URINARY TRACT INFECTIONS

Over view of Urinary Tract Infections

• Most common infectious disease

• Most Numerous specimens are received in the Laboratory
• 30 to 40 % of specimens received in Microbiology
laboratories are Urine specimens, to Identify the
Infection.
• Diagnostic information is important for the clinician.
• Appropriate clinical information gives many
clues for better diagnostic evaluations.
• Specimen collection is the primary objective in getting an
ideal sample.
Why women are at More Risk for Urinary
Tract Infections
• Women tend to have
urinary tract infections more
often than men do because
the urethra is shorter in
women than in men, so
bacteria have a shorter
distance to travel.
Who are at Risk with UTI
• Urinary tract infection is much more common in adults
than in children, but about 1-2% of children do get urinary
tract infections. Urinary tract infections in children are
more likely to be serious than those in adults and should
not be ignored.
Most Important facts to establish Infection

• Simple microscopic examination of wet films of

unconcentrated urine for detection of Polymorphonuclear
leucocytes - pus cells gives leading clues
• Semiquantitative culture of urine to detemine wether urine
contain potentially pathogenic bacteria in Numbers
sufficent to identify it as causative agent causing infection.
Common Presenting Symptoms

• Urgency
• Frequency of
Micturation
• Discomfort and pain in
abodemen or on
passing urine
Organs Involved in UTI
• The following organs are
infected

• Kidney
• Bladder
• Ureters

• Donot include Urethra,

Infections of Urethra is
called as Urethritis, dealt
under different clinical
syndromes
Common site and Microbes

• Patients in majority of
cases present with
infection of Urinary
Bladder and called as
Cystitis
• Most common
pathogen is
Escherichia coli.
 Common Pathogens causing UTI

• Staphylococcus saprophyticus
• Klebsiella pneumonia – var
aerogenes or oxytoca
• Proteus mirabilus, other
coliforms
• Pseudomonas aeruginosa
• Streptococcus faecalis
• Candida being a fungus can
cause infections in Diabetic or
Immunocompromised patients.
Rare Microbes causing UTI
• Streptococcus
agalactiae
• Streptococcus milleri
• Other Streptococci
• Anaerobic Streptococci
• Gardernella vaginalis
Serious Infections associated with UTI

• Acute pyelitis
• Pyelonephritis
• May lead to Bacterimias detected by Blood culture
• A prominent infection with Staphylococcus aureus
can cause above manifestions.
UTI without Routine Bacterial isolates

• Some times it puzzles the clinicians, patients

present with symptoms of urinary tract infection
but bacteria donot grow on Routine culture Media
• May be associated with
Organisms that donot grow on selected
media
Can be a Genito urinary tract Tuberculosis
Gonococcal infections
Nationally exacting or anaerobic bacteria
Non Bacterial Urethritis,Cystitis
and Urethral syndromes

• One should be familiar

with
Urethral or Bladder
infections with
Chlamydia
Ureaplasma
Trichomonas
Viral infections
Simple tests to rule out Urinary tract
infections

• In les equipped
laboratories routine testing
for detection of
Nitrite
Blood
Protein
• By rapid automated
dipsticks can give basic
information
• But eliminates about ½ of
culture negative specimens.
Collecting Urine for examination

• Collect the Mid stream

specimens of Urine
• Donot collect
spontaneously collected
urine without
instructions, which can
lead to contamination
with commensals
bacteria Colonised on
urethral orifice and
perineum
Specimen Collection
• The urine collected in a
wide mouthed container
from patients
• A mid stream specimen is
the most ideal for
processing
• Female patients passes
urine with a labia
separated and mid
stream sample is
collected
Specimen collected in young and Children
• Non invasive methods are safe
and ideal
• Follow the Broomhall et al
method
By tapping just above the pubis
with two fingers place on
suprapubic region after 1 hour
of feed, tapping on at the rate of
1 tap/second for aperiod of 1
minute, if not succesul tapping is
repated once agin.
The child spontaneously pass the
Urine and to be collected in a
sterile container
Transport of Urine for Culturing Urine

• All collected specimens of

urine to be transported to
laboratory with out delay
• Delay of 1 – 2 hour deter
the quality of diagnostic
evaluations.
• If the delay is anticipated
the specimens are at
preserved at 40c
• In field conditions Boric
acid can be added at a
concentration of 1.8 %
Proof of Urinary Tract Infection

• Needs presence of potential pathogens in the freshly

voided urine or scientifically preserved specimens in
numbers greater than those likely to result from
contamination from urethral meatus and the surrounding,
• Kass suggested the Number to be about 105 or more (
1,00,000 / ml of urine )
Diagnosis of Urinary Tract Infection

• Step 1
Microscopy of
Urine for detection of
Pyuria.
Leucocytes should
be found in numbers of
at least as great as 104
/ ml before the pyuria
is established
Wet Film examination of Urine
• All wet films to be examined with
high power ( x 40 ) objective.
• Prepare the drop of urine after
mixing the urine without
centrifugation
• Transfer 0.05 ml on the middle
of the microscope slide and
cover slip is applied.
• The prepared specimen show a
small excess of fluid along the
edges of the cover slip.
• A approximate finding of 1
leukocyte / 7 high power fields
corresponds to presence of
pyuria.
Culturing of urine for Isolation of Bacterial
pathogens
• Semiquantitative
culture
Select the Media
For common isolates
Mac Conkey’s agar
helps in differentation
of Lactose fermenting
organisms from non
lactose fermenting
pathogens
Selection of Loop for Semiquantitative
Method
Culture Media for isolations- CLED
Medium
It is also an excellent
universal culture medium
owing to its wide spectrum of
nutrients, lack of inhibitors
and the fact that it allows a
certain degree or
differentiation between the
colonies. It contains lactose
as a reactive compound
which, when degraded to
acid, causes bromothymol
blue to change its colour to
yellow. Alkalinization
produces a deep blue
colouration. The lack of
electrolytes suppresses the
swarming of Proteus
Culture Media for Isolation

• Blood agar
helps in isolation of
fastidious, extracting
strains
May extended incubation
for isolation of pathogens
for more than 48 hours
with added atmosphere of
5 – 10 % co2
Specimen Inoculations
• All cultures processed by
Semiquantitative method a loop
of standard dimension of
approximately known volume is
inoculated into selected culture
plate
• In general a loop of SWG – 28
with a diameter of 3.26 mm
internal diameter which can hold
a drop of water or urine 0.004
ml.
• After inoculation the culture
plates are incubated at 370c
extending to > 18 hours are
read
• The colony counts are made, as
each colony corropsdes to
number of viable bacteria per ml
of urine
Reading the Culture Plates
• A true infection in the absence of prior antibiotic therpay the number
of bacteria is likely to be at least 105 or more.
• Contaminated specimens present with colony counts <104, however
even less than 103
• On several occasions the colonies are diverse species
• Several studies prove counts >104 to be considered as presence of
Urinary tract infection with the supporting clinical history
• On some occasions more than one pathogen is isolated but should be
processed for all practical purposes
eg E.coli along with Streptococcus fecalis
• On few occasions even counts 103 are proved
significant
Identification of Gram + organisms

• All colonies identified

morphologically as
Staphylococcus to be
characterized as
Staphylococcus aureus
Staphylococcus
saprophyticus
Staphylococcus
epidermidis
Enterococci - fecal group of
organisms
Identification of Isolates
Gram + isolates

• The minimal tests to

differentiate Gram +
cocci include
1 Catalase
2 Coagulase test
3 Bile esculin testing
4 Bacitricin in
Streptococcus isolates
Biochemical tests in Gram -
bacilli

• Catalase test
• Oxidase test
• Nitrite reduction test
• Indole test
• Methyl red test
• V P test
• Citrate test
• Decarboxylation tests
Lysine, ornithine, Arginine
tests
Mac Conkey’s agar showing Proteus
and E.coli
Blood agar showing Coagulase
negative Staphylococcus
Most important

• Yet many theories on Significant bactenuria are

contraversioal.
• The reporting of results should be maninly based on
clinical history.
• Even a true infection may contain only 103
• In such circumstances tests to be reported as probably or
possibly significant
• A good coordination between a Microbiologist and
Physcian is the best solution associated with best
solutions to patients with Urinary tract infections.
Reporting of Contaminated specimens
• Microscopy helps to detect pus cells and epithelial cells,
an insignificant grwoth with few pus cells can ignored as
contaminants
• In females even the presence of leucocytes with
Squamous epthelial cells without a defined significatn
growth should be ignored.
Antibiotic Sensitivity
• Always use a pure
grwoth of the isolates.
• Perform testing for
antibiotic sensitivity
with inoculam which is
comparable to defined
Macfarland standards.
Most serious Infections presenting as
Urinary tract Infections

• Acute pyelitis
• Pyelonephritis
May present with loin
pain, fever,
Apart from Urine culture
patients present with
Bacteriaemia - can be
detected by Blood culture.
Causative agent can be
Staphylococcu aureus
Clinical Problems manifesting as Urinary
tract Infections

• An infection of the
Genitourinary tract
where the Microbes
donot grow on
selected media as in
Mycobacterium
tuberculosis
Gonococcus
Nutritionally exacting
or anaerobic bacteria
Non Specific Urethritis

• Several conditions mimic

Urinary tract infection which are
associated with organism other
than routinely isolated in simple
and few selective media, they
can be
Can be urethral or Bladder
infections with
Chlamydia
Ureplasma
Trichomonas,
Few viruses
Dealing with UTI

• The chemotherapy of proven infection may guided by in

vitrosensitivity tests on the pathogen isolated by culture
and outcome of therpay assessed by examination of urine
at the conclusion of treatment.
• Follow up examination of patients with UTI is important, if
neglected can lead to chronic and permanent
complications.
Antibiotic Sensitivity Testing

• All the isolated

bacteria identified as
pathogenic to be
tested for Antibiotic
Sensitivity/Resistance
pattern by disk
diffusion methods
Antibiotic Sensitivity
• Always use a pure
grwoth of the isolate.
• Perform testing for
antibiotic sensitivity
with inoculam which is
comparable to defined
Macfarland standards
Rationalsim of Antibiotic Selection
• If the patient is attending a
General practice, outpatient
clinic, drugs suitable by oral
administration should be
selected
• The discks are with defined
content to test the pathogens in
the urine

Amoxycillin or Ampicillin 25
Cephelexin 30 µg
Nalidixic acid 30µg
Ciprofloxacin 5µg
Nitrofurantoin 50µg
Trimethoprim 2.5
ß Lactamase producing Gram negative strains
• There is a grwoing incidence of ßlactamase producing strains in
particular associated with Hospital acquired infections
• The newly defined methods to be used as per the NCCL guidelines.
• There is a growing need for testing for
Amikacin,
Netilmicin,
Tobramycin
Netilmicin
Ticarcillin
There is a grwoing list organisms associated
with Hospital Infections need better
identification testing with new generation of
drugs.