UTI

Anup Poudyal, MD
Dept. of Microbiology
 Contents
• Definition
• General consideration
• Epidemiology
• Pathogenesis
• Clinical Presentation
• Laboratory Diagnosis
• Treatment & prophylaxis
 Definitions
• UTI– spectrum of disease caused by microbial invasion
of urinary tract
- single episode Vs recurrent
- uncomplicated Vs complicated
- Upper UTI Vs Lower UTI
• Recurrent UTI- 2 uncomplicated UTIs in 6 months
or, more traditionally, as 3 positive culture within the
preceding 12 months(2)
- Relapse- recurrent infection with same organism
- Reinfection- recurrent UTI caused by a different bacterial
isolate, or by the previously isolated bacteria after a negative
intervening culture
 General consideration
• Anatomy
• Physiology
• Microbiology
- Urinary bladder &above normally sterile
- Normal flora
• CoNS(except S. saprophyticus)
• Viridans and non-hemolytic streptococci
• Lactobacilli
• Diphtheroids
• Saprophytic Neisseria
• Anaerobic bacteria
 Epidemiology
>95% of UTI- single species
Common Uropathogens
• Escherichia coli – most common, ≈80%(2)
• Other Enterobacteriaceae (Klebsiella, Enterobacter,
Proteus, Citrobacter), Pseudomonas aeruginosa,
Enterococcus
- more common in recurrent than single episode UTI
- more common in hospital settings than in community
• Staphylococcus saprophyticus –UTI in sexually active
women- 5 to 15%
• Staphylococcus aureus
• Streptococcus agalactiae (group B)1
• Candida
1
Denotes vaginal colonization in pregnant women
Uncommon Uropathogens
• Corynebacterium urealyticum – imp.
Nosocomial uropathogen
• Haemophilus influenzae and H.
parainfluenzae
• Blastomyces dermatitidis
• Neisseria gonorrhaeae
• Mycobacterium tuberculosis
• In children
-frequency of UTI- 1 to 2%
-more common in boys up to 3 months
thereafter common in girls
• In adults
-up to 40-50% female experience symptomatic
UTI in lifetime
- Prevalence female- 1-3%
male- ≤0.1%
• In older population
- asymptomatic UTI more common
- Prevalence increase in both sex
Frequency of significant bacteriuria
• After 1 bladder catheterization: 2%
• Medical outpatient: 5%

• Pregnancy at term: 10%

• Hypertensive patients: 14%

• DM: 20%
• Congenital urologic disease: 57%

• Hydronephrosis; nephrolithiasis: 85%

• Indwelling catheter >48 hrs: 98%
 Pathogenesis
• Result of Interplay between bacterial virulence
factor & host factor
• UTI occurs by any of the following routes

-Ascending- Most imp.

-Descending(Hematogenous)-
[Link], candida
-Lymphathics route- rare
 Ascending UTI
• General consideration
Generally uropathogens comes from GIT,
colonizes perineum, vestibular area,
periurethral area and ascend through urethra
to vesicle & then after through ureters to
kidney
• Virulence factors
-In general
- Motility- ascends against urine flow
- Endotoxin- ↓ureteral peristalsis
- Inflammatory response
- Enzymes- eg. Urease
- Capsule- antiphagocytic
• E. coli
- In addition, the recognized virulence factors
for E. coli are;
-↑ed adherence to vaginal & uroepithelium
- Resistance to serum & urinary bactericidal
activity
- Higher quantity of K antigen in capsule
- Presence of aerobactin
- cytotoxic necrotizing factor type 1
- haemolysin production
• Special consideration
-Adhesins
- As filamentous fimbriae or non-filamentous
protein
a. P fimbriae
- Attaches to globoseries glycosphingolipid
receptors, distributed throughout urinary tract, esp. in kidney
- Mainly expressed by pyelonephritic strains
- P fimbriated strains
-remains longer in GIT
- spread more efficiently to urinary tract
- adhere, colonize, & persist in U.T
- Invariably associated with acute disease &
severity
b. Type 1 fimbriae
- Attaches to mannosylated proteins, s/a
secretory IgA, urinary mucus, THP
- mainly expressed by cystitic strains
- related to persistence of E. coli in U.T
- also mediates bacterial adherence to catheter
- also linked with bladder epithelial cell invasion
& intracellular persistence
 Host factors

A. Defensive
1. Innate immunity
a. Physical
- flushing action, ureteric peristalsis, epithelial
exfoliation
b. Chemical
- high osmolality, high urea concentration, low P H
- Prostatic secretion
c. cellular
- PMNs – recruited in response to
inflammatory mediators s/a IL-8
 d. Microbial
- resident flora

e. others
- antimicrobial property of epithelial secretion of
urinary tract
- THP- binds strongly to [Link] expressing type 1 & S
fimbriae- prevents attachment

2. Acquired immunity
- Though extensively studied, is poorly understood
for its role in pathogenesis of UTI
-IgA
B. Offensive
- Urine itself
- as a good culture medium
- inhibits migration & phagocytic activity
of PMNs
- Renal medulla
- high concentration of ammonia- inactivates
complement
- sluggish blood flow

- Female U.T
- Behavioral
- frequent sexual intercourse
- multiple partner
- use of spermicidal, diaphragm
- estrogen deficiency in postmenopausals
- Genetically determined host cell receptor for
uropathogenic [Link]
- structural & functional abnormalities
- obstructive uropathy
- vesicoureteral reflux
- Incomplete bladder emptying
- mechanical
- neurogenic
- instrumentation- eg catheterization
 Clinical Presentation
• Neonates & children <2yrs - Non-specific
-Failure to thrive
- vomiting
- Fever
• Children >2yrs & adults
- Upper UTI
- Fever, often with chills & rigor
- Flank pain- more severe with obstructive
uropathy
- vomiting, less frequent
- +/- lower tract symptoms
 - lower UTI
- lower tract symptoms
- frequency, urgency, dysuria
- low vol. turbid urine , st. blood tinged
- suprapubic pain
- Fever, rare
• Old(>65yrs)
- mainly asymptomatic
- symptoms, if present are non-diagnostic

• Recurrent UTI- same as group & site specific

- occurrence with every episode
- However upper tract infection may
present with only lower tract symptoms or
no symptoms at all
 Laboratory Diagnosis
Specimen:
• First-voided morning urine: optimal
• Midstream clean catch urine specimens
• Catheter specimens
• Suprapubic aspirates
• Cystoscopic collection of urine

[Link] diagnosis
a. Microscopy- 1st step in [Link] of UTI
-Presence of 1 bacteria/OIF in midstream,
clean catch, uncentrifuged, Gram stained urine
5
 - ≥104 leukocytes /ml of urine – Pyuria
- Finding of 1 leukocyte/ 7 HPF
corresponds with 104 leukocytes/ml
- Not always specific for UTI

b. Estimation of protein in urine

-proteinuria is commonly found in UTI, but not
always & is generally <2 gm/24 hrs
c. Dip-stick tests
[Link] leukocyte esterase test
-rapid screening test to detect pyuria
- sensitivity –up to 96%, specificity- up to 98%
- But a positive test, as pyuria, is not specific for UTI
2. Dipstick nitrite test
- False negative results are common
(<103bact./ml & with some species)
- False positive results are uncommon

Therefore, a negative leukocyte esterase test + a

negative nitrite test strongly predicts absence
of UTI
B. Diagnosis by culture
- semi quantitative method
- use of calibrated loops(0.01-0.001ml)
-significant bacteriuria- ≥105 CFU/ml
• The Infectious Diseases Society of America
consensus definition of cystitis is ≥103 CFU/mL
(sensitivity 90% and specificity 90%) and

for pyelonephritis, ≥104CFU/mL (sensitivity

90% and specificity 90%)(5)
• In more recent practice guidelines,
≥102CFU/mL is taken as significant
bacteriuria(5)
• A comparative study between suprapubic aspirate Vs
voided mid stream urine in actutely dysuric women
has found that ≥102 CFU/ml of mid stream urine had a
sensitivity & specificity of 95% & 85% respectively for
UTI(5)
• Kunin & co-workers has postulated that low count
bacteriuria represents an early phase of UTI(5)

• Fallacies of culture
false +ve- contamination, delayed culture
false –ve- antimicrobials, urine contaminated with
detergents, infection with fastidious organisms, renal
TB, Diuresis
 Treatment
• General consideration
- All symptomatic UTI must be treated
- Even asymptomatic, treat
- UTI in children
- Pregnant lady
- Complicated UTI
- Patients undergoing urological procedures
THANK -YOU