1. DR.PAVITHRA

2.  INTRODUCTION
 INCIDENCE
 DEFINITIONS
 CLASSIFICATIONS
 ETIOLOGY
 RISK FACTORS
 PATHOGENESIS
 LAB DIAGNOSIS-SPECIMEN
COLLECTION,SCREENING
PROCEDURE,AUTOMATED METHODS,CULTURE
 STERILE PYURIA
 TREATMENT

3.  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.  1.2% in women
- 0.6% in men
- 50% of women will experience an UTI during
their lifetime.
- Nearly 30% women will have had a symptomatic
UTI requiring antimicrobial therapy by age of 24.

5. •UTI-Presence of microorganisms in the urinary
tract including the bladder ,prostate, collecting
system or kidneys.
•Significant bacteriuria-colony count of 105
CFU/ml or greater depending on the clinical
setting ,manner specimen were collected.
• Pyuria - Presence of pus cells in urine
(more than 10 cells/HPF)

6. Infection Contamination
More than 105 Organisms/ml less than 104 Organisms/ml
A single bacterial spp More than one organism
•Bacteriuria –presence of bacteria in
the urine.
True infection or contamination.

7. A. Upper urinary tract infection and
Lower urinary tract infection
B .Uncomplicated and
complicated.
C .Hospital acquired and
community acquired

8. Community aquired UTI
 E.coli
 Klebseilla spp
 Enterobacteriacea
 Staphylococus
saprophyticus
 Enterococci
Complicated UTI
perticularly recent cases
Proteus,Psuedomonas spp,
Enterobacter spp,
Klebseilla spp.

9. Hospital –acquired infection
 E.coli
 Klebseilla spp
 Staphylococci
 Other enterobacteriacea
 Proteus mirabilis
 Psuedomonas aeruginosa
 Enterococci,

10. Fungi
 Candida,
 Histoplasma capsulatum
Parasites
 Trichomonas vaginalis
 Schistosoma heamotobium
Virus
 Adenovirus type 11 and 21 cystitis in children,
 Rubella
 Mumps ,HIV

11. MISCELLANEOUS RARE
 Acinetobacter spp
 Psuedomonas spp
 Citrobacter spp
 Gardnerella vaginallis
 Aerococcus urinea
 Beta hemolytic
sterptococci
 Mycobacteria
 Chlamydia trachomatis
 Ureaplasma urealyticum
 Campylobater spp
 Heamophilus influenza
 Leptospira
 Corynebacterium spp

12. Female Male
All ages Previous UTI LACK of
circumcision
Urethral
catheterization
do
Neurogenic
bladder
do
Urinary tract
obstruction
do
Renal
transplantation
do
Urologic
instrumentation
do

13. Adults Sexual intercourse Rectal intercourse
Lower socio
economic
Diabetes , surgery
Sickle cell trait in
pregnancy
HIV high viral load
Older age Functional and
mental impairment
Prostatic
enlargement

14. 1.Age and sex –infants 1-2%
 Boys –first 3 months
 Thereafter more often in girls
2.Stagnation of urine in the bladder
3.Inadequate fluid intake
4.Structural abnormality
5.Vesico –urethral reflex
6.Antibiotic treatment –Penicillin
7.Lactobacilli –urethral syndrome.

15. Host defences:
 Urinary bladder is usually resistant to bacterial
colonisation.
 Bacteria accessing the bladder are eliminated
by
 -Flushing mechanism
-Urine inhibitors (PH, osmolality, urea)
--Uroepithelial defences (cytokines,PMNs)
-Tamm- Horsfall protien

16.  UTIs are a result of interaction between the uropathogen
and the host.
 Successful infection of the urinary tract is determined by
virulence factor of bacteria,
 inoculum size,
 inadequacy of host defense mechanisms.
 These factors play a role in determining the ultimate
level of colonization and damage to the urinary tract.

17.  Routes of infection
 Ascending Route
 Hematogenous Route
 Lymphatic Route

18.  Bacterial virulence factors
 Adhesins
 Toxins (Hemolysin-A)
 Proteases
 Invasins
 Serum resistance factors or
 Motility mediators.
 UPEC strains produce an acid polysaccharide
capsule that protects the bacteria from phagocytosis
and inhibits activation of complement

20. 1.Urethritis-: Infection of
anterior urethral trat
.dysuria, urgency
and frequency of
micturition
2..Cystitis-infection of
bladder
 Frequency, dysurea ,
urgency.
 Suprapubic
discomfort +/-
tenderness.
 Fever is often absent.

21. 3.Asymptomatic bacteriurea-isolation of a
specified quantitative count of bacteria in an
appropriately collected urine specimen
obtained from a person without symptoms
or signs of urinary infection.
4.Acute urethral syndrome-seen in young
,sexually active women,who experience
dysuria ,frequency and urgency but yield
fewer organisms than 105 cfu/ml urine on
culture.

22. 5.Pylonephritis –inflamation of kidney
parenchyma ,calyces and pelvis .
 Fever, abdominal pain, vomiting.
 Dysuria ,frequency, flank or loin pain.
 Flank or loin tenderness.
 In elderly: symptoms are often atypical.
 Bacteremia is common.

23.  INDICATION-
1.Epidiomological
purpose
2.Diagnosis of infection

24. 1.Clean catch technique-
Female – periurethral area is
cleaned with soap and water
Labial folds are than retracted
Urethra is flushed by voiding
the first portion of urine
Mid stream urine is collected in
a sterile container and
processed within 1 hr.

25.  Non invasive methods are
safe and ideal
 Follow the Broom hall
method,
By tapping just above the
pubis with two fingers
placed on supra pubic
region after 1 hour of
feed, tapping on at the
rate of 1 tap/second for a
period of 1 minute, if not
successful tapping is
repeated once again.
The child spontaneously pass
the Urine and to be
collected in a sterile
container

26. Mycobacterium
tuberculosis-
entire quantity of first
morning urine sample
is collected for three
consecutive days.
2.Straight catheterized
urine
3.Suprapubic bladder
aspiration
4.Indwelling catheter

27.  Collected urine sample transported
immediately and cultured within 30mins .
 If delay –refrigerated at 40 c or preserved using
boric acid 1.8% ,cultured within 24 hrs.
 Urine transport tube containing boric acid
glycerol and sodium formate -24 hrs.

28.  GRAM STAIN
 PUS CELL COUNT
 GRIESS NITRATE TEST
 LEUKOCYTE ESTERASE TEST
 CATALASE TEST
 BAC-T-SCREEN
 TRIPHENYL TETRAZOLIUM CHLORIDE
REDUCTION TEST
 GLUCOSE TEST PAPER
 ACRIDINE ORANGE STAINING
 BACTERIURIA SCREENING IN LIQUID MEDIA
IN trypticase soy broth.

29.  PHOTOMETRY (tubidity)
 BIOLUMINESCENCE(ATPase)
 ELECTRICAL IMPEDENCE
 LIMULUS AMBEOCYTE ASSAY(endotoxin)
 MICROCALORIMETRY(heat production)
 COULTER COUNTER(Particle size)
 RADIOMETRY(bactec carbon 14)
 URISCREEN (lipid enzymatic test)
 Rapid detection of Enterobacteriacea cell in urine
by fluorescent 16rRNA insitu hybridisation.

30.  Enzyme linked immunosobent assay for
detection of immunoglobulin for diagnosis of
UTI
 Flurorescent antibody technique
 DNA probe test.

31.  Required when urine contain bacteria, cells, casts,
protein,nitrite
 Nutrient agar,
 CLED agar,
 Blood agar and
 MacConkey’s medium at 37°C
 CHROMOGENIC AGAR – Direct detection and
differentiation of pathogens on primary plate.

32. - Isolated colonies are identified in a systematic
way:
1. Microscopical examination :
 Gram staining to differentiate between Gram
negative and Gram positive
Shape, size and arrangement
2. Biochemical reactions :
- For Gram negative organisms: Sugar
fermentation, Indol test, Oxidase, MR, VP and
urease tests
- For Gram positive organisms : Coagulase test,
catalase test

33. 3.Serological identification : Detection of
microbial Ag by specific Ab
 Detection of significant numbers of
pathogenic bacteria from culture of the
urine remained gold standard , diagnosis
of UTI

34.  KASS defined ->105 cfu/ml ,significant in
women –pylonepritis or asymtomatic
bacteriuria
 Single voiding ,105 colonies /ml -80% -true
infection.
 Same organisms recovered from two separate
specimens 90-95%
 <104 colonies/ml -98% -no infection
 104 -105 colonies/ml –sample repeated.

35. A. QUANTITATIVE
Quantitative criteria distinguish bacterial
infection or colonisation of the urine from
contamination.
Criteria depends on the fact that the density of the
bacteria in infected urine is usually several
orders of magnitude higher than the density of
bacteria in contaminated urine.
1.Pour plate technique
2.Surface viable count

37. B.SEMI QUANTITATIVE
1.Standard loop technique
2.Filter paper method
(blotting paper)
3.Dip spoon method
4.Dip slide method
5.Agar cup method
6.Pad culture method
7.Swab culture method.

38. Principle
 Inoculating loop of
standard dimensions
 Fixed known volume of
mixed uncentrifuged
urine
 Spread over the agar
plate, inoculated.
 Number of colonies
counted or estimated
 Number used to calculate
the number of viable
bacteria /ml of urine
 procedure

39. Interpretation
 Presence of 100 or more colonies –significant
bacteriuria.

40.  Standard 6mm wide strip
of filter paper bent into L
shape with 12mm long
foot , sterilized at 160
degree for 1hr.
 Dip the whole of the
angulated end foot
 Uncentrifuged sample of
urine
 Press over the agar plate
 Remove the strip,incubate
 Count the coloneis
growing on the
impression area.

41. Interpretation
 Upto to 50 colonies may be countable and heavier
growth are noted as semiconfluent or confluent.
 Approximately ,105 bacteria /ml corresponds -25
colonies of bacilli ,30 colonies of cocci.
 Merit
 Rapid and economical ,8-10 sample can be tested
 Demerit
 Growth –confluent.

42. Procedure
 Small plastic tray carrying a layer of an
appropriate agar culture medium on both
surfaces provided with container with screw
capped. dip slide is immersed in urine sample
and removed and placed in container screw
capped ,incubated.
 Commercial supply of dip –slides provide
charts showing representative number and
patterns by comparison with which viable
count can be read.

44. Merit
 Least laborius,inexpensive,convinient for
screening large no of samples,inoculation done
at the site itself ,problems with transport of
urine are overcome.
Demerit
 Does not provide material for microscopic
examination
 Difficult to judge ,pure or mixed confluent
growth.

45.  Similar colonies found in numbers suggesting
significant bacteriuria should be identified by
standard procedure
 102 cfu/ml-symptomatic patient –significant.
 104 -105 cfu/ml –
-when multiple species are recovered
- depends on clinical presentation.

46.  Antibiotic sensitivity
carried out depending
upon isolate and
clinical condition of
the patient.
 Orally administered
drugs are tested –
ambulatory
 Parental drugs tested
–oral drugs can not be
taken.

47. - 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)

48.  Uncomplicated UTI:
Trimethoprim/Sulfamethoxazole
Nitrofurantoin
 Complicated UTI (Pyelonephritis):
Treatment with a systematic antibacterial agent
e.g. Beta-lactam (Ampicillin, amoxicillin, cefalexin)
Quinolone (Ciprofloxacin, levofloxacin)

49.  Text book of microbiology-Ananthnarayan
 Practical medical microbiology-Mackie and
McCartney
 Diagnostic microbiology-Bailey and scott’s
 Text book of medical microbiology –DAVID
GREENWOOD
 Text book of diagnostic mirobiology-KONEMAN’s
color atlas
 Text book of microbiology-jawetz
 MANDELL text book of infectious diseases
 HARISSON text book of internal medicine
 INTERNET

50. THANK YOU