Urinary Tract Infections complete detail 2023

Introduction:

Urinary Tract Infections is a common illness that arises when bacteria invade and grow in the urinary system. UTIs are infections that affect the urethra, bladder, and kidneys and may produce a range of unpleasant symptoms. Though UTIs are generally treatable, they can have serious consequences if left untreated.

Classification of Urinary Tract Infections:

Urinary tract infections (UTIs) can be classified according to anatomical location and complexity of clinical presentation.

Anatomical localization

a. Lower tract

Urethritis
Cystitis

b. Upper tract and systemic

Pyelonephritis
Renal or perinephric abscess

c. Male accessory gland involvement

Prostatitis
Epididymitis
Orchitis

Clinical presentation

a. Uncomplicated

Previously healthy women without known anatomic or functional abnormality of the urinary tract.

b. Complicated

All men, women, or children with functional, metabolic, or anatomic conditions may increase the risk of treatment failure or recurrence.

Additional conditions considered as complicated include: a functional or anatomic urinary tract abnormality (e.g., polycystic kidney disease, nephrolithiasis, neurogenic bladder, pregnancy, or urinary tract instrumentation/catheterization) as well as any patient with diabetes mellitus, or with an immunocompromised status, either from comorbid condition or immunosuppressive therapy.

Risk Factors:

Sexual intercourse (homosexuality and anorectal intercourse is also risk factor for men).
New sexual partner within the past year.
Use of spermicides in women.
Prior urinary tract infection.
Lack of circumcision in men.
Recent urinary tract instrumentation or surgical procedure.
Benign prostatic hyperplasia (BPH).
Spinal cord injury with neurogenic bladder.

Microbiology of UTIs:

Gram-negative rods:

Consists mainly of Enterobacteriaceae bacteria, with Escherichia coli as the most common infecting organism (75–90% in uncomplicated UTI); others include Klebsiella pneumonia and Proteus mirabilis. Pseudomonas spp can cause UTIs but are commonly associated with urinary tract instrumentation or surgical procedures.

Gram-Positive cocci:

Commonly include Staphylococcus saprophyticus, Enterococcus faecalis, and Streptococcus agalactiae (group B streptococci).

Fungal:

Candida spp commonly colonizes the urinary tract (especially in association with recent antimicrobial use, diabetes mellitus, and indwelling Foley catheterization) and does not typically represent a true urinary pathogen.

Diagnostics Tests for Urinary Tract Infections:

Urinalysis:

A urinalysis is one of the most common and important tests used to diagnose Urinary Tract Infections. This test examines the urine for the presence of bacteria, white blood cells, and other substances that may indicate the presence of infection.

Urinary tract infections are often caused by Proteus mirabilis, Escherichia coli, and Klebsiella pneumoniae.

A urinalysis can also be used to check for the presence of other substances, such as glucose, protein, and red blood cells, which can indicate other types of infections or medical problems.

Urine Culture:

A urine culture is a more sensitive test than a urinalysis and is used to identify the exact type of bacteria that is causing the UTI. To perform a urine culture, a sample of urine is collected and cultured in a laboratory.

The sample is then tested for the presence of bacteria. If bacteria are present, the type of bacteria is identified and a course of treatment is prescribed.

Kidney Ultrasound:

An ultrasound of the kidneys is a noninvasive imaging technique that employs sound waves to generate an image of the organs. This test is used to diagnose UTIs that are caused by kidney stones or other blockages in the urinary tract. It is also used to look for any signs of infection or inflammation in the kidneys.

Voiding Cystourethrogram:

A voiding cystourethrogram (VCUG) is an imaging test that uses X-rays to look at the bladder and urethra. This test is used to diagnose UTIs that are caused by structural problems or blockages in the urinary tract. It is also used to look for any signs of infection or inflammation in the bladder or urethra.

Intravenous Pyelogram:

X-rays and a contrast dye are used in an intravenous pyelogram (IVP) to examine the urinary tract (kidneys, bladder, and urethra).

This test is used to diagnose UTIs that are caused by structural problems or blockages in the urinary tract. It is also used to look for any signs of infection or inflammation in the kidneys, bladder, or urethra.

Urethroscopy:

With urethroscopy, the urethra’s interior is seen via a thin, flexible tube equipped with a camera and light.

This test is used to diagnose UTIs that are caused by structural problems or blockages in the urethra. It is also used to look for any signs of infection or inflammation in the urethra.

Urease Test:

The urease test is another form of UTI diagnostic test. It involves collecting a sample of urine and sending it to a lab for analysis. The sample is examined for the presence of the enzyme urease, which can indicate the presence of an infection.

Management of Urinary Tract Infections:

Cystitis:

In randomized, controlled trials, placebo groups have spontaneous resolution of symptoms in 25% to 42% of women; therefore, antibiotic therapy is not mandatory but is generally prescribed to limit morbidity and speed the resolution of symptoms.

Pregnant women who have asymptomatic bacteriuria must receive treatment with pregnancy-safe oral antimicrobials. Appropriate empirical oral antimicrobial choices include:

Nitrofurantoin 100mg twice daily for 5 days.
TMP-SMX 160g/800mg twice daily for 3 days.
Fosfomycin trometamol 3-g sachet single dose.
Ciprofloxacin 250 mg twice daily (or 500 mg extended-release once daily) for 3 days (only if other options cannot be used).

Prostatitis:

Acute prostatitis can be treated with agents appropriate for cystitis, pending results from urine culture to guide therapy. Cases of chronic prostatitis may require 4 to 6 weeks of oral fluoroquinolone therapy.

Epididymitis:

Most cases are due to N gonorrhea or C trachomatis; therefore, appropriately directed therapy for these agents is indicated and includes:

1. Ceftriaxone 250mg IM single dose

2. Azithromycin 1g PO, single dose

In older men, drug therapy directed at Escherichia coli or Pseudomonas spp should be selected, such as ciprofloxacin 500mg twice daily for 7 days. Symptomatic improvement should be seen in 3 days; however, if there is no response, reevaluation is indicated.

Orchitis:

Viral orchitis resolves within 2 weeks in most cases; however, antimicrobial treatment of bacterial orchitis should be based on culture results with the duration dictated by the resolution of symptoms.

Treatment Failure or Recurrence:

Failure of symptoms to resolve should raise concern for resistant organisms. In the case of empiric therapy failing in the setting of cystitis, midstream urine collection should be sent for culture and sensitivity testing to identify the appropriate organism. Negative routine cultures with recurrent or persistent cystitis symptoms should raise concern for mycobacterial infection or noninfectious causes of cystitis, such as malignancy or interstitial cystitis.
Gross hematuria or persistent microscopic hematuria may indicate malignancy, and CT imaging or cystoscopy are indicated for further evaluation.
Pyuria without bacteriuria suggests malignancy or mycobacterial infection.

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Conclusion:

Urinary tract infections are quite prevalent and may produce a variety of unpleasant symptoms. They may lead to major consequences if not treated. If you have any of the indications of a UTI, you should consult your doctor straight once. They can provide a diagnosis and discuss treatment options with you. It’s also important to practice good hygiene and to drink plenty of fluids to reduce your risk of developing a UTI.

ByDr. Saqib Khan