Urinary Tract Infections

SALT: November 2007

Dr Nizam Damani
MBBS, MSc, FRCPI, FRCPath, CIC, DipHIC
Consultant Microbiologist
Southern Health and Social Care Trust
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UTI: Case 1
A 24 yearyear-old female calls her GP complaining of increased
frequency & burning pain when urinating for last 2 days.

STD ?
Pregnancy ?
1st episode ?
Do a Urine dipstick ?
Send Urine specimen to the Lab ?
Advise on how to take proper MSU ?
104 cfu/ml ?
Which antibiotic to prescribe ?
Why ?
Duration ?

UTI: Case 1

2nd episode?
Previous culture ?
Organisms ?
Recurrent UTIs ?
Any prophylaxis ?
Which antibiotic ?
Is it working ?
Advice given on how to take prophylaxis ?

Case Study: Two

69 year old gentleman with enlarged prostate

Catheterised for 10 months
On waiting list for surgery
Low dose prophylactic Ciprofloxacin

Day 1: Present complaints

2 days history of feeling unwell.
Nausea
No fever
Dipstick result
RBC
WBC +++
Nitrate : negative
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Case Study: One

Day 2
General condition worse
Febrile
CSU specimen sent to the Lab. for Urine analysis
GP contacted
Advised to stop Ciprofloxacin and replace with Cephlaxin 250 mg TID
Day 4
No real change ? Worse
Developed rigor
Phoned microbiology Lab :
Microscopy : RBC and WBC not seen
Culture : Staph aureus ? MRSA

Urine analysis: Which one to believe ?

RBC

Dipstick

Microbiology Lab

Not seen
Microscopy

WBC
Nitrate

+++

Not seen

Leukocyte esterase

Microscopy

Negative

Staph. aureus
Culture
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Diagnosis of UTI: Microscopy

WBC 10/mm3 (Unspun MSU )
if WBC are lysed during transport
Febrile children often have pyuria in absence of
UTI
Pyuria is less strongly correlated with UTI in
catheterized patients
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Dipsticks : WBC

Leukocyte esterase in WBC

Detect both intact and lysed WBCs
Must be combined with Nitrate testing
False Positive:
Specimen with vaginal secretion
Decreased sensitivity
Cephalexin, oxalic acid ( iced tea drinkers)
High glucose, high specific gravity
Albumin & ascorbic acid inhibit this method
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Dipstick : WBC
False Negative
Neutropaenia

Poor predictor of positive Urine culture

Leukocytes esterase to detect > 10 WBC
~ 75-95% sensitivity
~ 65-95% specificity
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Organisms of UTI (%)

Organism

Community Hospital

Esch coli
Proteus
Klebsiella
Entero/citro
Pseudomonas
Acinetobacter

80-90
5-8
1-2

45-55
10-12
15-20
2-5
10-15
<1

Coag -ve staph

Staph aureus
Enterococci

1-2

1-2
<1
10-12

<1

In patients with indwelling catheters,

infections are frequently polymicrobial and
multi-resistant
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Kass Criteria
Study in asymptomatic female
First morning Mid Stream Urine specimen
Positive predictive value for MSU
80% for one specimen & 95% for two specimens :

20 % of women and 10 % of men > 65 years have

significant bacteriuria
_______________________________________________
Transported within 2 -4 hours11 or refrigerate at 4C
Use ice box during transportation
Boric acid ( 0.1g/10ml ) can be used as a preservative to
inhibit bacterial growth
Lower count if not first-morning MSU
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Significant growth: Kass criteria

Urine specimens are almost
inevitably
contaminated during collection

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Diagnosis of UTI: Culture

Culture

Not for

105 cfu/ml for MSU only

Candida infections: 104 cfu/ml
102 - 103 for CSU cfu/ml obtained
from urine collected with a needle from
the sampling port of the catheter
Suprapubic specimen in noncatheterised patient
Urine obtained during cystoscopy
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Dipstick : Nitrite testing

Need enzyme reductase to convert Nitrate to Nitrite
Absent if the infection is caused by the following organisms as they
don't contain reductase to convert nitrate to nitrite. :

Enterococci spp,
Streptococci spp
Staphylococci spp eg Staph saprophyticus
Neisseria gonorrhoeae
M Tuberculosis

Urine has to be in the bladder for 4 hours so that adequate reduction

of nitrate can occur
Obstetric patients: detect only 50% of patients with asymptomatic
UTI
Moderate sensitivity & specificity
Catheterised patients may have polymicrobial infection
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Dipstick : Nitrite testing

False negative
Dipstick stored in an ambient humidity
Storage of sample at Room temp for > 2 hours
( reduce nitrite to Nitrogen)

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Dipstick for MSU: Bottom line

Dipsticks ( leucocytes esterase & nitrate)
Highly specific: Negative predictive value of 90%-100%
Low sensitivity: Positive predictive value of 30%.
Must not use in pregnancy & younger children to detect
asymptomatic bacteriuria
Not a replacement for microscopy & culture

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Treatment of UTI
Recommended therapy for uncomplicated UTI
Trimethoprim 200 g BD for 3 days
Nitrofurantoin 100 mg QID for 3 days

Single dose therapy: high failure rate (12%-35%)

14 days for Pyelonephritis
Lab reports higher rate of resistance due to :
Selected patients who have received antibiotic therapy for
Recurrent UTI
CSU specimen from Catheterized Patients
Multiple specimens from same patients

Higher clinical cure rate due concentration of antibiotic in bladder

Encourage fluid intake

Recurrent UTI
Two or more episodes of urinary tract infection with
acute pyelonephritis or upper urinary tract infection
One episode of urinary tract infection with acute
pyelonephritis or upper urinary tract infection plus
one or more episodes of urinary tract infection with
cystitis or lower urinary tract infection
Three or more episodes of urinary tract infection
with cystitis or lower urinary tract infection
NICE Guidelines, 2007

Bacteriuria in catheterized patient

Incidence of bacteriuria in patients with indwelling
catheter :

Average daily risk : 5 % (range 3 -10 %)

2- 10 days :
25 %
30 days :
100 % patients are bacteriuric
Develop bacteraemia : 1-4 %

Urinary catheter interferes with normal defences,

allows attachment & colonization of microorganisms
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Risk factors associated with development of UTIs

in catheterized patients
Increasing duration of catheterization
Avoid catheterization, if possible
Remove when it is no longer needed
Method of last resort NICE guideline, 2003

Faulty aseptic management

Strict asepsis during insertion and maintenance is
essential
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Formation of Biofilm
Antibiotic is not effective in presence of
biofilm because:
microorganisms are embedded in the
biofilm grow slower therefore they have
reduced uptake of antimicrobial agents
biofilms may also escape the protective
action of phagocytes
Presence of foreign body may initiate gene
activation which increases antibiotic
resistance

Saint S, Biofilms and catheter-associated urinary tract infections.

Infectious Disease Clinics of North America. 2003;17(2):411-32

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Antibiotic treatment
Treat patient and not the Laboratory report !
Asymptomatic colonisation does not warrant treatment
Choice of antibiotic depends on the susceptibility testing; difficult if
infection is polymicrobial
Recommended duration : 7-10 days
Because of presence of biofilm, treatment will work best if
catheter removed
Removal of catheter may be necessary if the catheter is in place
for > 1 week.
Candiduria usually resolves without treatment if the catheter can
be removed
Dont perform bladder wash out or put antiseptic in the urinary bag
Strict aseptic technique during insertion and maintenance and
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keep system closed !

Prophylactic antibiotics
Routine use of prophylactic antibiotics in catheterized patients is not
recommended because of

Cost
Adverse effects
Selection of antibiotic-resistant organisms
Bacteriuria will develop resistance regardless of antibiotic therapy

Removal of a catheter in presence of infection can cause

bacteraemia.
Antibiotic prophylaxis is recommended for

Instrumentation or surgery on Urinary tract

Previous history of CA-UTI
Heart valve replacement
Septal defect
Patent ductus arteriosus
Prosthetic valve
? other conditions

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Bottom line
Bacteriuria

Symptoms

Treatment

No

No

Yes

Yes

Presence of fever, urgency,

frequency, dysuria or suprapubic
tenderness.

Antibiotics are unable to penetrate biofilm

to eradicate microorganisms; removal of
catheter may be necessary if the catheter
is in place for > 1 week.

Routine use of prophylactic antibiotics

in catheterized patients is not recommended
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