Causes of Urinary Tract Infection
UTI develops when microbes enter the urinary tract and cause infection. Normally, urine in the
bladder, ureter, and kidneys is sterile. However, the external genitalia of both sexes harbor
several types of microorganisms such as bacteria and fungi which can get access to the urinary
and cause infection. Possible pathogens of the urinary tract include parasites such as
Schistosoma haematobium, Trichomonas vaginalis, and occasionally Enterobius vermicularis,
Wuchereria bancrofti and Onchocerca volvulus; fungi such as candida species also infect the
urinary tract though they are not primarily pathogens of the urinary tract. Bacterial pathogens
include Escherichia coli, Proteus species, Staphylococcus species, streptococcus species,
klebsiella species and Pseudomonas aeruginosa (Monica cheesbrough, 2012).
2.2.3 Epidemiology of urinary tract infection
Urinary tract infection is among the most common infections, particularly among women, and
prevalence is age and sex dependent.
As the most frequently seen infection, UTIs affect more than 150 million people annually.
Approximately 1% of children, many of whom demonstrate functional or anatomic abnormalities
of the urinary tract, develop infection during the neonatal period. It is estimated that 20% or
more of the female population suffers from one form of UTI or the other in their lifetime. Infection
in the male population remains uncommon though common in the fifth decade of life, when
enlargement of the prostate begins to interfere with emptying of the bladder. In the elderly of
both sexes, gynecologic or prostatic surgery, incontinence, and chronic urethral catheterization
push UTI rates to 30 to 40%. A single bladder catheterization carries an infectious risk of 1%,
and at least
10% of individuals with indwelling catheters become infected (James et al., 2012).
Signs and symptoms of urinary tract infection
The symptoms of UTIs will vary depending on the etiologic agent, age, gender and what part of
the urinary tract has been infected. Common symptoms of UTI include:
* Strong and frequent urge to urinate
Cloudy, bloody, or strong-smelling urine
● Pain or a burning sensation when urinating
● Nausea and vomiting
● Muscle aches and lower abdominal pains
● Fever
● Back pain.
Pyelonephritis is usually an acute infection, and individuals with this condition experience upper
back pain, side pain, high fever, chills, fatigue and in some cases mental changes.
People with cystitis present with low fever, lower back pain, and pressure and cramping in the
abdomen. Among older adults, UTIs may cause symptoms such as confusion or agitation which
are not seen in younger people (James MCIntosh, 2018).
2.2.5 Etiology (causative organisms) of urinary tract infection
The Gram negative rods E. coli is the commonest urinary pathogen causing 60-90% of
infections.
Some strains are more invasive, for example capsulated strains are able to resist phagocytosis,
other strains are more adhesive. UTIs caused by Pseudomonas, Proteus, Klebsiella species and
Staphylococcus aureus, are associated with hospital-acquired infections often following
catheterization or gynecological surgery. Proteus infections are also associated with renal
stones.
S. saprophyticus infections are usually found in sexually active young women Infection of the
anterior urinary tract (urethritis) is mainly caused by N. gonorrhea(especially in men),
Staphylococci, Streptococci, and Chlamydia (Cheesbourgh, 2006).
Escherichiacoli
E.coli belong to the large group of gram negative rods referred to as Enterobacteria, those that
cause primary and opportunistic infections in humans, belong mainly to the lactose fermenting
genera, often referred to as coliforms, they are aerobes and facultative anaerobes,non-sporing
and motile or non-motile.
E.coli is the cause of UTI.Certain serotypes of E coli are particularly common in urinary tract
infection (for example 02,04,06,07,018,075). Some strains are more invasive fr example
capsulated strains are able to resist phagocytosis, other strains are more adhesive
(Cheesbourgh., 2006).
Klebsiella species
Gram negative, non-motile, usually capsulated rods, associated with hospital acquired infections
of UTI (Cheesbourgh., 2006).
Proteus species mirabilis is a common cause of urinary infection in the elderly and young males
and often following catheterization or cystoscopy. Infections are also associated with the
presence
of renal stones (Cheesbourgh., 2006).
Staphylococcus aureus
Gram positive cocci of uniform size, occurringcharacteristically in groups but also singly and in
pairs. They are non-motile and non-capsulated. Fermentsmannitol, is coagulase, DNA-ase and
catalase positive. It rarely causes UTI (Cheesbourgh., 2006).
Staphylococcus saprophyticus
Gram positive cocci of uniform size occurring in groups but also singly and in pairs. They are
nonmotile and non-capsulated.S. saprophyticus causes UTI in sexually active women. It is
coagulase and DNA-ase negative and ferments mannitol. The surface agglutinins of this
pathogen is a key determinant of the virulence promoting it's colonization of the urinary tract
(Cheesbourgh.,
2006). Enterococcus faecalis
Are gram positive cocci, occurring in pairs or short chains. They are non-capsulated and the
majority are non-motile. It causes about 95% of enterococciinfections including infections of the
urinary tract (Cheesbourgh., 2006).
Pseudomonas aeruginosa
Gram negative, on-sporing motile rods. Some strains are capsulated. P. aeruginosa infections are
often difficult to eradicate due to P.aeruginosa being resistant to many antimicrobials. P.
aeruginosa causes urinary infections, usually following catheterization or associated with chronic
urinary disease (Cheesbourgh., 2006).
OTHER BACTERIA
These species are not primarily pathogens of the urinary tract, but may be found in urine for
example Mycobacterium tuberculosis, Leptospirainterrogans, Chlamydia, Mycoplasma and
Candida species (Cheesbourgh et al., 2006).
PARASITES
Very few parasites can cause UTIs for example Trichomonas vaginalis which cause urethritis in
both male and females, but most often considered as a cause of vaginitis. Onchocercavolvulus,
Wuchereria bancrofti and Schistosoma hematobium were also uncommon UTlagents.
FUNGI
Candida albicans usually in diabetic patients and those with immunosuppressed systems, cause
bladder infection.
VIRUSES
Viral causes of UTIs appears to be rare although there are associated with hemorrhagic cystitis
and renal syndromes (Ondari et al., 2021).
2.2.6 Diagnosis of urinary tract infection
The diagnosis of UTIs is based on clinical grounds and also laboratory examination of the
normally sterile urine for evidence of bacteria. A UTI is usually diagnosed by seeing a healthcare
provider, who will ask you about your symptoms and health. Diagnosis in this case is based on
having he typical symptoms and the history of the patient in relation to risk factors (Maria
Robinson, 2020).
Routine laboratory diagnosis of UTIs is commonly achieved through the following the
macroscopic and microscopic examination of the urine sample, and by performing chemical
screening tests. And for specific bacteriological diagnosis a direct Gram staining of the sample is
done after which if the facility is available a urine culture is done.
1. Macroscopic examination
The macroscopic examination of urine involves determining the volume, Color, Odor and its
appearance.
★ Volume
normally, 600-2000ml of urine is voided per 24 hr.
Volume of urine excreted is related to:
●
● Individual fluid intake
● Body temperature
★ Climate
● Individual's health status, e.g. : dehydration
● Abnormally higher amount (greater than 2000 ml/24) or very low amount i.e. less than
600 ml/24 occur mostly due to some pathological conditions.
* Odor
Normally fresh voided urine from healthy individuals has faint aromatic odor, which comes from
volatile acids, normally found in urine, mostly, ammonia.
★ Foam
Normally when urine specimen is voided in a container, it temporally produces small amount of
white foam which disappear almost immediately. But during certain abnormal physiological and
metabolic conditions, the color and amount of foam may be changed. For example, when there is
high bile pigment in the urine, the amount of foam increases, and the color of foam becomes
yellowish. This may indicate the presence of bilirubin in the urine. But the presence of yellowish
foam should not be taken as a confirmatory test for the presence of bilirubin in urine. Chemical
analysis of urine for billirubin should be done.
* Color
Normally color of urine may vary within a day; in the morning it has dark yellow color, while in the
afternoon or evening, the color ranges from light yellow to colorless. Normal urine color varies
from straw (light yellow color) to dark amber (dark yellow).
Light yellow indicate that the urine is more diluted, and has low specific gravity. Such exceptional
Light yellow indicate that the urine is more diluted, and has low specific gravity. Such exceptional
condition occurs in case of diabetes mellitus. In this condition the color of urine is mostly light
yellow, but because of having high glucose content, its specific gravity is high.
● On the other hand, dark amber (dark yellow) color mostly indicates that the urine is
concentrated, and has high specific gravity. This type of urine is seen normally in the first
morning urination.
● Normal urine color results from three pigments.
They are:
● Urochrome: responsible for yellow color formation. This pigment is found in high
proportion than the other two.
● Uroerythin: responsible for red color formation.
● Urobilin: responsible for the orange-yellow color formation. Thus, normal urine gets its
color from a combination of the above-mentioned three pigments.
2. Microscopic examination of urine
Most UTIs are diagnosed by performing a urine analysis, which looks for evidence of infection
such as bacteria, and white blood cells in urine sample. This test looks at urine under a
microscope.
It can see cells from the urinary tract, blood cells, crystals, bacteria, parasites and fungal
elements.
This test is often used to confirm the findings of other tests or add information to a diagnosis.
3. Chemical examination of urine
The most successful chemical examination test detects Glucose, Protein, Ketones, Bilirubin,
Urobilinogen, Blood, Leukocyte Esterase and nitrite produced fromnitrates by bacteria
metabolism. It also determines the PHI and the specific gravity of the urine sample. Like
microscopic examination, they do not reliable detect bacteriuria below the level of 105 organisms
per milliliter.
4. Urine culture
Urine culture is required when the urine contains bacteria cells, casts, protein, and nitrite. This
test looks for and identifies bacteria in urine. It is used to help diagnose and treat a UTI.
A small sample of urine is added to a substance that promotes bacterial growth. If no growth is
detected, the urine culture is negative. However, if it contains bacteria or yeasts, an infection is
present and in this case the organism can be isolated and identified using standard biochemical
tests.
The best medium for urine culture is CLED (Cysteine Lactose Electrolyte Deficient) agar. Blood
agar, chocolate agar and Mc Conkey agar can also be used to culture urine.
Some of the biochemical tests for identification of isolates include; citrate utilization test, indole
test, motility test, catalase test, oxidase test, nitrate reduction test, urease production test,
test, motility test, catalase test, oxidase test, nitrate reduction test, urease production test,
carbohydrate fermentation test H2S production test (James et al., 2012).
5 Antimicrobial Susceptibility Testing
Antimicrobial susceptibility testing is a procedure used to determine which antimicrobial will
inhibit the growth of bacteria or fungi causing specific infection. It determines which drugs are
likely to be most effective in treating a person's infection.
With this technique, once bacteria have been identified following microbiological culture,
antibiotics are selected for susceptibility testing.
Antimicrobial susceptibility can be performed using the following methods.
observed around that particular disk. The zone of inhibition is then measured in millimeter and
compared to a standard interpretation chart used to categorize the isolate as susceptible or
resistant.
Other methods of performing antimicrobial susceptibility testing include;
2 E-test (AB Biodisk, Solna, Sweden); which utilizes a plastic test strip, impregnated with a
gradually decreasing concentration of a particular antibiotic
● The automated testing systems
● The mechanism specific tests (James et al. 2012).
2.2.7TREATMENT OF URINARY TRACT INFECTION
a) Empirical Treatment
Empiric antimicrobial therapy is directed against an anticipated and likely cause of infectious
disease. It is used when antimicrobials are given to a person before the specific bacterium or
fungus causing an infection is known.
The Infectious diseases society of America recommends that uncomplicated UTIs should be
treated empirically with Trimethoprim-sulfamethoxazole (TMP-SMZ), unless the community
resistance among uropathogens exceeds 10% to 20%, in which case a fluoroquinolone should be
used (John L Brush, 2020).
b) Treatment Based On Susceptibility Testing
To ensure response to therapy, adequate drugs and adequate urinary antibiotic concentration is
important. This is achieved by performing a susceptibility testing using common antibiotics.
Some
commonly used antibiotics for the treatment of UTIs include;
Doxycycline
Chloramphenicol(CAF)
Gentamyein
Levofloxacin
Ciprofloxacin
Amoxicillin
Ampicillin
Cefixime
Augmentin
Nitrofurantoin
Tetracycline
Ornilox
Ciprozole
Tequin
Clarithromycin
Thiamphenicol (Helen & Jennifer, 2018)
2.2.8 Complications of UTIs
If left untreated, urinary tract infection can progress to worsen renal function, cause
pyelonephritis, sepsis, septic shock, and even death. Hence it is important to treat UTI in earlier
stages to prevent significant morbidity and mortality (Vasudevan et al., 2021).
2.2.10 PREVENTION AND CONTROL OF URINARY TRACT INFECTION
* Prevention and control of UTIs include the following measures:
● Drinking plenty of liquids, especially water. It helps dilute urine and ensures that you will
urinate more frequently allowing bacteria to be flushed from the urinary tract before an
infection can begin;
● Wipe from front to back. Doing so after urinating and a bowel movement helps prevent
bacteria in the anal region from spreading to the vagina and urethra;
● Emptying your bladder soon after intercourse. Also, drinking a full glass of water to help
flush bacteria;
● Avoiding potentially irritating feminine products, using deodorant sprays or other
feminine products such as douches and powders in the genital area can irritate the
urethra;
● Avoid using birth control method such as diaphragm, or unlubricated or spermicide-
treated condoms which can all contribute to bacteria growth;
● Emptying the bladder often as soon as you feel the need to urinate; do not rush and be
sure
you have emptied your bladder completely (CDC, 2019).
