URINARY TRACT INFECTIONS

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1 URINARY TRACT INFECTIONS Dr Caroline CHARLIER-WOERTHER Université Paris Descartes Paris, France

2 Definitions Clinical presentation by type Complications Spectrum of pathogens Pathophysiology Management by type Urinary tract infections Know how to diagnose UTI Know the basics of treatment by type

3 Urinary tract infections Colonization Asymptomatic bacteriuria Infection Cystitis Pyelonephritis Prostatitis Epididymo-orchitis

4 Cystitis Burning when urinating Frequent urination Urge to urinate Pain above the pelvic bone Rare traces of blood in urine or rare traces of pus (pyuria) Dysuria in uropathy Clinical presentation NO FEVER (temp < 38 C) NO FLANK PAIN

5 Pyelonephritis Same urinary symptoms FLANK PAIN FEVER Nausea/ vomiting/ headache Young children : Loss of bladder control Acute prostatitis Older patients : Clinical presentation Same Confusion/ symptoms altered mental status Abdominal Urine retention pain / incontinence Warm Fecalith swollen and tender prostate at digital rectal examinatioe retention

6 Clinical presentation Acute prostatitis Same urinary symptoms FEVER Abdominal pain Warm swollen and tender prostate at digital rectal examination Possible urine retention

7 Chronic prostatitis Untreated / insufficiently treated prostatitis Milder symptoms Fever or not Burning/ frequent / urgent urination Recurrent symptoms Rectal examination May be normal Milder symptoms Clinical presentation

8 Epididymo-orchitis Orchitis Epididymitis Both Clinical presentation Acute infection (first symptoms < 6 weeks) Unilateral pain/ tenderness Warm, swollen epididymis / hydrocele Spermatic cord and testis extension possible FEVER Concomitant prostatitis / uretritis?

9 Epididymo-orchitis Clinical presentation Acute infection (first symptoms < 6 weeks) Chronic infection (> 6 weeks) Mild recurrent symptoms

10 Complications Cystitis Pyelonephritis Recurrence Pyelonephritis Sepsis Kidney abscess/ pyonephrosis Acute renal failure if obstruction

11 Prostatitis Sepsis Urine retention Prostatic abscess Epididymitis/ epididymo-orchitis Chronic infection if left untreated Complications Epididymo-orchitis Sepsis Testicular abscess Ischemia and necrosis Reactive arthritis in Chlamydia infections

12 UTI classification Simple episode No complication, no risk of complication

13 UTI Simple episode, no risk of complication At risk of complication Pre-existing uropathy/ urological device Renal insufficiency Immunosuppression including pregnancy Men Older patients > 75 years or > 65 years + > 2 Fried frailty criteria

14 UTI Simple episode No complication, no risk of complication At risk of complication Pre-existing uropathy/ urological device Severe infection : by definition Severe sepsis /shock Requirement for surgery

15 Pathogens involved Cystitis / pyelonephritis UTI pathogens Prostatitis and epididymo orchitis UTI pathogens STI pathogens And specific pathogens for orchitis

16 Cystitis UTI Bacteria Prostatitis Pyelonephritis Escherichia coli 70% Escherichia coli 80% Staphylococcus saprophyticus 10% Proteus mirabilis 5% Proteus mirabilis 10% Klebsiella sp. 5% Klebsiella sp. Enterococcus sp. 10% Enterobacter sp. Serratia sp. E. coli : 50% R amoxicillin 30% R amoxicillin-clav 30% R cotrimoxazole 10% R fluoroquinolones 5% R 3 rd generation cephalosporins Nosocomial context : + Staphylococcus aureus + Pseudomonas aeruginosa + Enterococcus sp. + Candida sp.! Fluoroquinolones in the last 6 months Most are ESBL producing enterobacterias

17 Urinary tract infections Diagnosis on a mid-stream urine sample After local cleaning Image courtesy of PL Woerther

18 Urinary tract infections Bacteriological definition in the urine Leukocytes count 10/mm 3 ou 10 4 /ml Bacterial colony count in the urine culture : Cut-off 10 3 UFC/ml 10 4 UFC/ml 10 5 UFC/ml Context Any infection in men Infection in women due to E. coli, other Enterobacteriacae or Staphylococcus saprophyticus Infection in women with other pathogens Asymptomatic bacteriuria in pregnancy Health care-associated bacteriuria 10 3 UFC/ml in every situation except

19 Prostatitis Prostatitis is either a UTI or a STI UTI : UTI pathogens pre-existing adenoma /carcinoma : older male or not : young adults STI : mostly N. gonorhoeae,? M. genitalium

20 Epididymo- orchitis EO is either related to a UTI or to a STI or UTI : UTI pathogens STI pre-existing adenoma /carcinoma : older male or not : young adults N. gonorhoeae C. trachomatis Specific pathogens in specific contexts : 3 to remember Mycobacterium tuberculosis Brucella melitensis Mumps virus

21 UTI : Pathophysiological features 4 infection pathways Ascendant infection ++++ Fecal flora urethra bladder kidneys/ prostate Hematogenous infection (kidney, Candida sp.) Direct inoculation (endoscopy ) Sexually transmitted : epididymo-orchitis

22 UTI : Pathophysiological features Host defenses Urine flux Length of the urethra (! Shorter in Female) Regular voiding Mucosal defenses Vaginal flora Bacterial virulence factors Fimbriae and pili enhancing bacterial adherence

23 UTI : Main epidemiological features Frequent disease Women : sexual activity ( honeymoon cystitis ) and post-menopausal period Men : older population with prostatic lesions If Children : malformation in 50% (boys)

24 UTI : Main epidemiological features Specific age groups Urinary catheters (3% colonization/day) ID: diabetes, pregnancy Anatomic or functional disorders Vesico-ureteral reflux Voiding dysfunction (post mictional residue) Other local factors Constipation Vaginal dryness (post menopausal inadequate lubrification)

25 Diagnosis Management of cystitis DO urianalysis by urinary stick Leukocytes Urinary nitrites (nitrate reductase in Enterobacteriacae) Urine culture only if Ttt failure = persisting symptoms > 7 days after tt Early recurrence > 4 episodes / year Cystitis at risk of complication

26 Management of cystitis Treatment 1. single dose fosfomycine-trometanol 3g 2. pivmecillinam 5 days 3. fluoroquinolone single dose or nitrofurantoin 5 days 4. Cystitis at risk of complication 7 days treatment Try and defer treatment to the reception of ATBg Amox > pivmecillinam > nitrofurantoin> amox/clav/ FQ/ Cotrimoxazole If ttt before ATBg : nitrofurantoin Men never have cystitis

27 Management of cystitis Treatment S. saprophyticus!!! Failure of single dose fosfomycine /fluoroquinolones choose nitrofurantoine or 3 days fluoroquinolones <30 years No nitrite on the urine stick analysis

28 Management of cystitis Treatment Hyperhydration 30% cure without antibiotics

29 Recurrent cystitis Management of cystitis 1. check for uropathy (echography/cystoscopy/ CT scan w/o IV) Malformation Urine Reflux Voiding dysfunction 2. check for gynecological disorder Urogenital prolapse Vaginal dryness

30 Recurrent cystitis Management of cystitis 3. hygiene /lifestyle rules Regular drinking and regular miction Post coital miction Anus wiping from from to back Cotton underwear, not to tight Genital hygiene : not too much scrubbing Treatment of constipation/ vaginal dryness

31 Recurrent cystitis Management of cystitis 4. treat every episode Urine culture documentation 5. antibiotic cycling in most severe cases >12 / year Nitrofurantoin contra-indicated in this situation because of long term lung/ liver toxicity

32 Urine culture (Blood culture) Management of pyelonephritis (Complete blood count / C-reactive protein) (Creatinine, glomerular filtration rate) Beta HCG if relevant Echography if very painful infection Stones Ureteral/ pyelic dilatation IV CT scan if pyelonephritis at risk of complication or severe infection

33 Management of pyelonephritis Ambulatory / hospitalization? Outpatients : simple episode, no comorbidity, home monitoring and observance OK Inpatients : complicated infections, severe infections, no reliable home monitoring or observance Intensive care unit? Severe sepsis / septic shock Other organ failure Urology? Urinary tract obstruction urine drainage in emergency

34 Management of pyelonephritis Initiate antibiotics after bacteriological samples 3 rd generation cephalosporins Cefotaxime 1g x 3/d IV Ceftriaxone 1-2g x 1/d IV/IM Fluoroquinolones (AVOID if exposure < 3-6 months) Ofloxacine 200mg x 2/d PO Ciprofloxacine 500mg x 2/d PO Pefloxacine 400 mg x 2/d PO Levofloxacine 500 mg x 1/d PO Aminoglycosides if severe infection (severe sepsis, septic shock) Amikacine 20mg/kg/d Gentamicine 5-7 mg /kg/d

35 Management of pyelonephritis Initiate antibiotics after bacteriological samples Antibiotics are not strictly similar to those for cystitis For cystitis you choose antibiotics that concentrate in the urine (= urinary elimination) For pyelonephritis you choose antibiotics that concentrate in the parenchyma

36 Fluoroquinolones spectrum 1. urinary tract quinolones Ex : norfloxacine Urinary tract enterobacteriacae 2. classical fluoroquinolones Ex : ciprofloxacin, ofloxacin, pefloxacin Enterobacteriacae (90%) + some Pseudomonas aeruginosa (ciprofloxacin) + some S. aureus (pefloxacin) + intracellular bacterias + in vitro inhibition of M. tuberculosis growth 3. recent respiratory quinolones Ex : levofloxacin, moxifloxacin + S. pneumoniae + anaerobic flora (moxifloxacin) + M. tuberculosis ++++ (moxifloxacin)

37 Fluoroquinolones : the 4 flags Tendon injury Tendinitis Tendon rupture (Achilles tendon) Mostly older patients, corticosteroids, pefloxacin Photosensibility/toxicity (sun protection) Moxifloxacin : QT interval prolongation and hepatic toxicity Check for pregnancy

38 Fluoroquinolones administration Oral administration if possible Excellent bioavailability except for norfloxacin 10 times less expensive prescription No empiric quinolone-based treatment in patients exposed to quinolones in the last 6 months

39 Septic shock with pyelonephritis Consider ESBL if Recent (<6mths) tt by FQ, penicillin + inhibitor, C2G C3G Documented urinary colonization < 6 months Recent stay in high endemic area Long-term facilities Carbapeneme + amikacine

40 Management of pyelonephritis Complications Severe sepsis Kidney abscess/ pyonephrosis Acute renal failure if obstruction if persisting fever at 72 hours : reevaluate Urine culture / blood cultures IV CT scan Other cause of fever (nosocomial infection )

41 Management of pyelonephritis Antibiotics switch to oral drug when afebrile, according to urine culture / antimicrobial susceptibility testing Amoxicillin Amoxicilin-clavulanate Cotrimoxazole Fluoroquinolone Cefixime Treatment duration 7 days simple infection, tt f.quinolones or C3G IV only days other cases

42 Management of acute prostatitis Diagnosis Urine culture Blood cultures x 2 Trans-abdominal ultrasound evaluation MR imaging if abscess suspected

43 Management of acute prostatitis Ambulatory / hospitalization? Outpatients : moderate infection, no major co-morbidity, reliable home monitoring and observance OK Urine retention Urethral catheter Prostatic abscess Discuss drainage if large prostatic abscess No urethral catheter but percutaneous supra-pubic urinary bladder catheterization

44 Management of acute prostatitis Initiate antibiotics after bacteriological samples Moderate infection, no quinolones < 6 months Fluoroquinolones Ofloxacine 200mg x 2/d PO Levofloxacine 500 mg x 1/d PO Excellent prostatic diffusion Moderate infection, quinolones < 6 months 3 rd generation cephalosporins Cefotaxime 1g x 3/d IV Severe infection 3 rd generation cephalosporins + aminoglycosides Gentamicine 5 mg /kg/d / amikacine 20 mg /kg/d

45 Management of acute prostatitis Treatment duration 14 days moderate infections + fluoroquinolones Otherwise 21 days

46 Management of chronic prostatitis Diagnosis Urine culture Semen culture Urine culture before/ after prostatic massage Prostate ultrasound / MRI calcifications reflecting previous infections Heterogeneous parenchyma Prostatic antigen

47 Management of chronic prostatitis Treatment On documented infections Antibiotics Fluoroquinolones Cotrimoxazole 3 rd generation cephalosporins Treatment duration Not studied 4 weeks (quinolones), otherwise 6 weeks (surgery in refractory cases)

48 Management of epididymo-orchitis Diagnosis Rule out testicular torsion Torsion is more likely if patient is under 20 years (but can occur at any age) the pain is sudden (within hours) the pain is severe preliminary tests do not show UTI Doppler ultrasound can help but should not delay surgery

49 Management of epididymo-orchitis Diagnosis Rule out testicular torsion Urine culture Blood cultures N. gonorrhoeae + C. trachomatis PCR in first voided urine TB? : chronic, hardened bead-line thickening of the epididyme, no fever, 25% bilateral Parotitis? mumps Brucella? Environmental exposure, spondylodiscitis

50 Management of epididymo-orchitis Treatment STI Ceftriaxon 500 mg once IV/IM + doxycyclin 100mg x 2/d, 14 d Sexual partners/ diagnosis of other concomitant STDs (8wks) Check microbiological cure UTI Like prostatitis Antalgic drugs, jock-strap NSAID contra-indicated (necrosis++) Surgery if abscess IUSTI _WHO guidelines 2013

51 Management of urine colonization No treatment except Pregnancy Before urological examination /procedure In women with persistent bacteriuria > 48H after the removal of an indwelling urethral catheter NOT with diabetic patients NOT with patients with spinal cord injury NOT with patients with long term indwelling urethral catheters

52 Management of urine colonization No treatment except Pregnancy Before urological examination /procedure In women with persistent bacteriuria > 48H after the removal of an indwelling urethral catheter No follow-up except pregnancy

53 Urinary tract infections in pregnancy Pregnancy is a risk of UTI DO urine culture (uristick not enough) Treat asymptomatic bacteriuria (5-7 days) Pyelonephritis : hospitalization and treat 10 days Avoid fluoroquinolones, avoid trimethoprime T1 Consider gentamicine in severe infections (1-3 days) Evaluate urine culture / month until delivery

54 Asymptomatic bacteriuria in pregnancy Is a risk of pyelonephritis : 40% after a median of 3 weeks Is probably a risk of prematurity Is checked by urine stick / month Should be confirmed by urine culture 10 5 bactéries / ml including Streptococcus B Should be treated 7 days or 1 day (fosfomycine) Cure should be checked by uriculture Urine culture 10d after tt completion and / month

55 Cystitis and pregnancy Treatment 1. Fosfomycine trometamol single dose 2. Pivmecillinam 3. Nitrofurantoine 4. Ciprofloxacine Duration 7 days (1 d for fosfomycine) Follow-up : uriculture / month

56 Pyelonephritis and pregnancy Increased prematurity Major cause of maternal sepsis (25%) Mostly right side for physiological reasons Work-up : Do urine culture and echography Treatment Hospitalization C3G /Aztreonam (+ amikacine in sepsis) For days Uriculture 10 d after tt completion then monthly

57 Balanitis - posthitis Balanitis Inflammation of the glans penis Posthitis inflammation of the prepruce + Syphilis 2013 European guidelines Balanitis

58 Long-term indwelling catheters Colonization is constant Bacterial acquisition 3%/ day Cloudy urine Don t treat if no symptoms / fever No antibiotic during catheter replacement Remove catheter when unnecessary Prefer intermittent catheter

59 Wikimedia commons Sources

UTI are the most common genitourinary disease of childhood. The prevalence of UTI at all ages is girls and 1% of boys.

UTI are the most common genitourinary disease of childhood. The prevalence of UTI at all ages is girls and 1% of boys. 1-3% of Below 1 yr. male: female ratio is 4:1 especially among uncircumcised males,