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[REV. MED. CLIN. CONDES - 2010; 21(4) 629-633]
resistant bacteria. The appropriate duration of
treatment of urinary tract infection should be
completed. Research is needed in new strategies for
prevention of recurrent urinary tract infections and
development of new oral antibiotics for drug-resistant
bacteria.

Key words: Bacterial infections/urine, Humans,

Pyelonephritis/drug therapy, Pregnancy, Cystitis/drug

INFECTIONS therapy, Recurrence / prevention & control, Risk factors,

Urinary Tract Infections / etiology.

URINARY TRACT INTRODUCTION

The urinary tract is usually sterile, with the exception of
URINARY TRACT INFECTIONS the most distal segment of the urethra. ITU is a generic
name that includes multiple clinical pictures, depending
DR. ANDRES WURGAFT, K. (1) on the location of the infection and the type of
patient. Each of the clinical pictures, listed in table 1,
requires a study and own treatment, described later in
1 unit of Nephrology, Department of internal medicine. Clinica this article.
Las Condes.

awurgaft@clc.cl
EPIDEMIOLOGY

OVERVIEW
Infection of the urinary tract (ITU), with their
The ITU is one of the most frequent infections. The
multiple clinical presentations, is among the most
annual incidence in adult women is up to 15% and half of
common infectious diseases, both in how hospital
the women had
outpatients. The use of the test comprehensive
urine and urine culture should be
[REV. MED. CLIN. CONDES - 2010; 21 (4) 629-633]
rational. Asymptomatic bacteriuria should not be
sought or treated, partly because this favors the
development of antibiotic-resistant
bacteria. Different clinical pictures require different
durations of antibiotic therapy, and both the excess
days of treatment and their lack must be
avoided. Research in pursuit of more effective
strategies to prevent the recurring ITU and in the
development of new oral antibiotics for the ITU
resistant is required.

Key words: bacterial infection / cystitis/therapy,

urine/pyelonephritis/therapy, pregnancy,
recurrence/prevention and control of risks,
etiology/urinary tract infections.

SUMMARY
Urinary tract infection, with its multiple clinical
presentations, is one of the most common
infectious diseases in both ambulatory and
hospitalized patients. The urinalysis and urine
culture should be used when
appropriate. Asymptomatic

Item received: 31-03-10

Article approved for publication: 31-05-10
bacteriuria should not be handsearching or treated, in
part because of a concern for the selection of antibiotic

629
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TABLE 1. ITU CLINICAL PICTURES (1)
Cystitis in young women
Recurrent ITU
Acute pyelonephritis
Complicated ITU
ITU in men
ITU in the older adult
ITU associated with urinary catheter
Asymptomatic bacteriuria
ITU in pregnant women
at least one episode before age 32
(2). Recurrences are frequent, and over a period of
6 months after the first episode, 27% of women
have at least one recurrence (3). In men the ITU is
much less frequent, but increases with age.
PATHOGENESIS
The mechanism of invasion of the urinary system is
the rise of microorganisms Uropathogenic through
the urethra. The Uropathogenic, typically
Escherichia coli, they come from the rectal flora,
but they can colonize the perineum and the
introitus. They favor this colonization factors of
virulence of the bacterium, including the presence
of fimbriae, which adhere to the mucous
membrane (4). This accession is also favoured by
genetic determinants expressed in the epithelium
of the woman. Estrogen deficiency alters genital
trophism, alters its flora and also favors
colonization by bacteria uropatogenas. The
following factors could explain the higher
incidence of ITU in women in relation to man:
shorter length of the urethra, less distance
between the year and the urinary meatus,
periurethral driest environment in man and the
antibacterial activity of the fluid prostate. In
women, urethral massage that occurs during
intercourse promotes the entry of bacteria.
A healthy urinary system is a defense mechanism
against infection. Urine has antibacterial
properties, and the flow of urine diluted and
eliminates bacteria that have entered. Alterations
in the function or structure of the urinary system,
including the blockage, presence of stones or
foreign bodies, as well as vesicoureteral reflux
favor infection.
ETIOLOGY
Escherichia coli is a bacterium that frequently
produces ITU. In some countries, but not in ours,
described a high incidence of ITU by
Staphylococcus saprophyticus in sexually active
young women (5). In infections nosocomial,
recurrent or complicated, it increases the relative
frequency of Proteus, Pseudomonas, Klebsiella,
whole-
630
bacter and Enterococcus. In these cases are also e. coli
resistant to antibiotics, infections by more than one
organization and ITU Candida.
DIAGNOSIS
Front of a compatible clinical picture, diagnosis is
performed with a urinalysis and a urine culture
test. Pyuria is the presence of more than 5 white blood
cells per field in the sediment or more than 10
leukocytes per mm3 of urine. The test with the test tape
(dipstick) positive for the presence of Leukocyte esterase
and nitrite is consistent with ITU. However, urine test is
only presumptive of ITU. The call sterile pyuria, pyuria
with negative urine culture, may be due to noninfectious
inflammation (acute interstitial nephritis), acute sexually
transmitted urethritis, or tuberculosis of the urinary
system.
A quantitative urine culture is performed to statistically
differentiate a uit of pollution that can be produced by
bacteria from the urethra. In the ITU over 105 there are
usually bacteria per mL of urine (6). There are cases in
which this concentration is lower, and is also considered
a positive urine culture with more than 103 uropatogenas
bacteria per mL, in the presence of symptoms of
ITU. The urine sample must be "second shot", probing or
suprapubic puncture. All these techniques minimize the
contamination of the sample.
The urine culture is not indicated in all the clinical
presentations of ITU. Cystitis in young women starts
antibiotic treatment without the need for cultivation.
CLINICAL PICTURES
Acute uncomplicated cystitis in young women
The symptoms of cystitis or low ITU are the result of
inflammation of the bladder and urethral mucosa:
dysuria and urgency, urinary frequency, pujo, murky and
foul-smelling urine. There may also be suprapubic pain
and hematuria. There may be a temporary relationship
with sexual activity, including the start of this
("honeymoon cystitis"). In a sexually active woman,
dysuria may be caused by urethritis by Neisseria
gonorrhoeae or Chlamydia trachomatis. Genital herpes
and by candida or vaginitis Trichomonas can cause a
dysuria which is described as "external" (7).
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Front of a typical clinical picture of uncomplicated acute
cystitis in a woman, the urine culture is not necessary
because the organisms causing and its sensitivities to
antibiotics are predictable (8). The treatment involves
typically 3 days cotrimoxazole or a fluoroquinolone,
ciprofloxacin (9). Cephalosporins are less used because
they have been less studied and nitrofurantoin requires
up to one week of therapy (10).
The urine culture is performed only if there has been no
clinical response or symptoms recur then of completed
therapy. In these cases, is a more prolonged therapy,
assuming a clinically silent infection, but that requires
more days of antibiotics to eradicate the bacteria.
Recurrent acute cystitis in women
The following terms are distinguished in the
recurrent ITU: 1) reinfection is recurrence after
the eradication of the first infection-causing
bacteria.
( 2) relapse is recurrence when the first infection-
causing bacteria persisted despite treatment
urinary tract.
The vast majority of cases of recurrence in healthy
women is due to reinfection, sometimes by the
same organism that persists in the rectal or
perineal flora. They are usually recommended
behavioural measures of prevention, as perineal
hygiene "from front to back", the abundant intake
of water, or urination after sex (11). However, the
usefulness of these measures have little basis in
studies.
Antibiotic prophylaxis is effective. It is indicated in
women with at least 3 ITU on a period of 1
year. The alternatives are daily or postcoital use of
antibiotics. The latter when the patient notices a
temporal relationship with sexual activity. In some
cases directs the patient to start a 3-day antibiotic
course just start (12) symptoms.
In postmenopausal women has been used topical
intravaginal estrogen to favor tissue trophism and
normalization of the vaginal flora. The
development of Lactobacillus antagonized by
Uropathogenic perineal colonization.
Acute pyelonephritis in women
In acute pyelonephritis, the typical clinical picture
includes fever and back pain. The symptoms of low
infection may or not be present, and these can
precede fever. There may be nausea and
vomiting. On physical examination, there is pain to
palpation or lumbar puno-percusion. In the
laboratory, apart from alterations in urine, there is
Leukocytosis and reactive C protein
lift. Sometimes the pain is abdominal (not back)
and the picture may mimic other abdominal septic
pictures.
The urine must be always in these
cases. Treatment can be an outpatient, typically
with oral ciprofloxacin, analgesia and oral
hydration, unless there is one of the indications
for hospitalization (table 2).
TABLE 2. INDICATIONS FOR
HOSPITALIZATION IN
ACUTE PYELONEPHRITIS
1 Inability to make oral intake of water and
medicines (nausea and vomiting).
2 Conditions psychosocial that hamper adherence to
treatment.
3 Severe illness with high fever, severe pain, or
prostration.
4 Doubtful diagnosis.
5 Suspected pyelonephritis complicated.
[URINARY TRACT INFECTIONS - DR. ANDRÉS WURGAFT K.]
Ceftriaxone is a treatment with antimicrobial activity
spectrum suitable for patients with indication for
hospitalization. Pyelonephritis by Enterococcus requires
ampicillin. Aminoglycosides are less used because of its
potential toxicity. Usually patients can switch to oral
therapy after one or two days and end the treatment on
an outpatient basis. The total duration of the antibiotic is
10 to 14 days. Patients treated with ciprofloxacin and
whose symptoms blinked then, treated for 10 days. It is
not necessary to take urine cultures post treatment,
unless the symptoms have recourse.
In the event of recurrence of pyelonephritis, these
should be handled in a similar way and the presence of
complicantes factors should be considered (see below).
Complicated urinary tract infections
Complicated ITU refers to the existence of a systemic,
anatomical or functional alteration (table 3) favoring one
or more of the following:
1. It increases the risk of infection or recurrence.
2. It reduces the effectiveness of antibiotics.
3. It increases the risk of ITU for resistant organisms.
4. It increases the morbidity and mortality of the ITU.
Complicated ITU requires urine culture, longer duration
of antibiotics and consideration of most broad-spectrum
antibiotics prior to the result of cultivation (14). Some of
these require hospitalization and/or evaluation by
urology or other specialties.
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ITU in men with probe and systemic signs of infection you can
The ITU in men becomes more frequent with the not assume that the cause is an ITU only by the
appearance of prostate disorders. It is rare in young men presence of bacteriuria or pyuria, because this can
with normal urinary systems, but it can occur. These be only a concomitant finding The management of
cystitis "not complicated" man are linked to anal sex and this infection is based mainly on prevention
sexual partners vaginal colonization with (16). Urinary catheters should be used when they
Uropathogenic. They require urine and can be treated are strictly indicated. The probes "to stay" should
with 7-10 days of ciprofloxacin. The complicated ITU are be replaced periodically because the emergence of
typically associated biofilm promotes bacterial growth.

Asymptomatic bacteriuria
Asymptomatic bacteriuria is the presence of a
TABLE 3. SOME FACTORS THAT DEFINE AN ITU AS positive urine culture in the absence of clinical
COMPLICATED (13) manifestations of urinary tract infection. The
prevalence of bacteriuria is low in healthy
Factors anatomical / functional Urinary obstruction individuals. However, the prevalence of
bacteriuria is high in certain groups: older women
Vesicoureteral reflux Prostatic hyperplasia (20%), institutionalized elderly (up to 50%) and
users of urinary catheters to permanence
Neurogenic bladder Lithiasis (100%) (17). the asymptomatic bacteriuria should
not be treated. Treatment does not decrease
Urological Instrumentation Tumors mortality nor the subsequent emergence of
urinary symptoms. Treatment can also be
Urological reconstruction -Based diseases deleterious in terms of

Renal Transplantation Diabetes Mellitus

Monorreno Chronic renal failure

Polycystic kidneys Immunosuppression

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