Definition

  • What is UTI?
  • What is strangury and dysuria?
  • What do you mean by lower urinary tract infection?
  • What is pyelonephritis?
  • What do you mean by complicated and uncomplicated UTI?
  • What are the types of recurrent infection?
  • What are relapse and reinfection?
  • What is asymptomatic bacteriuria?

Epidemiology

  • Q

Etiology and Pathophysiology

  • What are the organisms responsible for UTI?
  • Why is UTI more common in woman?

Clinical manifestations

  • What are the spectrum of presentations of urinary tract infection?
  • What are the common presentations of lower UTI?
  • What are the common features of pyelonephritis?

Examinations

  • Q

Investigations

  • How can you collect midstream clean catch morning sample of urine?

Diagnosis

  • Tell the criteria for diagnosis of UTI.

Treatment

  • What is the treatment for uncomplicated UTI?
  • Which prophylactic measures should be taken by women with recurrent urinary infections?
  • Which drugs would you use to treat UTI in a pregnant lady?
  • When treatment is needed in asymptomatic bacteriuria?

Complications

  • Q

 


Rimikri

SOLVES


Definition

What is bacteriuria?

Bacteriuria:

Bacteria in the urine is called bacteriuria. It may be asymptomatic or symptomatic.

* Oxford Handbook of Clinical Medicine, 9th Edition Page: 288
What is asymptomatic bacteriuria?

It is defined as >105/mL organisms in urine of apparently healthy asymptomatic patients.

* Pre-exam preparation for medicine, HN Sarker
What is UTI?

Urinary tract infection (UTI) is defined as multiplication of organisms in the urinary tract.

  • It is usually associated with the presence of neutrophils and >105 organisms/mL in midstream clean catch morning sample of urine (MSU).
  • Exception in pregnancy >104 organisms/mL as UTI has deleterious effects.
* Pre-exam preparation for medicine, HN Sarker; Oxford Handbook of Clinical Medicine, 9th Edition Page: 288
What do you mean by upper UTI and lower UTI?

Upper UTI:

Upper urinary tract infection includes pyelonephritis (renal pelvis inflammation).

Lower UTI:

Lower urinary tract infection includes urethritis and cystitis (urethral and bladder inflammation respectively) (and prostatitis).

* Oxford Handbook of Clinical Medicine, 9th Edition Page: 288; Pre-exam preparation for medicine, HN Sarker
What is pyelonephritis?

The infection to the pelvis and kidney is known as pyelitis or pyelonephritis.

* Pre-exam preparation for medicine, HN Sarker
What do you mean by complicated and uncomplicated UTI?

Uncomplicated UTI means UTI occurring without any anatomical, physiological and immunological defect.

  • Here, persistent or recurrent infection seldom results in serious kidney damage.

Complicated UTI means UTI occurring with anatomical (e.g.urethral stricture), physiological (e.g.vesicoureteric reflux) or immunological defect (e.g.diabetes).

  • Here, persistent or recurrent infection results in serious kidney damage.
* Pre-exam preparation for medicine, HN Sarker
What are the types of recurrent infection?

Relapse and reinfection are the types of recurrent infection.

* Pre-exam preparation for medicine, HN Sarker
What are relapse and reinfection?

Relapse is diagnosed by recurrence of bacteriuria with the same organism within 7 days of completion of antibacterial treatment and implies failure to eradicate infection.

Reinfection is when bacteriuria is absent after treatment for at least 14 days, usually longer, followed by recurrence of infection with the same or different organisms.

* Pre-exam preparation for medicine, HN Sarker
What is strangury and dysuria?

Strangury—Painful urge for micturition but unable to pass urine.

Dysuria—Painful micturition.

* Pre-exam preparation for medicine, HN Sarker

Etiology and Pathophysiology

What are the organisms responsible for UTI?

Typical organisms causing UTI in the community—

  • E. coli (about 75% of infections)
  • Proteus spp
  • Pseudomonas spp
  • Streptococci
  • Staphylococcus epidermidis.

In hospital—

  • E. coli
  • Klebsiella
  • Streptococci
* Pre-exam preparation for medicine, HN Sarker
Why is UTI more common in woman?

Because of—

  • The urethra is shorter
  • Closer to perineum
  • Absence of bactericidal prostatic secretions
  • Sexual intercourse may cause minor urethral trauma and transfer bacteria from the perineum into the bladder.
* Pre-exam preparation for medicine, HN Sarker
What are the risk factors for UTI?

Risk factors for urinary tract infection –

  1. Incomplete bladder emptying
    • Bladder outflow obstruction
      • Benign prostatic enlargement
      • Prostate cancer
      • Urethral stricture
      • Vesico-ureteric reflux
    • Uterine prolapse
    • Neurological problems
      • Multiple sclerosis
      • Spina bifida
      • Diabetic neuropathy
  2. Foreign bodies
    • Urethral catheter or ureteric stent
    • Urolithiasis
  3. Loss of host defences
    • Atrophic urethritis and vaginitis in post-menopausal women
    • Diabetes mellitus
* Davidson’s Principles and Practice of Medicine, 22nd edition Page: 511

Clinical manifestations

What are the spectrum of presentations of urinary tract infection?

The spectrum of presentations are:

  • Asymptomatic bacteriuria
  • Symptomatic acute urethritis and cystitis
  • Acute pyelonephritis
  • Acute prostatitis
  • Septicemia (usually Gram-negative bacteria).
* Davidson’s Principles and Practice of Medicine, 22nd edition Page: 511
What are the common presentations of lower UTI?

Typical features of cystitis and urethritis (lower UTI) include:

  • abrupt onset of frequency of micturition and urgency
  • scalding pain in the urethra during micturition (dysuria)
  • suprapubic pain during and after voiding
  • intense desire to pass more urine after micturition, due to spasm of the inflamed bladder wall (strangury)
  • urine that may appear cloudy and have an unpleasant odour
  • microscopic or visible haematuria
  • Systemic symptoms are usually slight or absent.
* Davidson’s Principles and Practice of Medicine, 22nd edition Page: 511
What are the common features of pyelonephritis?

Ans. Common features of pyelonephritis are:

  • Loin pain, guarding and tenderness
  • Prominent systemic symptoms—Fever with rigors, vomiting and hypotension.
* Davidson’s Principles and Practice of Medicine, 22nd edition Page: 511

Investigations

Name the investigations for diagnosis.

Investigation of patients with urinary tract infection:

  1. All patients
    • Dipstick1 estimation of nitrite, leucocyte esterase and glucose
    • Microscopy/cytometry of urine for white blood cells, organisms (MSU or urine obtained by suprapubic aspiration)
    • Urine culture
  2. Infants, children, and anyone with fever or complicated infection
    • Full blood count; urea, electrolytes, creatinine
    • Blood cultures
  3. Pyelonephritis; males; children; women with recurrent infections
    • Renal tract ultrasound or CT
    • Pelvic examination in women, rectal examination in men
  4. Continuing haematuria or other suspicion of bladder lesion
    • Cystoscopy
1May substitute for microscopy and culture in simple uncomplicated infection.
* Davidson’s Principles and Practice of Medicine, 22nd edition Page: 512

 

How can you collect midstream clean catch morning sample of urine?
  • A sterile test tube/container should be taken.
  • Patient should be instructed to –
    • collect urine during first voiding after overnight sleep,
    • first part of urine flow is allowed to pass and
    • collect the middle part of the stream.
* Pre-exam preparation for medicine, HN Sarker

Diagnosis

Tell the criteria for diagnosis of UTI.

Criteria for diagnosis of bacteriuria are:

  1. Symptomatic young women
    • ≥ 102 coliform organisms/mL urine plus pyuria (> 10 white blood cells/mm3) Or,
    •  ≥ 105 any pathogenic organism/mL urine Or,
    • any growth of pathogenic organisms in urine by suprapubic aspiration
  2. Symptomatic men
    • ≥ 103 pathogenic organisms/mL urine
  3. Asymptomatic patients
    • ≥ 105 pathogenic organisms/mL urine on two occasion.
* Kumar and Clark’s Clinical Medicine, 9th Edition Box 20.23; Pre-exam preparation for medicine, HN Sarker

Treatment

What is the treatment for uncomplicated UTI?

Treatment is started while awaiting urine C/S report

  • Antibiotic:
    • Amoxicillin 250 mg 8-hourly
    • Nitrofurantoin 50 mg 6-hourly
    • Cephalexin 250 mg 6-hourly
    • Ciprofloxacin 100 mg 12-hourly
    • Co-amoxiclav 250/125 mg 8-hourly
  • Duration:
    • 3 days in women
    • 10 days in men.
* Pre-exam preparation for medicine, HN Sarker

* Davidson’s Principles and Practice of Medicine, 22nd edition Page: 513
How will you manage a child with UTI?
  1. Counselling the parents about the disease
  2. Antibiotics
    • Acute pyelonephritis
      • Ceftriazone IV 100 mg/kg/day or,
      • Cefotaxime IV 150 mg/kg/day or,
      • Gentamicin IV 5 mg/kg/day
      • Duration: 10–14 days.
    • Acute cystitis
      • Cotrimoxazol or
      • Amoxicillin or,
      • Co-amoxiclav or,
      • Cefadroxil or,
      • Ciprofloxacin
      • Duration: 5–7 days
  3. Supportive treatment: More liquid intake, avoiding risk factors.
* Step on to Paediatrics, Md Abid Hossain Mollah, 3rd Edition Page: 220
Which prophylactic measures should be taken by women with recurrent urinary infections?

Prophylactic measures to be adopted by women with recurrent urinary infections are:

  • Fluid intake of at least 2 L/day
  • Regular complete emptying of bladder
  • Good personal hygiene
  • Emptying of bladder before and after sexual intercourse
  • Cranberry juice may be effective
* Davidson’s Principles and Practice of Medicine, 22nd edition Page: 513
Which drugs would you use to treat UTI in a pregnant lady?
  • Antibiotic:
    • Co-amoxiclav 250/125mg 8-hourly
    • Amoxicillin 250 mg 8-hourly
    • Cephalexin 250 mg 6-hourly
  • Duration: 7 days
Note:
Avoid trimethoprim and quinolones during pregnancy.
* Davidson’s Principles and Practice of Medicine, 22nd edition Page: 513
When treatment is needed in asymptomatic bacteriuria?

Treatment is usually needed in –

  • infants,
  • pregnant women and
  • those with urinary tract abnormalities.
* Pre-exam preparation for medicine, HN Sarker
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