Diagnostic approach and microorganism

resistance pattern in UTI

Yeva Rosana , Anis Karuniawati, Yulia Rosa, Budiman Bela

Microbiology Department

Medical Faculty, University of Indonesia

Urinary Tract Infection (UTI)

Upper urinary tract : ureters and kidneys

Lower urinary tract: bladder and urethra

urinary tract inflammation that results

from any one of a number of distinct

syndromes

It is most commonly caused by a

bacterial infection

Urinary Tract Infection Lower urinary tract : bladder and urethra

The bladder wall is covered with a surface mucopolysaccharide that inhibits the attachment of bacteria via their adhesins

Uropathogenic strains of bacteria can attach to the cell wall of the bladder

Diagnostic approach in UTI Symptom UTI: localization of the site of infection 1. Acute bacterial pyelonephritis: - Fever, loin pain - Significant bacteriuria

2. Acute bacterial cystitis: - Frequency, & dysuria syndrome - Significant bacteriuria

3. Acute prostatitis - Perineal pain after sitting, a tender prostate, & fever - Significant bacteriuria

4. Symptomatic patients without significant bacteriuria urethritis, subacute or chronic bacterial prostatitis

UTIs INTO PERSPECTIVE

Upper urinary tract : ureters and kidneys

Lower urinary tract : bladder and urethra

150 million UTIs

(uncomplicated and complicated)

occur yearly in the world

UNCOMPLICATED UTIs are

the most frequent

BACTERIAL INFECTION

IN WOMEN

Stamm and Norrby, CID, 2005

The shorter urethra is a predisposing factor for Cystitis in women

Women lack the bacteriostatic properties of prostatic secretions: UTI >>

Risk factors for UTI: In females:

pregnancy, spermicidal contraceptives,

diaphragm, estrogen deficiency.

In males:lack of circumcision, prostatic hypertrophy,

use of catheter.

old age, obstruction, vesicoureteric reflux,

instrumentation, neurogenic bladder, renal

transplantation.

UTI frequency is roughly equal in women and men among the elderly

Men: an enlarged prostate in older men obstructs the urethra, leading to increased

frequency of urinary retention UTI

Menopause women: the loss of estrogen will be thins the lining of the urinary tract, which increases susceptibility to bacterial infection.

Struthers, Clinical Bacteriology, 2005

Epidemiology of UTI

Overview by sex and age

Diagnostic approach in recurrent bacterial cystitis :

• Someone who have had one bacterial cystitis have a risk recurrences, which follow the resolution of a previous treated or untreated episode

• Recurrent: at least 2 infections of the bladder in 6 months, or 3 infections in 1 year

Risk Factor for Recurrent UTI:

• Patients who do not empty their bladder completely

• Some large kidney stones

• Other foreign objects in the urinary system

Methods of urine collection :

No Methods Comments

1. MSU (main method) If possible, collect 2 specimens

to increase the percentage confidence of

organisms detection 2. a. Adhesive bags-infants

b. Clean-catch

specimen (CCS)-

infants

3. Suprapubic aspiration occasionally necessary in infants

4. Catheterization of urethtra - should never occur just to obtain a urine

specimen introducing infection

- If already catheterized, collected from the

catheter into a syringe and needle before

- it enters the drainage bag

5. Ureteric catheterization during operation

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Transport to laboratory

• Urine sample in sterile container should reach the microbiology laboratory for culture within 2 h of collection

• The following methods can be used in delay transportation:

1. Refrigeration at 4 0C (24 - 48 h)

2. Dip-slide technique

3. Boric acid (1.8% boric acid in the urine)

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Microscopic, Culture urine and determination of bacterial counts:

1. The white cells are counted

2. A. Surface viable count

B. Semi-quantitative

- Filter paper screening method

- Standard loop method

- Dip-slide method

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Mid-stream, clean-catch, & adhesive bag urine samples

No Interpretation Comments

1. Significant bacteriuria - >105 bacteria per ml

- usually a pure growth of one organism

- confidence ~ symptoms & pyuria

2. No evidence of infection - <104 bacteria per ml & not receiving

antibiotic

3. Equivocal results - 104 -105 bacteria per ml, especially if

Proteus or staphylococci are present

- Suggest repeat culture

4. Probable contamination - mixed growths in MSU sample

- < 104 bacteria per ml

- epithelial cells in microscopy

suggesting vaginal contamination

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Catheter or suprapubic urine samples:

Evidence of infection:

>105 bacteria per ml when infected urine

two organisms common when indwelling catheter

< 104 -105 bacteria per ml, may still be significant

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Interpretation of sterile pyuria: No Interpretation Comments

1. Possible

tuberculosis - consider early morning specimen of urine (EMSU)

X 3 for acid fast bacilli culture esp.if persistent pyuria

2. Treatment / non-

infective causes - antibiotic therapy; tumours or foreign bodies incl.

catheters; recent surgery; analgesic nephrophaty

3. Urethritis /

abacterial cystitis

- pus cells from ‘urethritis’ & ‘abacterial cystitis’

if low to moderately high counts of white cells

4. Vaginal discharge - pus cells from vaginal contamination

5. Other possible

causes

- due to a fastidious organism such as M. hominis,

Ureaplasma urealyticum

- look at Gram-stain of urine deposit. If numerous

short bacilli are present, infection due to diphtheroids

or anaerobes is a possibility

ESSENTIAL OF DIAGNOSIS:

Acute Cystitis-Urethritis

– Women and girls older than 2 years

– Acute onset dysuria, increased frequency of urination

– Pyuria: more than 10 leucocytes (high power field of centrifuged urine) or positive leukocyte esterase test

– Positive urine culture : 1,000-100,000 CFU/ml urine

ESSENTIAL OF DIAGNOSIS:

Acute Pyelonephritis

Fever, chills, costovertebral angle pain

Pyuria

Positive urine Gram stain

Positive urine culture (> 100.000 CFU) or blood culture

ESSENTIAL OF DIAGNOSIS:

Acute Prostatitis (subjects older than age 35)

◦ Fever, chills, dysuria, increased frequency of urination, low back or pelvic pain

◦ Pyuria

◦ Positive urine culture for gram-negative bacilli or enterococci

Chronic urinary tract infection

◦ persistence or frequent re-infection of the kidney, bladder, or prostate

• To know the most common bacteria-causing cystitis

• Resistance pattern to be able to perform adequate therapy

Microbial Pattern of UTI

0

5

10

15

20

25

30

35

40

45

E. coli (%) K. pneumoniae (%) Proteus mirabilis (%) Staphylococcus aureus(%)

Pseudomonasaeruginosa (%)

2009

2010

2011

2012

Resistance Pattern

• E.coli Antibiotic 2009

%S

2010

%S

2011

%S

2012

%S

Fosfomycin 92 92.3 90 73

Ciprofloxacin 32.3 42.9 40 27

Trimthoprim/ Sulfamethazole

45.2 21.4 40 35

Piperacilin/

Tazobactam

85.7 85.7 92 66

Imipenem 96.7 100 90 78

LMK Mikrobiologi FKUI,

2009-2012