بسم الله الرَحمن الرَحيم

1. بسم الله الرَحمن الرَحيم

2. Urinary Tract Infections (UTIs)

3. Introduction * UTIs are common, especially among women * UTIs in men are less common and primarily occur after 50 years of age * UTIs infection usually occur by ascending route (urethra to bladder) * UTIs infection is less common by haematogenous spread (kidney) * UTIs occur in two general settings: community-acquired and hospital (nosocomially) acquired

4. Definitions * Urethritis : Infection of anterior urethral tract dysuria, urgency and frequencyofmicturition - Dysuria (burning pain on passing urine) - Urgency (the urgent need to pas urine) - Frequency of micturitionتعدد مرات التبول * Cystitis : Infection of urinary bladder dysuria, frequency, pyuria and haematuria * Bacteriuria: Presence of bacteria in urine A count of 10 organisms/ml or more in urine * Pyuria : Presence of pus in urine (more than 10 cells/HPF) • Pyelonephritis: Infection of kidney(lion pain, pyuria, rigors زفزفةورعشة , fever

5. Etiology Of Urinary Tract Infections *Causative organisms: Escherichia coli Klebsiella, proteus and pseudomonas 1- Bacterial S. aureus, S. epidermidis and S. saprophyticus Enterococci (Strept. faecalis) Mycobacterium tuberculosis Chlamydia trachomatis, Mycoplasma 2- Viral Rubella, Mumps and HIV 3- Fungal Candida, Histoplasma capsulatum 4- Protozoal T. vaginalis,S. haematobium

6. Notes on pathogens * Escherichia coli : the commonest urinary pathogen causing 60-90 % of urinary infections * Pseudomonas, Proteus, Klebsiella and S. aureus are associated with hospital acquired infections because their resistance to antibiotics favor their selection in hospital patients (catheterization, gynaecological surgery) * Proteusinfections are associated with renal stones Proteus produce a potent urease which act on ammonia, rendering the urine alkaline * S. saprohyticus infections are found in sexually active young women

7. Notes on pathogens * Candida urinary infection is usually found in diabetic patients and immunosuppression * Infection of the anterior urinary tract (urethritis) is mainly caused byN. gonorrhoae, staphylococci, streptococci and chlamydiae * M. tuberculosisis carried in blood to kidney from another site of infection (e.g. respiratory T.B.)

8. Mechanical And Functional Factors Predispose to UTI * Disruption of urine flow or complete emptying of bladder - Pregnancy - Renal stones -Tumor - Prostate hypertrophy - Strictures = narowing of ureter * Loss of neurologic control of bladder and sphincters Paraplegia, and multiple sclerosis Paraplegia شلل نصفى فى الرجلين multiple sclerosis تكوين طبقة على العصب تقلل قدرته * Vesicouretral reflux (reflux of urine from bladder up the ureter) Anatomic abnormalities in children * Catheterization facilitate bacterial access to bladder - During insertion - In situ, bacteria access to bladder

9. Virulence Factors of Causative Organisms - Fimbriae enable adherence to urethral epithelium - Capsular polysaccharide inhibite phagocytosis - Haemolysin production by E. coli -Membrane damaging toxin - Production of urease enzyme (proteus spp.)

10. Healthy Urinary Tract Bacterial colonization in urinary tract is prevented by: - pH of urine (acidic) - Chemical content of urine - Flushing mechanisms اندفاع البول

11. Clinical Features Acute lower UTIs (Urithritis and cystitis): Rapid onset of: - Dysuria (burning pain on passing urine) - Urgency (the urgent need to pas urine) - Frequency of micturition Upper UTIs (Pyelonephritis): - Fever - Chills - Dysuria - Urgency - Frequency of micturition

12. Difference between infected and contaminated urine Infection Contamination More than 105 Organisms/ml less than 104Organisms/ml A single bacterial spp. More than one organism

13. Diagnosis of Urinary Tract Infections * Specimen : Urine - An aseptic collection technique essential to prevent contamination - The first urine passed by patient in the morning - A ”mid stream” urine sample under a septic precaution - Boric acid is used as a preservative for urine specimens * Special urine specimens are required to detect: a- Mycobacterium tuberculosis : Three early morning urine samples on 3 consecutive days b- S.haematobium : The last few milliliters of a morning urine sample after exercise

14. Diagnosis of Urinary Tract Infections * Detection of significant bacteruria a- Microscopic examination : - Wet film to detect : . Pus cells, red cells, casts, yeasts . Bacteria T.vaginalis, S. haematobium b- Viable bacterial count : - A measured volume (calibrated loop 0.002 ml) of urine is spread on surface of a solid medium - Incubation of the solid medium at 37°C for 18-24 hours - Enumerate the number of colonies

15. Diagnosis of Urinary Tract Infections(cont.) c- Cultures : - Culture is required when urine contain bacteria, cells, casts, protein,nitrite - Nutrient agar, CLED agar, Blood agar and MacConkey’s medium at 37°C - Isolated colonies are identified in a systematic way: 1- Microscopical examination : Gram staining to differentiate between Gm negative and Gm positive Shape, size and arrangement 2- Biochemical reactions : - For Gm negative organisms: Sugar fermentation, Indol test, Oxidase, MR, VP and urease tests - For Gm positive organisms : Coagulase test, catalase test 3- Serological identification : Detection ofmicrobial Ag by specific Ab

16. Sterile Pyuria - Presence of pus in urine in absence of bacterial growth - Causes : a- Infection with: Chlamydia trachomatis M. tuberculosis Ureaplasma Anaerobic bacteria Mycoplasma and L-forms Viruses b- Previous antibiotic therapy (Suppress growth of bacteria)

17. Treatment * Uncomplicated UTI: An oral antibacterial as a single dose or for 3 days * Complicated UTI (Pyelonephritis): Treatment with a systematic antibacterial agent e.g. Beta-lactam (Ampicillin, amoxicillin, cefalexin) Quinolone (Ciprofloxacin, levofloxacin)

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