Urinary Tract Infections

Urinary Tract Infections

• UTI is Lodgment and multiplication of bacteria in the

urinary tract

• Only lower part of urethra has a resident bacterial

flora

• Rest of the urinary tract is normally sterile

– Flushing effect of urine flow
– Mucosal IgA and secretions from prostatic and
urethral glands
Definitions
Bacteriuria Presence of bacteria in the urine

Pyuria Presence of WBCs in the urine

Cystitis UTI associated with superficial mucosa of bladder

Pyelonephritis UTI of renal parenchyma and or collection system

Uncomplicated UTI Infection involving structurally and functionally

normal urinary tract (simple UTI)

Complicated UTI Infection involving structurally and functionally

abnormal urinary tract

Urethritis Infection of the urethra

 Concept of Significant Bacteriuria

• Up to 104/ml considered normal

i.e. Insignificant
• 105/ml and above considered to
be Significant
• Concept valid only for voided
specimen of urine
• Exceptions - slow growing
organisms, patient on antibiotic
therapy, diuretic therapy

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 Predisposing factors for UTI

• Shortness of female urethra

• Sexual intercourse
• Pregnancy & Contraceptive devices
• Prostatic hypertrophy
• Abnormal kidney & bladder or stones
• Catheterization or surgical instrumentation
 Bacteria Commonly Encountered in UTI

• E. Coli • Enterococcus ie Group

• Proteus D streptococci.
• Klebsiella
• Pseudomonas
• Citrobacter
• Staph aureus
• Staph saprophyticus
• Anaerobes particularly
bacteroides
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 Etiology
• The commonest is Escherichia coli, which is
responsible for 80 percent of infections that are
acquired outside of hospitals.

• Other Gram-negative rods such

as Klebsiella, Enterobacter, Leptospira
interrogans ,and Proteus spp are relatively
common

• Within the hospital environment, Pseudomonas

aeruginosa, Providencia ,Serratia marscesens,
and other, more resistant, hospital-associated
pathogens.
 Klebsiella are non-motile, lactose-fermenting, capsulated
 The infection may also be endogenous in which the organism
travels from the intestine to the urinary tract → UTI.
 Strains of E. coli that are associated with UTI often possess
adhesins called P pili
 More P pili containing strains are reported in more severe forms of
urinary tract disease such as pyelonephritis (inflammation of the
kidney usually arising from infection ascending from the ureter).
 Invasins: hemolysisn, siderophores for intracellular invasion and
spread.
 Antiphagocytic surface properties: capsules, K antigens and
LPS.
 Enterohaemorrhagic E. coli (EHEC, serogroup O157:H7 can
progress to haemolytic uraemic syndrome with renal failure
Proteus mirabilis causes UTI.
 Proteus infected urine has an alkaline reaction.
 P. mirabilis is a common cause of urinary infection in the
elderly and young males and often following catheterization or
cystoscopy.
 Infections are also associated with the presence of renal calculi
or stones.
 Proteus vulgaris, a rare cases of nosocomial urinary tract
infection and more resistant to antibiotics
 Virulence factors; motility, urease, haemolysins, proteases,
IgAase
 Proteus vulgaris………... Indole positive.

 Proteus mirabilis……….. Indole negative

• Gram-positive organisms, particularly coagulase-
negative staphylococci and enterococci
– Staphylococcus saprophyticus in young
women.

• Candida albicans in hospitalized patients,

particularly if diabetes is present.

• Anaerobes and fastidious organisms rarely

• A number of viruses, particularly mumps virus,

cytomegalovirus, adenovirus and coxsackieviruses,
can be present in the kidneys and urine.
Staphylococcus
Spherical gram-positive cocci arranged in irregular grape like
clusters.
 Important properties:-
-none motile
-aerobic or facultative anaerobic
-catalase positive.
-grow in a medium containing ~10% NaCl
-Temp. range for growth is 10- 400C
S. aureus is a coagulase positive and grows on manitol salt agar
S. saprophyticus coagulase-negative novobiocin sensitive
infections are almost always community acquired.
It causes mainly UTI, particularly in sexually active young women
S. saprophyticus
normal human flora on skin & mucosal surfaces.
Organisms can survive on dry surfaces for long periods.
 Person-to-person spread through direct contact or exposure
to contaminated fomites are the means of transmission

Enterococci are G+ cocci

catalase negative.
 grow in the presence of 6.5% NaCl,
 Tolerate 40% bile salts,
 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
 E. coli is the most common pathogen
 However, also other Enterobacteriacae (Proteus, Klebsiella
pneumoniae, Enterobacter, Serratia, Providencia species) and
Pseudomonas aeruginosa)
 Enterococci: often in obstructive uropathy
 Yeasts: Candida albicans, others
Pathogenesis
• Bacteria invade the urinary tract by ascending or
hematogenous routes.

• The ascending route is the most common, with

hematogenous spread causing kidney abscesses.

• The most important virulence factor for E.coli is

the enhanced ability to adhere to uroepithelial
cells mediated by specific pilus adhesins on the
surface of E coli.
• The mucosal epithelial cells of women and
children with recurrent urinary tract infections
have been shown to have an increased avidity for
attachment of E. coli.

• Motility has been shown to facilitate ascending

infection and bacterial endotoxins can decrease
urethral peristalsis.

• Alterations of urine flow by scarring, obstruction

due to stones, or catheterization greatly
enhances the risk of acquiring a urinary tract
infection.
 Clinical Manifestations
• Acute cystitis is a superficial inflammation of the
bladder and urethra which leads to urinary
frequency, painful urination, a feeling of fullness
following voiding, and suprapubic discomfort.

• Acute pyelonephritis is due to bacterial invasion of

the renal tissue with inflammation and swelling,
leading to fever, back pain, and sometimes renal
dysfunction.

• Acute prostatitis occurs when bacteria invade the

prostate, causing perineal pain and fever.
• Recurring kidney infection in childhood
sometimes leads to renal damage and ultimate
kidney failure.

• Asymptomatic infections of the urinary tract—

asymptomatic bacteriuria—are common.

• Occasionally, individuals do have symptoms

such as incontinence or ongoing malaise that
are not recognized as due to bacteriuria until it is
diagnosed and treated.
 Urease splits urea into ammonia, which has a direct toxic effect on the
kidney; alkalinizes the urine with production of struvite crystals
(MgNH4P04.6H20) crystals
Proteus mirabilis most often; also Providencia, Morganella, S.
saprophyticus, Klebsiella, Corynebacterium D2; Ureaplasma
urealyticum
Ureaplasma urealyticum non-gonococcal, non-chlamydial urethritis
 UropathogenicE. coli use adherent molecules to climb to
the bladder and use them to stick to the walls of the bladder
 Normal flushing unable to remove them
 Bladder infections cause an inflammatory response.
 Neutrophilsmigrate to infection.
 Irritate lining of the bladder and urethra
 Bacterial toxins and enzymes also irritate
 This irritation causes the symptoms of bacterial
UTIs.
Increased frequency of urination
Urgency to urinate Dysuria
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Antimicrobial properties of urine:
Extremes of osmolality
High urea concentration
High organic acid concentration
Low pH

Anaerobic and fastidious organisms that make up most

the urethral flora do not multiply in the urine
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: coating of E. coli by this protein might
prevent attachment
Miscellaneous:
Mucopolysaccharide lining of the bladder
Urinary immunoglobulins
Spontaneous exfoliation of uroepithelial cells with bacterial
detachment
Mechanical flushing
 Caused by Leptospira interrogans
 Slender spirochetes with hooked ends
 Infects numerous species of wild and domestic animals
 Excreted in the urine-mode of transmission to other hosts
 Spots on the ground where urine has been deposited can
remain infectious as long as 2 weeks, while Leptospira
in muds and waters survive for several weeks

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Pathogenesis:
Water or animal urine contaminated with Leptospira species
splash on to the mucous membrane or abraded skin
The bacteria infect the blood stream and are carried
throughout all the body tissue causing fever, intense pain
Symptom subside and bacteria disappear from blood and
tissue except kidney
Symptoms recur associated with sever damage to liver and
kidneys
Complete recovery occurs if kidney failure can be effectively
treated
Excretion of Leptospira continues in urine

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• Relapse: is a recurrence with the same infecting
microorganism
that was present before therapy was started (due to persistence
of organism in the urinary tract)
• Reinfection: recurrence with a microrganism that is
different from the original infecting bacterium . It is a new
infection. Sometimes can be the same microorganism .
 Between 20% and 25% of young women with acute

uncomplicated cystitis have two or more infections per year,

usually due to reinfection with a different E. coli strain
 Predisposing factors: genetically-determined receptors on

uroepithelial cells; diaphragm-spermicide use

 Bacteriuria occurs 2-7% all pregnancies
 Usually occurs in the first trimester
 Smooth muscle relaxation and urethral dilatation seen in
pregnancy
 Greater tendency to progress to pyelonephritis (up to 40%)
 Microorganisms same as in nonpregnant women
 If left untreated, associated with preterm birth, low birth
weight, perinatal mortality
 UTI occurs in approximately 1% of pregnant women
Microbiology of Kidney and
Urinary 7/28/2014 45
system/Kirubel
 Streptococcal Acute
Glomerulonephritis
–Some antibody-antigen complexes against group
A
streptococci strains are not removed from the body
–Complexes are deposited in the glomeruli of the
kidneys
–Cause inflammation of the glomeruli and nephrons
–Produce hypertension and low urine output
–Irreversible kidney damage can occur in adults

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 Microbiologic Diagnosis
• The diagnosis of a urinary tract infection is
confirmed by culturing the organism from urine.

• Most bacteria that cause urinary infection grow

readily, and is usually confirmed within 24 hours.

• Patients suspected of urinary infection are usually

asked to collect a mid-stream sample after
cleaning the perineum or glans penis with soap
and water.
• An early-morning collection is best because the
concentration of bacteria in the urine is greatest
prior to the morning voiding.

• Approximately 65 percent of patients with acute

cystitis have >105 organisms/ml of urine and
– almost 90 percent of patients with acute
pyelonephritis and asymptomatic bacteriuria
also have counts in excess of 105 organisms/ml.

• Examination of urine to demonstrate the presence

of pus cells is an important part of diagnosing
urinary infection.
 Collection of Specimens
• Clean catch mid-stream specimen of urine
• Early morning sample preferred

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• Catheter specimen
• Differential specimen from two ureters
• Instructions to the patients
• Early transport to the lab essential
 Instruction for collection of mid stream urine
Sterile specimen container

Begin passing urine

Female patients Male patients

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Stop flow in midstream
Spread labia, Retract
Pass several ml into pen container prepuce, using
using plain without touching rim plain soap or
soap or antiseptic clean
Stop flow before it ends
antiseptic glans. Dry with
wipe front to Recap container tissues.
back, dry with Pass remaining urine into lavatory
tissues
Send specimen to laboratory
immediately
 Processing of Specimen
• Uncentrifuged specimen inoculated on CLED
medium

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– Cystein, lactose, electrolyte-deficiency medium

• Centrifuged specimen used for microscopic

exam
 Urine strip test , nitrate to nitrite reduction
 Creatinine, BUN
 Highly
significant!
 Presence suggests
pyelonephritis

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 How to suspect anaerobic UTI?
• Extremely foul smelling urine
• Failure to respond to usually useful antibiotics
against aerobes
• Failure to grow bacteria seen in Gram stain
prepared from centrifuged specimen
 Prevention and Treatment
• For acute cystitis - oral regimens of nitrofurantoin,
a sulfonamide-trimethoprim, amoxicillin,
cephalexin, and ciprofloxacin or other quinolones.

• Recurrence is common, and may be prevented by

prolonged therapy.

• Intravenous antimicrobials for patients acutely ill

with acute pyelonephritis or acute prostatitis.
– Aminoglycosides and cephalosporins are frequently
chosen.
Thank you