Urinary Tract Infections Overview

Urinary Tract Infections (UTIs)

• UTIs are infections in any part of the urinary system, including kidneys, ureters, bladder, and urethra.
• A significant sign is 100,000 organisms per milliliter of mid-stream urine.
• Women are at a higher risk of UTIs than men.
• Women are more prone to cystitis and pyelonephritis, while men are more prone to urethritis and prostatitis.

Risk Factors

• Female: Short urethra, Urethral damage (e.g., from sexual trauma), and Immunodeficiency states. Diabetes also increase the risk of UTIs in women.
• General: Abnormal urine drainage (residual urine), renal calculi, benign prostatic hyperplasia (BPH), pelviureteric junction obstruction, Vesicoureteral reflux (VUR), instrumentation, uterine prolapse, and neurologic bladder problems.
• Pregnancy: Increases UTI risk.

Causative Organisms

• Primarily ascending infections.
• Gram-negative bacteria, particularly E. coli (about 75%), are common causes. Other gram-negative organisms (Klebsiella, Proteus, and Pseudomonas) are also implicated.
• Gram-positive bacteria (Streptococci and Staphylococci) can also cause UTIs.

UTI Types

• Location:
  • Upper UTI: Pyelonephritis (kidney infection), Ureteritis (ureter infection).
  • Lower UTI: Cystitis (bladder infection), Prostatitis (prostate infection), Urethritis (urethra infection).
• Nature of the disease:
  • Complicated UTI: Underlying factors predisposing to ascending bacterial infections (e.g., recurrent UTI in patient with BPH).
  • Uncomplicated UTI: Occurs without underlying abnormalities or impairments in urine flow (UTI in a young adult).
• Pregnancy: Asymptomatic bacteriuria (no symptoms) and symptomatic bacteriuria need treatment. Amoxicillin is a suitable antibiotic choice.
• Male: Often due to structural or functional anomalies. Antibiotics are selected based on the affected organ (e.g., epididymitis, prostate). Ciprofloxacin is a common choice
• Catheterized patients: Sudden fever, flank pain, hematuria (blood in urine), mental status changes, are indicative of infection in people with urinary catheters.

Clinical Features

• Urethritis: Dysuria (painful urination), strangury (straining to urinate).
• Cystitis: Hematuria (blood in urine), pyuria (pus in urine), dysuria, frequency (urination more often), low abdominal pain, back pain, smelly cloudy urine.
• Pyelonephritis: Fever (with or without chills), upper back pain, nausea, vomiting.

Complications

• Recurrent infections
• Renal damage
• Risk of preterm labor and low birth weight (LBW) in pregnancy.
• Sepsis
• Urethral stricture(s) in males

Diagnosis

• Urine sample (clean, mid-stream): Dipstick test for albumin, white blood cells (WBCs), nitrites, Microscopes for WBCs, pus cells and red blood cells (RBCs), Cultures (to identify bacteria).
• Imaging: X-ray KUB (kidney, ureters, bladder), ultrasound, CT scan, voiding cystourethrography.
• Cystoscopy: Visualization of the urethra and bladder.
• Renal function test: To assess kidney function.

Management

• Antibiotics (oral or intravenous): Course depends on the severity and type of infection. (e.g., Ciprofloxacin, Amoxicillin, Norfloxacin, Cephalosporins)
• Alkalinizer: potassium citrate mixtures, increases the urine's pH, relieves pain in urination.
• Pain relief: Bladder Relaxants (Flavoxate).
• Hospitalization depending on the severity of the illness.

Prophylactic Measures

• Plenty of fluids
• Frequent bladder emptying
• Double Voiding (before and after intercourse)
• Applying 0.5% cetrimide cream to the preurethral area before intercourse in females.
• Antibiotic prophylaxis (preventative antibiotic use)
• Estrogen creams (for postmenopausal women).

UTIs in Dialysis Patients

• UTIs increase the risk of complications in people with chronic kidney disease (CKD).
• Factors affecting treatment: compromised immune system , inability to completely empty bladder, and chronic comorbidities.
• High-range antibiotics (e.g. vancomycin, ertapenem) are often required.
• Antibiotics are typically given 30 minutes before or after dialysis.