Renal and Bladder Infections Lower UTI • Urethritis • Cystitis Upper UTI • Pyelonephritis • Intra-renal abscess • Perinephric abscess Complicated UTI: UTI + Risk factors of treatment failure • Pregnancy • Gender: BPH in men or due to proximity of vagina and anus to urethra in women • Elderly • DM • Immunosuppressed • Renal failure/renal transplant • Hospital-acquired infections, MROs • Recent antimicrobial use Note: Neonate males are more likely than females to have a UTI, but as they get older, female are more likely to get UTIs than males. Factors Predisposing to Infection • Short urethra in females • Sexual intercourse • Not voiding after intercourse • Diaphragm use • Spermicide use  ↑pH  toxic to normal flora Anti-Adherence Mechanisms in the Urinary Tract • Normal bacterial flora of vaginal, introital, and periurethral regions and urethra • Uromucoid (Tamm-Horsfall protein) • Urinary oligosaccharides • Urinary immunoglobulins (IgG, IgA, S-IgA) • Bladder mucopolysaccharide (glycosaminoglycan) • Mechanical effects of flushing Clinical Presentation • Adults: o Dysuria o Suprapubic pain o ↑Frequency of urination o ↑Urgency o Malodourous/cloudy urine  Lower UTI: o As above but usually no systemic symptoms  Upper UTI: • As above but systemic symptoms including: o Fever, rigors, flank tenderness • Prostatitis o Acute systemic symptoms: fever, rigors o Pelvic, perineal pain o Voiding symptoms: dribbling, hesitancy, retention  Epididymoorchitis: o Systemic symptoms: fever, rigors o Testicular, epididymal pain/tenderness • Urethritis o Usually due to STIs Diagnosis • Made by microscopy and urine sample culture. • Urine sample should be taken mid-stream (MSU) • Sometimes blood culture can be taken if systemic symptoms are present  Microscopic exam provides: o No. of leukocyte (sig. of >10/μL) o No. of RBCs o Presence of bacteria o Epithelial cells: shows contamination Culture: • Pathogen identification • Antibiotic susceptibility of pathogen • Positive culture is >105 CFU/mL Sterile Pyuria • Significant amount of WBCs in urine, but no culture  Potential causes: o Antibiotic administration prior to urine collection o Contamination of urine sample with vaginal leukocytes o Nephrolithiasis (usually causes haematuria) o Uroepithelial tumour o Infection with atypical organism that doesn’t grow on usual media  Tuberculosis  Chlamydia  Ureaplasma urealyticum Organisms • Non-Catheter UTIs o E. coli (75-95%) o Proteus mirabilis o Klebsiella pneumoniae o Staphylococcus saphrophyticus • Catheter related UTIs o E. coli (25%) o Enterococcus (15%) o P. aeruginosa (11%) o Klebsiella (11%) STIs • Bacterial o PID (pelvic inflammatory disease) o Syphilis o Gonorrhoea o Chlamydia • Viral o Genital warts o Herpes o HIV • Fungal: Thrush • Parasitic: Crabs Antimicrobial Resistance • Geographic variability • Even uncomplicated UTIs should get urine samples and cultures to reduce antibiotic resistance and treatment failure • People at high risk of having resistant bacteria o <6months travelled to south east Asia o Recent antibiotics o Unresponsive to initial therapy o Aged-care facility residents Treatment: • LUTIs: 3-5 days of antibiotics • UUTIs: 10-14 days of antibiotics • Prostatitis: 4+ weeks of antibiotics due to poor penetration of most anti-microbials into prostatic tissue