URINARY TRACT INFECTIONS: CURRENT APPROACH IN PREVENTION, DIAGNOSIS AMD CARE

Definition

Urinary Tract Infections can be defined as Infections that occur in any part of the urinary tract(kidneys, bladder or urethra)

Types

Pyelonephritis – infection of kidney (UUTI)

Cystitis – infection of bladder (LUTI)

Uncomplicated UTI

Acute, occasional or recurrent UTI in a non pregnant women without any comorbidities or structural or functional abnormalities within the urinary tract

Complicated UTI

UTI in men, pregnant women, patients with significant structural or functional abnormalities within the urinary tract, renal diseases, diabetes, indwelling urinary catheters and/or immunocompromised patients

Recurrent UTI

UTIs with a frequency of atleast 3 within the last 12 months or 2 within the last 6 months

Asymptomatic Bacteriuria

Presence of significant amount of bacteria(>10⁵ CFU/ml) in an uncontaminated urine sample in a patient without any signs and symptoms of infections

Urosepsis

Dysregulated organ dysfunction that occurs due to infections arising from the urinary tract

Causative organisms

Common

• E.coli
• Klebsiella spp
• Enterococcus species
• Non fermenting gram negative bacilli

Rare

• Proteus spp
• Citrobacter
• Staphylococcus aureus

Risk factors

• Advanced age (>80yrs)
• Gender(Female > male)
• Catheterization
• Prior UTI
• Renal calculi
• Bladder dysfunction
• Diabetes mellitus
• Immunocompromised status
• Benign Prostatic Hyperplasia
• Family history and genetics

Diagnosis

Clinical signs and symptoms

Cystitis - Acute onset of dysuria with urgency and frequency, suprapubic tenderness without vaginal discharge associated with fever and chills

Pyelonephritis - Acute onset of back or flank pain, costovertebral angle tenderness, nausea and vomiting associated with fever and chills with or without typical symptoms of cystitis

Urinalysis

Significant pyuria and/or positive Dipstick test

Laboratory findings

Elevated total WBC counts, CRP and/or procal (consider in patients with severe UTI)

Microscopy

Positive urine culture with common or rare suspected organism*

Positive blood culture (may be necessary in severe patients)

*A positive urine culture in asymptomatic patients indicate contamination and treatment is usually not necessary

Management

Catheter Associated Urinary Tract Infections

CAUTI refers to the infection of the urinary tract that occurs in a patient who is currently being catheterized or has been catheterized within the previous 48 hours

Methods of diagnosing CAUTI

CAUTI can be diagnosed by the presence of signs and symptoms compatible with UTI with no other source of infection along with CFU >/= 10³/ml of >/= 1 bacterial species in a patient with indwelling urethral, suprapubic or intermittent catheterization.

CAASB is defined by the presence of CFU >/= 10⁵/ml of >/= 1 bacterial species in a patient with indwelling urethral, suprapubic or intermittent catheterization without signs and symptoms compatible with UTI

Agreeable signs and symptoms of CAUTI include worsening fever/chills, altered mental status flank pain, altered mental status, acute hematuria, pelvic discomfort and urgent/frequent urination associated with suprapubic pain or tenderness in those whose catheters have been removed

Pyuria is not a diagnostic criteria for CAUTI in a catheterized patients. Pyuria with CAASB is not an indication for antimicrobial treatmen. The absence of pyuria in a symptomatic patient suggests a diagnosis other than CAUTI

Methods to reduce the risk of CAUTI

- Limiting unnecessary catheterization

- Discontinuation of catheters promptly

- Using alternatives for indwelling urethral catheters (Eg.Condom catheters, suprapubic catheters etc.)

- Following strict aseptic and sterile techniques while insertion of catheters

- Considering the use of antibiotic coated catheters

Management strategies to reduce the risk of CAUTI

It is not necessary to screen and treat patients with CAASB except for pregnant women and patients who undergo urological procedures

Antimicrobial treatment can be considered if there is persistent CAASB (beyond 48 hrs after removal of indwelling catheters) to reduce the risk of subsequent CAUTI

Management strategies for patients with CAUTI

Appropriate urine culture should be sent prior initiating antimicrobials for CAUTI

At the time of onset of CAUTI if indwelling catheters are placed for > 2 weeks and still indicated, it is recommended to replace the catheter

Recommended duration of antibiotic therapy

7 days – CAUTI with immediate onset of symptoms

10-14 days – CAUTI with delayed onset of symptoms

Abbreviations

Reference

1. Gopalkrishnan, R., Walia, K., & Ohri, V. (2019). Treatment guidelines for antimicrobial use in common syndromes.
2. Bonkat, G., Pickard, R., Bartoletti, R., Bruyère, F., Geerlings, S., Wagenlehner, F., ... & Veeratterapillay, R. (2018). Urological infections. Arnhem: European Association of Urology.
3. Hooton, T. M., Bradley, S. F., Cardenas, D. D., Colgan, R., Geerlings, S. E., Rice, J. C., ... & Nicolle, L. E. (2010). Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clinical infectious diseases, 50(5), 625-663.
4. Bettcher, C. M., Campbell, E., Petty, L. A., Rew, K. T., Zelnik, J. C., Lane, G. I., ... & Proudlock, A. L. (2021). Urinary tract infection.