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Urinary Tract Infection in Adults

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Urinary Tract Infection in Adults ADULT UTI URINARY TRACT INFECTION IN ADULTS Urinary tract infection in adults is common and may be complicated or uncomplicated. Infection of the urinary tract (UTI) is frequently encountered in clinical practice — in the USA these infections account for approximately 7 million office visits annu- ally. The reported incidence in women is 11% per year and approximately 50% of all women have at least one UTI in their lifetime.1,2 UTI accounts for 40% of nosocomial infections and catheter use is the leading cause.3 Up to 25% of hos- pitalised patients undergo catheterisation and the incidence of bacteriuria is 5% per day.4 Symptomatic UTI exists when clinical symptoms are attributable to bacteria in the normally sterile urinary tract. Symptoms vary depending on the site of infection (lower or upper tract). • Uncomplicated UTI describes infection where the urinary tract is entirely nor- ELIZABETH COETZER mal. MB ChB, FCP (SA) • Complicated UTI occurs where the urinary tract is compromised, either struc- Specialist Physician turally, functionally, metabolically or immunologically. Pretoria East Hospital Asymptomatic UTI is identified when organisms can be isolated in appropriate numbers from urine in the absence of symptoms. Elizna Coetzer graduated at the University of Pretoria and did her internship at Adult patients with UTI can be categorised according to different clinical syn- Boksburg-Benoni Hospital. She was dromes (Fig. 1). Medical Registrar in the Department of 1,5 Medicine at Groote Schuur Hospital from DEFINITIONS AND DIAGNOSTIC TESTS 1998 to 2001. She completed 2 years at Bacterial invasion of the urinary tract causes an inflammatory response resulting the UCT Renal Unit and is currently a spe- in bacteriuria and pyuria. Indirect dipstick tests and/or direct microscopy of cialist physician in private practice at urine should be performed in all patients suspected of having a UTI. Pretoria East Hospital. Indirect dipstick tests Dipstick nitrite is used as a surrogate marker for bacteriuria. Infection due to uropathogens which do not reduce nitrate to nitrite (e.g. Gram-positive cocci) may be responsible for false-negative results. The dipstick leukocyte esterase test is a rapid, convenient and cheap screening tool for detecting pyuria. However, neither is diagnostic of significant bacteriuria, and urine microscopy and culture are required for confirmation. Microscopic urinalysis and culture Pyuria is the presence of white blood cells (WBC) in the urine and is indicative of urothelial inflammation. This is a nonspecific finding, but the vast majority of symptomatic patients have pyuria. In a random clean-catch urine specimen ≥10 WBC/mm3 will be consistent with infection. WBC casts in the presence of symp- toms is strong evidence for pyelonephritis. Sterile pyuria warrants investigations for other conditions such as tuberculosis, calculi or urinary tract malignancy. 182 CME April 2004 Vol.22 No.4 ADULT UTI urological reasons, or those with URINARY TRACT INFECTION an altered sensorium. In non-infect- Cystitis (lower tract) / Pyelonephritis (upper tract) ed patients samples obtained in this manner are less likely to be contaminated enough to demon- strate 105 organisms/ml. With ASYMPTOMATIC careful technique numbers as low as 102 organisms/ml are highly SYMPTOMATIC indicative of infection. • Suprapubic aspiration is particular- ly useful in adults with paraplegia. UNCOMPLICATED This invasive procedure is unpleas- ant for the patient but, when per- formed properly, is not dangerous. RECURRENT Bladder urine obtained this way is either sterile or contains significant growth, even if bacterial numbers COMPLICATED are < 105/ml. Associated factors5 • Structural abnormality/obstruction PATHOGENESIS Prostatic hypertrophy, bladder divertic- uli, genital prolapse Urinary tract invasion occurs in differ- Ureteric obstruction (strictures, pelvical- ent ways: iceal junction) • Ascending. Most pathogens are Renal cyst Urolithiasis intestinal, and enter the urinary tract through the urethra into the • Functional bladder. In women vaginal coloni- Neurogenic bladder Vesico-ureteral reflux sation is an important factor. Once Foreign bodies/catheters (urethral in the bladder, bacteria may multi- catheter, nephrostomy tube, ureteral stent) ply and ascend via the ureters to Pregnancy the renal pelvis and parenchyma. • Immuno-metabolic • Haematogenous. This is uncom- Diabetes mellitus mon in normal individuals, but Renal transplantation Cystic kidney disease, nephrocalcinosis blood-borne organisms can infect Renal failure the kidneys in patients with staphy- HIV infection (with CD4 counts < 200/mm3) lococcal bacteraemia from infective endocarditis or infected oral sites. Fig. 1. Classification of UTI. Secondary renal infection has also been described with Candida fun- Bacteriuria is the presence of bacteria Collecting urine specimens gaemia. in normally sterile urine. It implies that • The clean-catch method is preferred micro-organisms are from the urinary for routine collection, as it avoids Once colonisation and invasion has tract and not contaminants from the the risk of infection associated with taken place, host-parasite interaction distal urethra, vagina or skin. invasive methods. With proper col- becomes important in the development Bacteriuria without pyuria indicates lection voided urine usually con- of UTI. Strong host resistance needs to bacterial colonisation rather than tains < 104 organisms/ml. In be overcome by increased bacterial infection. Significant bacteriuria is asymptomatic patients 104 - 105 virulence factors. Conversely, less viru- ≥ 5 defined as 10 organisms/ml of organisms/ml represents contami- lent bacteria are able to infect patients voided urine (i.e. the number of bacte- nation 95% of the time. In patients who are compromised. Normal anti- ria that exceed the number usually due with symptoms of UTI, a titre of bacterial defences of the urinary sys- to urethral contamination).The possibil- ≥ 105 organisms/ml carries a 95% tem include high osmolality, low pH ity of contamination is inversely pro- probability of true bacteriuria and and presence of organic acids in portional to the reliability of the collec- even counts as low as 102 organ- urine, urine flow and micturition, spe- tion technique. Acceptable collection isms/ml confirm the diagnosis. cific inhibitors of bacterial adhesion, methods include: • Catheterisation performed under the inflammatory response (neu- • segmented voided urine specimens scrupulous aseptic technique may trophils, cytokines) and the immune or midstream clean catch be necessary in those who are system. • catheterisation unable to void for neurological or • suprapubic aspiration. April 2004 Vol.22 No.4 CME 183 ADULT UTI CLINICAL SYNDROMES — In healthy adult men between the ages are only found in about 20% of MICROBIOLOGY, of 15 and 50 years, cystitis is very patients. Major differential diagnoses MANIFESTATIONS, AND uncommon and uncomplicated are outlined in Table I. MANAGEMENT pyelonephritis hardly ever occurs. In men, cystitis presents with irritative Uncomplicated UTI Uncomplicated cystitis voiding symptoms, but in some A relatively narrow spectrum of In women, sexual intercourse, patients may mimic urethritis. Major uropathogens cause UTI in patients diaphragm and/or spermicide use, differential diagnoses are outlined in with normal urinary tracts. Escherichia delayed postcoital micturition and a Table II. coli is the main organism isolated, fol- history of a recent UTI all increase the lowed by Staphylococcus saprophyti- risk of infection. In postmenopausal In women, uncomplicated cystitis cus. Enterococci and other Gram-nega- women, oestrogen deficiency with rarely progresses to symptomatic tive enterobacteriaceae such as atrophic vaginitis, and less abundant upper UTI, and does not have long- Klebsiella, Enterobacter and Proteus protective lactobacilli is another con- term negative effects with respect to 1,2,5 species infrequently cause infection in tributing factor. Reasons for infec- renal function or mortality. The this group.6 tion in men are not always clear, but causative organisms are predictable, risk factors include intercourse with an as are their antimicrobial susceptibility Acute cystitis and uncomplicated infected partner, anal intercourse and profiles. This means that women gener- 2 pyelonephritis are common problems lack of circumcision. ally require only an abbreviated in women, particularly sexually active workup and empirical therapy. women from 20 - 40 years of age, Cystitis is typically diagnosed clinical- Uncomplicated cystitis rarely occurs in and in the postmenopausal popula- ly. In women, symptoms include men, so pre-treatment urine culture is tion. dysuria with frequency and urgency, recommended and clinicians should but no fever or constitutional symp- have a low threshold for urology refer- toms. Suprapubic pain and tenderness ral and investigation. Table I. Differential diagnosis of uncomplicated cystitis in women Condition Clinical findings in addition to dysuria and pyuria Common aetiology Urethritis or Urethral/vaginal discharge containing numerous WBCs Sexually transmitted infections vaginitis No suprapubic pain/tenderness, urinary frequency/ (STIs): Chlamydia trachomatis, urgency and fever Neisseria gonorrhoeae, Trichomonas vaginalis Cervicitis Irritative voiding symptoms with mucopurulent vaginal or STIs cervical discharge (containing numerous WBCs) and postcoital bleeding Cervical erythema and/or oedema with swabbing-induced bleeding Pelvic
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