Urinary tract infection in females

Urinary tract infection in females: causes and prevention

1. URINARY TRACT INFECTIONS IN WOMEN Dr Nupur Gupta MBBS, MS, MICOG Ex AIIMS Experience 2 decades

2. What is Urinary Tract Infection?

3. First description – 1550 BC Earlier treatment – herbs, rest Antibiotics - 1930 Introduction

4. Female anatomy.  A woman has a shorter urethra than a man does, which shortens the distance that bacteria must travel to reach the bladder. Sexual activity.   Having a new or multiple sexual partners also increases your risk. Certain types of birth control.  Women who use diaphragms or spermicidal agents for birth control may be at higher risk. Menopause.  After menopause, a decline in circulating estrogen causes changes in the urinary tract that make you more vulnerable to infection . Risk Factors: Women

5. Urinary tract abnormalities Blockages in the urinary tract -  Kidney stones A suppressed immune system -  Diabetes and other diseases that impair the immune system Catheter use (CAUTI) -   People who are hospitalized, people with neurological problems and people who are paralyzed A recent urinary procedure or  Urinary surgery Neurogenic bladder, spinal cord injury Pregnancy & postdelivery Other Risk Factors

6. Urethritis Cystitis Ureteritis Pyelitis Pyelonephritis Classification of UTI: Level

7. Pain or burning during urination The urge to urinate often Pain in the lower abdomen, pelvic area & around pelvic bone Urine that is cloudy or foul-smelling Pelvic pressure Lower abdomen discomfort Frequent, painful urination Blood in urine Some people may have no symptoms Symptoms of UTI: Bladder Infection

8. Upper back and side (flank) pain (costovertebral angle tenderness) High fever Shaking and chills Nausea, Vomiting Headache Symptoms of UTI: Kidney Infection

9. Burning with urination Discharge, dysuria & PID Symptoms of UTI: Infection in urethra

10. Rule out vaginitis, cervicitis Differentiate UTI from STI Is it UTI or something else?

11. It refers to persistent, actively multiplying bacteria within the urinary tract in an asymptomatic woman A person may have no symptoms at all. Yet , a urine test shows the presence of bacteria   Prevalence (5-6%) in pregnant & non pregnant women Highest incidence - African-American multi paras with sickle-cell trait Lowest incidence - affluent white women of low parity Asymptomatic Bacteriuria /Stealth UTI

12. Untreated UTIs may  spread from the bladder to one or both kidneys. Causing damage that will permanently reduce kidney function - can raise the risk of kidney  failure. A small chance that the infection may enter the   bloodstream (Urosepsis) Complications of UTI

13. Many types of bacteria live in the intestines and genital area , but this is not true of the urinary system. In fact, urine is sterile. So when E . coli is accidentally introduced into the urinary system, it can start a UTI   How does UTI begin?

14. Not drinking enough fluids Taking frequent tub baths Holding urine in the bladder too long Kidney stones What increases your risk?

15. The first step in diagnosing a UTI is usually a simple urine test called a urinalysis. It looks for bacteria, as well as abnormal counts of WBC, RBC. Your doctor may also send urine to a lab for culture to confirm the type of bacteria. Significant: 10 (3) CFU/ml in asymptomatic & 10 (5) CFU/ml in symptomatic Diagnosis of UTI

16. E coli Staphylococcus Proteus mirabiis Kleibsella Enterococcus Most common pathogens in Urine Culture Chlamydia & Gonorrhoea in Urethritis (vaginal swab)

17. Prescription antibiotics will almost always cure a UTI Your health care provider may recommend drinking lots of fluids and emptying your bladder frequently to help flush out the bacteria Kidney infections can often be treated with oral antibiotics, too. But severe kidney infections may require hospital care, including a course of intravenous antibiotics Treating UTI

18. Phenazopyridine can help ease your pain, burning, and irritation. It also reduces frequency and urgency . But it doesn't cure your infection. You still need to see your doctor to make sure you get treatment to fight the bacteria that's causing your UTI. Also, one common side effect: It turns your pee dark red or orange while you take it . Flavoxate/URISPAS is a smooth muscle relaxant Symptomatic Relief

19. Alkalinises the urine Reduces painful urination Does not allow bacteria to colonise and divide in the urinary tract Flushes the urinary tract Prevents stone formation in kidney (by reducing urates) Role of Citralka/Disodium potassium Citrate

20. Which is the best drug for you? Drug with high bacteriolethal concentration in all fluids of urinary tract Highest efficacy (not altered by change in pH of urine or blood Drug with zero nephrotoxicity Drug broadly effective against all common bacteria causing UTI Drug with wide margin of safety Drug that is easy to administer Drug whose dosage schedule is simple Bacteria should not be able to develop resistance too early/ frequently

21. Only if left untreated, a urinary tract infection can have serious consequences. Recurrent infections, especially in women who experience two or more UTIs in a six-month period or four or more within a year. Permanent kidney damage from an acute or chronic kidney infection (pyelonephritis) due to an untreated UTI. Increased risk in pregnant women of delivering low birth weight or premature infants. Sepsis , a potentially life-threatening complication of an infection, especially if the infection works its way up your urinary tract to your kidneys . Complications

22. Perinephric or renal abscess Suspect in a patient not improving on antibiotics Diagnosis (CT or renal USG) May need surgical drainage SEPTICAEMIA Complications of Acute Pyelonephritis

23. Management of Acute pyelonephritis Hospitalization Urine culture and sensitivity, blood culture Evaluate hemogram , serum creatinine , and Serum electrolytes Monitor vital signs frequently, including urinary output (catheterization) Maintain UOP to 50 mL /hr with intravenous crystalloid Administer intravenous antibiotics CXR if there is dyspnea or tachypnea Repeat hematology and blood chemistry studies after 48 hours Change to oral antimicrobials when afebrile

24. Management of Acute pyelonephritis Discharge when afebrile for 24 hours, continue same antimicrobial therapy for 7 - 10 days Repeat urine culture 1 to 2 weeks after antimicrobial therapy is completed If there is no clinical improvement in 48 to 72 hours, then USG is done to look for urinary tract obstruction indicated by presence of abnormal ureteric or pyelocaliceal dilatation Suspect Nephrolithiasis (stones) if severe flank pain: plain X Ray or IVP should be performed

25. Recurrent UTI

26. Two episodes in 6 months or 3 - 4 in a year Diagnosed by urine culture Recurrent UTI in women

27. Pathogenesis of Recurrent UTI The genetic background influences the individual susceptibility to recurrent UTI Women with recurrent UTI are more likely to have had their first UTI before 15 years

28. Prevention of Recurrent UTIs Antibiotic prophylaxis - Taking a low dose of antibiotics long-term - Taking a single antibiotic dose after sex Immunoactive prophylaxis Probiotic prophylaxis Cranberry prophylaxis

29. UTI after Menopause

30. Estrogen has a protective effect in the urinary tract Low estrogen levels can make it easier for bacteria to thrive in the vagina or urethra UTI in Postmenopausal Women: Role of estrogen

31. UTI in postmenopausal women: other risk factors Atrophic vaginitis Incontinence, cystocoele Post void residual urine Urethral stenosis Management: Estrogen Cream/Surgical prolapse

32. UTI in Pregnancy

33. Kidneys become larger, VUR increases Dilatation of the renal calyces & ureters Ureteric compression ( dextrorotation of uterus) Overt bacteriuria has been reported to be associated with preterm or low-birth weight infants Bacteriuria that persists or recurs after delivery has been associated with pyelographic evidence of chronic infection, obstructive lesions , and congenital abnormalities. ACOG recommends screening for bacteriuria at the first antenatal visit (if untreated, 25% develop infection) Urinary Tract Changes in Pregnancy

34. Aymptomatic Bacteriuria in pregnancy Bacteriuria is typically present at the time of the first prenatal visit in pregnancy, and if an initial positive urine culture is treated, <1 % of women develop urinary infection It may be prudent to treat in pregnancy when lower concentrations are identified, because pyelonephritis develops in some women with colony counts of 20,000 to 50,000 organisms/ml

35. UTI in Pregnancy Renal infection (acute pyelonephritis ) is the most common serious medical complication (septic shock) of pregnancy Increased risk in second trimester, nullipara and young age It is usually unilateral in most of cases Right-sided in 50% of cases Bilateral in 25% cases

36. Nitrofurantoin Amoxicillin Amoxicillin & Clavulanate Cephalexin Safe antibiotics in pregnancy

37. How to Prevent UTI in pregnancy Repeat urine culture after treatment of bacteriuria & UTI Postcoital prophylaxis in women with H/o frequent UTIs in pregnancy

38. UTI in Puerperium /POSTPARTUM Bladder sensitivity to intravesical fluid tension is decreased as a consequence of the trauma of labor (episiotomy, periurethral lacerations, or vaginal wall hematomas) as well as analgesia Catheterization to relieve retention and distension commonly leads to urinary infection Operative and instrumental delivery delays early mobilization

39. Prevention of UTI

40. Drink plenty of liquids, especially water allowing bacteria to be flushed from your urinary tract before an infection can begin. Drink cranberry juice.  Although studies are not conclusive that cranberry juice prevents UTIs, it is likely not harmful. Wipe from front to back Empty your bladder soon after intercourse Avoid potentially irritating feminine products (deodorant sprays, douches and powders) in the genital area can irritate the urethra. Change your birth control method.  Diaphragms, or unlubricated or spermicide-treated condoms, can all contribute to bacterial growth. Preventing UTIs

41. Some studies suggest it can prevent , but not treat an infection, and is more effective in young and middle-aged women. Cranberries contain a substance that prevents  E. coli  bacteria from sticking to the walls of the bladder.   Is there a Cranberry Connection?

42. They don ’ t treat UTI that you already have But they reduce the risk of UTI ? H ow much ? How long Contraindicated for women with acidity & women who are on blood thinners Is there a Cranberry Connection?

43. FACTS

44. Nearly 20 percent of women who have a UTI will have another, and 30 percent of those will have yet another While they're not 100% avoidable, there are ways to help prevent infection. Fact 1: They are fairly common

45. Most people who get UTIs will experience similar symptoms such as pain or burning during urination and the frequent urge to urinate But not everyone will have the same experience In fact, it is possible to have a UTI and not experience any symptoms at all. Fact 2: Symptoms or No Symptoms

46. The main reason that the chances of infection are increased is that the hormone progesterone , which your body produces at an increased amount during pregnancy, relaxes the muscle in your ureters and bladder . This decrease in muscle tone , along with the pressure that your growing uterus puts on your bladder, can slow the flow of urine and put you at a higher risk for a UTI . Fact 3: Risk increases during pregnancy

47. It’s true that a UTI may subside without treatment, but it’s also true that the infection could spread to your kidneys and cause serious and permanent damage. Fact 4: We take it lightly

48. LET US UNRAVEL THE MYTHS

49. Myth 1: P oor hygiene If you get one, you must have poor hygiene But it can be due to hot tubs, tight clothes, tampons etc

50. Myth 2: Only Women get UTIs Men in 60s and 70s More common in women (short urethra, proximity to anus and vagina) Women’s lifetime risk is more than 50% (men 12%)

51. Myth 3: Only Sexually Active Women Any age Women who are prone: pregnant & menopausal Sex & spermicides can be a predisposing factor but not always (Always pass urine) There can be other reasons (immunity or urinary tract abnormalities)

52. Myth 4: Getting more than one UTI is dangerous Look for causes Should be treated promptly

53. Thank You