UTI

a.k.a I S K

Basic Structures of the Urinary

System
The urinary
system consists
of:
two kidneys
two ureters
one urinary
bladder
one urethra

Functions of the Basic Structures

of the Urinary System
Kidney small, dark red kidney bean shaped
structures. The kidneys are responsible for
continuously cleansing the blood and adjusting
its composition, urine formation, excretion of
Nitrogen containing wastes, maintaining water
and electrolyte balance of the blood,
maintaining the acid base balance of the
blood and the formation of urine.
Ureters slender tubes each 10 to 12 inches
in long and inch in diameter. Each ureter
runs from the kidney down to the urinary
bladder and attaches itself to the posterior
aspect of the bladder on a slight angle. The
ureters are passageways to carry urine from

 Urinary Bladder is a smooth,

collapsible, muscular sac with 3 openings, the 2

ureter openings and the urethra opening. When
the bladder is empty, it is collapsed and it is 2
to 3 inches long at most, when the bladder is
moderately full about 500ml it is about 5
inches long. The bladder is able to hold twice
that amount though. The main function of the
urinary bladder is to provide a temporary
storage tank for urine.

Urethra is a thin walled tube that carries

urine by peristalsis from the bladder to the
outside of the body. The length and relative
function of the urethra differs in both sexes.

Functions of the Urinary

System
The principal function of the urinary system is to

maintain the volume and composition of body

fluids within normal limits. One aspect of this
function is to rid the body of waste products that
accumulate as a result of cellular metabolism.
The urinary system maintains an appropriate fluid
volume by regulating the amount of water that is
excreted in the urine. Other aspects of its
function include regulating the concentrations of
various electrolytes in the body fluids and
maintaining normal pH of the blood
In addition to maintaining fluid homeostasis in the
body, the urinary system controls red blood cell
production by secreting the hormone

Differences Between the Male and

Female Urinary System
Male
Urethra

Female
Urethra

Approx 8
inches long

Approx 1.5
inches long

Located
further from
anus

Located
more
proximate to
anus

Has two
functions,
urination &
passageway
for sperm

Has one
function,
urination

Overview of UTI
7 million office visits yearly
1 million hospitalizations
About 2/3rds of patients are women; 40%
to 50% of women have UTI at some point
during their lives
Important complications of pregnancy,
diabetes mellitus, polycystic disease, renal
transplantation, conditions that impede
urine flow (structural and neurologic)

Overview of UTI by age and sex

Terms (1)
UTI: the finding of
microorganisms in bladder urine
with or without clinical symptoms
and with or without renal disease
Significant bacteriuria: the
finding of > 105 cfu/ml of urine
(but lower counts can be
significant)

Symptoms versus Asymptomatic

Bacteriuria
Asymptomatic Bacteriuria (ASB)
Defined as the presence of bacteria in
urine of patients who do not have dysuria,
urinary frequency, urgency, fever, flank
pain, or other symptoms related to
irritation of the urethra, bladder, or kidney
Swart, Soler & Holman, 2004

Strictly definedexists when 2 urine

cultures done with clean-catch specimens
are positive in a patient who has no
urinary tract symptoms
Foxman, 2003

Terms (2)
Asymptomatic bacteriuria:
Significant bacteriuria without
clinical symptoms or other abnormal
findings.
Acute bacterial pyelonephritis: a
clinical syndrome of fever, flank
pain, and tenderness, often with
constitutional symptoms, leukocyte
casts in the urine, and bacteriuria;
or histologic findings thereof

Terms (3)
Chronic bacterial pyelonephritis: Longstanding infection associated with active
bacterial growth in the kidney; or the
residuum of lesions caused by such
infection in the past
Chronic interstitial nephritis: renal disease
with histologic findings resembling chronic
bacterial pyelonephritis but without
evidence of infection

Terms (4)
Upper UTI: infection above the
level of the bladder
Lower UTI: infection at or below the
level of the bladder
Urethral syndrome: clinical
manifestations of lower UTI (dysuria,
frequency, urgency) without
significant bacteriuria

Terms (5)
Pyuria: the presence of pus (WBCs
[leukocytes] in urine, which may or
may not be caused by UTI. The
preferred method for quantitation
is enumeration in unspun urine
using a counting chamber. The
leukocyte esterase nitrite test has
a sensitivity of between 70% and
90% for symptomatic UTI

Recurrent UTIsculture-confirmed UTIs

* >3 in 1 year or
* > 2 in 6 months
Relapse UTI
occurs within 2 weeks
of Rx
of an earlier UTI
same pathogen
Re-infection UTI occurs >4 weeks after
earlier UTI
different pathogen
Swart, Soler & Holman, 2004

Risk Factors in UTIs

Males
Age
Loss of bactericidal
properties of
prostatic secretions
sperm
Obstructive Uropathy
BPH
Presence of
indwelling
catheter
Foley

Females

Sexual intercourse
poor fitting diaphragms
use of spericide
Pregnancy/Menopause
Clothing
tight jeans
wet bathing suits
pantyhose
synthetic underwear
Allergens/Irritants
feminine hygiene sprays
bubble baths
perfumed toilet paper /
soap
sanitary napkins
Presence of indwelling
catheter
Foley

Asymptomatic bacteriuria
In patients with asymptomatic
bacteriuria without infection, a
colony count of > 105 cfu/ml
defines infection
Screening has little apparent
value in adults except during
pregnancy and prior to urologic
surgery
Up to 40% of elderly men and
women have asymptomatic
bacteriuria

Frequency of significant bacteriuria

(1)
After one bladder
catheterization: 2%
Medical outpatients: 5%
Pregnancy at term: 10%
Hypertensive patients: 14%
Diabetes mellitus: 20%
Women with cystocoele: 23%

Frequency of significant bacteriuria (2)

Congenital urologic disease: 57%

Hydronephrosis; nephrolithiasis:
85%
Indwelling catheter, open
drainage > 48 hours: 98%

Screening for significant bacteriuria

Screening for asymptomatic
bacteriuria in adults has little value
except for two situations: pregnancy
(because of the high risk of acute
pyelonephritis with its accompanying
risk of fetal complications) and prior
to urologic surgery (because of the
risk of postoperative sepsis).

Urinary tract bacteriology

At room temperature, the doubling
time of common aerobic bacteria is
about 20 minutes
Some contaminants in voided urine:
Lactobacilli, Cornyebacterium species,
Gardnerella, alpha-hemolytic
streptococci, anaerobes
Any bacterial growth is significant if
the specimen is collected from a
normally-sterile site (e.g., direct
bladder puncture)

Urinary tract bacteriology

(2)
In pyelonephritis, the >10 5 cfu/ml
rule breaks down; fewer colonies can
be significant. Up to 20% of young
women with acute uncomplicated
pyelonephritis have between 10 3 and
104 cfu/ml. In catheterized patients in
whom specimens are obtained directly
from the catheter, between 102 and
104 cfu/ml should may be significant.

Urinary tract bacteriology

(3)
Patients with uncomplicated infection
almost invariably have a single
organism; this is not necessarily the
case with complicated infections
Unspun midstream urine: One
bacterium/high-powered field (hpf)
correlates with > 105/ml (thus, high
positive predictive value)

Urinary tract bacteriology

(4)
Grams stain of spun urine:
absence of visible bacteria
makes > 105 cfu/ml highly
unlikely (that is, high negative
predictive value)
20% of patients with urinary
tract infection do not have pyuria

Etiology of community-acquired UTI

Aerobic gram-negative rods most
often
E. coli accounts for about 90%
Staphylococcus saprophyticus has
been increasingly appreciated in
recent years (with seasonality,
tending to occur in the summer)
Rare: anaerobes; pyogenic cocci;
viruses

Etiology of nosocomial UTI

E. coli is the most common pathogen
However, also common are other
Enterobacteriacae (Proteus, Klebsiella,
Enterobacter, Serratia, Providencia
species) and Pseudomonadaceae
(notably, Pseudomonas aeruginosa)
Enterococci: often in obstructive uropathy
Yeasts: Candida albicans, others

Urease-producing
microorganisms
Urease splits urea into ammonia,
which has a direct toxic effect on the
kidney; inactivates C4, and
alkalinizes the urine with production
of struvite crystals (MgNH4P04.6H20)
crystals
Proteus mirabilis most often; also
Providencia, Morganella, S.
saprophyticus, Klebsiella,
Corynebacterium D2; mycoplasma
Eradicate if at all possible

UTI in adults
Women: bacteriuria increases
with age and sexual activity
Men: bacteriuria is rare before
age 50 (and as a corollary, calls
for more aggressive evaluation
than in women). Subsequently,
bacteriuria increases with onset
of prostatism

Role of bacterial virulence

in UTI
Bacterial adherence to
uroepithelial cells involves
specific binding of bacterial
surface receptors (adhesins) to
complementary components on
the epithelial cells (receptors).
The ability of E. coli to adhere to
uroepithelial cells is associated
with the presence of pili or
fimbriae.

The role of bacterial virulence

(2)
Specificity has been associated with
the Gal-alpha-->4-Gal specific
adhesion localized at the fimbrial
polymer.
However, virulence of E. coli strains
does not seem to depend upon a
single virulence factor. There may well
be an additive effect among multiple
virulence factors (including adhesins,
hemolysin, capsular polysaccharide,

Host defenses:
antibacterial properties of urine

Osmolality (extremes of high or

low osmolalities inhibit bacterial
growth)
High urea concentration
High organic acid concentration
pH

Host defenses:
anti-adherence mechanisms
Bacterial interference (naturally
endogenous bacteria in the urethra,
vagina, and periurethral region)
Urinary oligosaccharides (have the
potential to detach epithelial-bound E.
coli
Tamm-Horsfall protein (uromucoid):
coating of E. coli by this protein might
prevent attachment

Host defenses:
miscellaneous

Mucopolysaccharide lining of the

bladder
Urinary immunoglobulins
Spontaneous exfoliation of
uroepithelial cells with bacterial
detachment
Mechanical flushing of
micturition

Routes of urinary tract

infection
Ascending infection is thought to be
the common route of nearly all
forms of urinary tract infection
(bacteria initially colonize
periurethral tissues)
Descending (hematogenous)
infection can be important for a few
organisms such as S. aureus and
Candida albicans, but in general the
kidney resists metastatic

Mechanisms of lower UTI

Experimentally, 99.9% of a

bladder inoculum of bacteria is

promptly excreted by voiding.
Possible biologic explanations for
the frequency of UTI in some
women include: deficient
antibodies in vaginal secretions;
and biochemical differences in
receptors on uroepithelial cells.

Mechanisms of upper UTI

Ascent of bacteria from the
bladder to the kidneys is
promoted by obstruction and by
reflux. In addition, motile
bacteria can ascend against the
flow of a column of urine. Gramnegative bacteria (or endotoxin
derived from them) can inhibit
ureteral peristalsis.

Mechanisms of upper UTI

(2)
The renal medulla is an

immunologic desert. Its low pH

(< 5. 5) and high osmolality
(which may reach 1300
mOsm/LK with a sodium of 425
mM and urea of 850 mM)
drastically interfere not only with
all aspects of leukocyte function
but also with antibody and
complement function.

Localization of upper versus lower

UTI (2): in practice
Frequency, dysuria, and urgency

(lower UTI symptoms) can occur with

upper UTI as well.
Fever and flank pain indicate acute
upper urinary tract infection.
Scarring of the kidney by imaging
procedures suggests chronic UTI.
The distinction is sometimes difficult.

Signs and Symptoms of

UTIs

Dysuria (burning pain upon urination)

Frequency
Urgency
Voiding in small amounts
Inability to void
Incomplete emptying of bladder
Low back / Suprapubic pain

Assessment Findings in
UTIs

Hematuria (bloody urine)

Cloudy urine
Flank pain
Abdominal pain
Fever
Chills
Nausea
Vomiting

Urinalysis Laboratory
Findings
Abnormal Findings

Normal Findings

pH - 4.6 8.0
Appearance clear
Color pale yellow to
amber yellow
Odor aromatic
Specific Gravity
1.005 1.030
Protein - none
Glucose none
Ketones none
Blood none
Leukocyte esterase
(WBCs) none

pH Alkaline ( increases)
Appearance cloudy
Color - deep amber
Odor foul smelling
Specific Gravity may change
Protein maybe present
Glucose maybe present
Ketones - maybe present
Blood maybe present
Leukocyte esterase (WBCs)- present

Urinalysis Laboratory Findings

Microscopic Examination
Normal Findings
Red Blood Cells
(RBCs) none
White Blood Cells
(WBCs) none
Casts none
Crystals none
Bacteria - none

Abnormal Findings

Red Blood Cells

(RBCs) present
White Blood Cells
(WBCs) present
Casts none
Crystals present
Bacteria - present

Screening/Diagnosis
Infectious Disease Society of America:
Guidelines for Dx & Rx of ASB in adults
1.

ASB Dx based on results of a culture from cleancatch specimen (* important to minimize

contamination)
Women:
bacteriuria = 2 consecutive
voided urine samples w/isolation of same
strain in cfu/mL >100,000
Men:
bacteria = single, clean-catch
specimen with 1
bacterial species isolated in > 100,000
cfu/mL
Both:
single catheterized urine

Screening/Diagnosis
Guidelines, continued
2. Pyuria accompanying ASB not an indication for
antimicrobial Rx (A-2)
3. Pregnant women should be screened in early
pregnancy, at least once & treated if positive (A1)
4. Screening of ASB & Rx if positive before these
urological procedures:
Transurethral resection of prostate (A3)
Procedures anticipated to cause possible mucosal
bleeding (A-3)

Screening/Diagnosis
Guidelines, continued

5.

6.
7.

No screening for ASB: (A-1 & A-2 strongly

recommended via research evidence)
Pre-menopausal, non-pregnant women (A-1)
Diabetic women (A-1)
Community older adults (A-2)
Institutionalized elderly (A-1)
Spinal cord injury (A-2)
Indwelling-catheterized patients (A-1)
Antimicrobial Rx of asymptomatic women with
catheter-acquired bacteriuria persisting 48 hrs after
removed, should be considered (B-1/good)
No screening or Rx of ASB renal transplant or solid
organ transplant recipients (C-3/weak)

Infectious Disease Society of America, 2005

Nicolle et al. 2005
www.guideline.gov/summary/summary

Screening/Diagnosis
Guidelines, continued
Guide to Clinical Preventive Services, 2005
Similar consensus of IDSA recommendations
Clinical considerations
Dipstick analysis & direct microscopy have poor
positive & negative predictive value for detecting
ASB
Urine culture = gold standard, but expensive for
routine screening in populations of low
prevalence
New enzymatic urine screening test (Uriscreen TM)
showed 100% sensitivity & specificity of 81%
No clinical benefit to screen individuals other
than pregnant womendid not improve clinical
outcomes.
Guide to Clinical Preventive Services, 2005
http://www.ahrq.gov/clinic/ppcletgp/geps2b.htm#bacteriaria

Screening & Diagnosis

Guideline Criteria for Treatment
The following are a recommended minimum set of criteria adapted from the
McGeer (1991) and Loeb et al. (2001) studies necessary to initiate diagnostics
and AB Rx.
Indwelling catheter present:
Catheter is not present:
two of the following must be met
three of the following must be met
Fever

(>38C/100.4F) or increase of
1.5C (2.4F) above baseline
temperature.
Chills
New costovertebral angle
tenderness
New suprapubic pain, flank pain or
tenderness
Decreased mental or functional
status (delirium)
New-onset hematuria, foul-smelling
urine, or amount of sediment

Acute

dysuria alone (key indicator) or fever

(>38C/100.4F) or increase of 1.5C (2.4F)
above baseline temperature
Chills
Frequency
Urgency
New costovertebral angle tenderness
Decreased mental or functional status (may
be new or increased incontinence related) *
New-onset hematuria, foul-smelling urine or
(+) sediment
New suprapubic pain, flank pain or
tenderness

Laboratory Analysis
Dipstick Testing
Used in primary care & LTC settings. But for institutionalized
adults, urinalysis is preferable.
Chemically impregnated reagent strips (UA Chemstrip
Screen) provide
preliminary/quick determinations of:

pH
bilirubin
protein
blood
glucose
*nitrite
ketones
*leukocyte esterase
urobilinogen
specific gravity
Fischback, 2004

Fairly reliable, although U.S. Preventive Services Task

Force (USPSTF)
report from research studies these have poor positive
& negative

Laboratory Analysis, continued

Routine UrinalysisKey Indicators of Infection
Urine collection

1st morning specimen is best

Straight catherization for those incontinent, functionally or
cognitively impaired

Specific gravity

Measure of kidneys abiltiy to concentrte urine

Range of SG depends on state of hydration

Appearance

Cloudy, may not indicate WBCs

Could indicate a change in urine pH causes precipitation
Alkaline urine phosphates cloudy
Acid urine urates cloudy

Color

Pale yellow to amber

Variations can be caused by medications, disease processes (*nl
urine darkens on standing 30 min. after voidingoxidation of
urobilinogen to urobilin)

Odor

nl faint odor when freshly voided

Foul-smellingoften presence of bacteria which splits urea to form
ammonia
Fischbach, 2004

Laboratory Analysis, continued

Routine Urinalysis, continued
pH

Acid or basemeasures free H+ ion concentration in urine

7.0neutral. Indicates kidney function
Determines if systemic acid-base disorders of
metabolic/resp. origin
control of pH manages bacteriuria, renal calculi & drug
Rx
bacteria from a UTI produce alkaline urine

Blood or
Hemoglobin

Always an indicator of kidney/UT damage

Protein
(Albumin)

Single most important indication of renal disease

Microalbuminur Below dipstick range of detection

ia
Detects deteriorating renal function in diabetic patients
(standard screener)
Fischbach, 2004

Laboratory Analysis, continued

Routine Urinalysis, continued
*Nitrite
(Bacteria)

Dipstick - rapid, indirect method to detect bacteria

common gram-negative organisms contain enzymes
reduce nitrate
in urine to nitrite
some UTIs are caused by organisms that do not convert
nitrate to nitrite
(e.g., staphylococcus, streptococci)

*Leukocyte
Esterase

Esterase is released by leukocytes (WBCs) in urine

Microscopic exam & chemical test

__________
*U/A testing positive for nitrite & leukocyte esterase should be cultured for
bacterial pathogen
Fischbach, 2004

Urine Culture and Sensitivity

Traditional gold standard for significant
bacteriuria >100,000 cfu/mL of urine. Some
argue criteria for bacteriuria is only 100
cfu/mL of a uropathogen in symptomatic
females or 1,000 in symptomatic males.
Bacterial identification from urine C&S, key
in males and females with complicated
UTIs.

Other Laboratory Tests

Complete Blood Count with Differential
Indicated to R/O bacterial infection supports
treatment plan
Careful evaluation of WBC & differential (left
shift)

Electrolytes
R/O dehydration & if IV fluids replacement
needed

BUN, Creatinine
Determine renal function for nephrotoxic
medications

Blood Culture
Identify bacteremic organism in suspected

Treatment Plan
Early detection/Rx goal is to prevent systemic
infection, bacteremia
Initiation of antibiotic treatment is recommended for a
clinically-diagnosed UTI. Adjust medication when urine
C&S is final
Selection of antibiotic must be individualized and
consider:
Side effect profile
Cost
Bacterial resistance
Likelihood of compliance (convenience, fewer
pills/day s compliance)
Effect of impaired renal function on dosing
Possible adverse drug reactions in elderly
(multiple drugs, co-morbidities.

Treatment Plan

Recommended Treatment Regimens for Acute, Uncomplicated UTIs in the Elderly

Treatment

Dosage/Duration

Bacterial Coverage/
Resistance

Common Side
Effects

Compliance/
Convenience

Sulfonamide
TrimethoprimSulfamethoxazole
TMP-SMX

160/800 mg po bid x 3-14* days

*available in a syrup
If CrCl <15-30 mL/min, in half

(E. coli 20%)

resistance
Less effective

nausea, rash

Fluoroquinolones
Ciprofloxacin (2nd
gen)

100- 250 mg po bid x 3-14* days

If CrCL <30mL/min by half

gram (-) effective

gram (+) only fair

headache,
dizziness, nausea,
diarrhea

Good/Good
bid, longer
duration
compliance
Excellent

Levofloxacin (3rd
gen)

Fair/Good

Cost
I/E

Men

Women

longer duration of
bid compliance

250 mg po daily x 10 days

(complicated upper and lower
UTI)

Fosfomycin

3 g powder, dissolved in water

*single dose

gram (-) effective

gram (+) less effective

diarrhea, vaginitis,
nausea, rhinitis

Excellent

Nitrofurantoin
(Macrobid)

100 mg po bid x 7 days

If CrCL <40 mL/min
not recommended

Narrow spectrum
gram (-) effective
gram (+) effective

nausea, vaginitis,
diarrhea
rate of severe
pulmonary &
hepatotoxicity

Fair
7-day regimen &
bid, compliance

Prostatiti
s
NR

resistance 2 Beta
Lactamase enzymes in
resistant bacteria
2nd/3rd gen
Cephalosporins
>resistant to beta
lactamase

PCN-anaphylaxis
Abdominal
cramping diarrhea

Fair for bid dosing

Prostatiti
s
NR

Miscellaneous
Beta Lactam ABs:
Cephalosporins (Cefuroxime, cefpodoxime)
Penicillins (ampicillin), Carbapenems (imipenem)
Phenazopyridine (Pyridium)not appropriate
for elderly or patients with renal insufficiency

VE, often
not on
formularies

adapted from Swart et al. (2004), Osborne (2004), Wagenlehner et al. (2005), Mahan-Buttaro et al.
(2006) and Evercare Corp (2004)
I = inexpensive; E = expensive; VE = very expensive; NR = not recommended
*Longer duration for complicated UTI per individuals clinical status
Data

Treatment Plan
AB Rx for at least 10 days for institutionalized
elderly, as short-term therapy may not be as
effective.
Ten-14 days, if indicated, for complicated UTI.
(recommended for males)
Evercare, 2004

Conventional regimen of 7-10 days duration is

usually recommended.
Wagenlehner et al. 2005

Treatment Plan
Complicated UTI
Can be common in LTC patients
Associated with azotemia, obstruction, or
indwelling foley
Can lead to bacteremia, life-threatening systemic
infection
Recommended Treatment for Acute Complicated UTI
IV antibiotic therapy--*consider renal & hepatic elimination,
creatinine clearance for dosage adjustment
3rd generation cephalosporin (Ceftriaxone =
Rocephin) Rx 1 gram IV every 24 hours
Or if fluoroquinolones (Levofloxacin = Levaquin)
250-500 mg IV every 24 hours
Continue until afebrile, minimum of 48 hrs, then
start oral therapy and fluids x 14 days.
Mahan-Buttaro et al., 2006