reflux and other abnormalities need to be excluded Treatment : - treat the infection - investigate for possible underlying cause - ? Need for prophylaxis - treat the underlying cause if present