Bacteriuria

Bacteriuria - the presence of bacteria in the urine. Normally, urine is sterile. Bacteriuria is a symptom of inflammatory diseases of the kidneys and urinary tract. However, not every detection of microorganisms in a centrifuged urine sediment is clinically significant.

A common indicator reflecting the true nature of bacteriuria is the titer of microbial bodies, which is 10 ⁴ -10 ⁵ cfu in 1 ml of urine. The titer reaches 10 ⁴ cfu / ml. Treat as a bacterial contamination of urine.

It must be borne in mind that these parameters are conditional. Each clinical situation requires their correction. With a decrease in the rates of cellular and humoral immunity due to various factors (including immunosuppressive therapy), under conditions of hemodilution of polyuria, the activity of the inflammatory process in the kidney and urinary tract may be indicated by a lower level of microbial bodies titer - up to 10 ⁴ cfu / ml.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12]

Causes of the bacteriuria

If the kidneys of a person are healthy and their tissues are not damaged, bacteria will not be able to penetrate the bloodstream into the urine. Bacteriuria is observed with inflammation in the kidneys, when the renal parenchyma is affected by bacteria, with infection of the bladder, inflammation in the prostate gland, it also provokes catheterization of the ureters and bladder, the introduction of bougies into the urethra, and cystoscopy.

The degree of bacteriuria may be different and become severe in the following pathological conditions:

1. Obturation (closure) of the ureter with concrement, when a pathological breach of contractions is formed and urine returns to the kidney already infected with bacteria. Other causes of outflow disorders from the upper urinary tract are also possible.
2. Adenoma of the prostate gland, which becomes the source of the inflammatory process and consequently provokes bacteriuria. Also increase the degree of bacteriuria can significantly narrow the urethra (stricture) and urine retention.

[13], [14], [15], [16], [17], [18], [19], [20], [21], [22]

Bacteriuria causes can have both descending and ascending.

The downstream way of getting infection in urine is the penetration of bacteria into the urine from the inflamed vesica urinaria - the bladder, from the infected kidney tissue, from the prostate gland that has hyperplastic glandular tissue. The upward path of urine infection is the penetration of microorganisms into urine as a result of unsuccessful catheterization, urological endoscopy - cystoscopy, bougie, and also from the large intestine or vulva, if personal hygiene rules are not observed (lymphohematogenous pathway).

Bacteriuria is observed when different kinds of bacteria enter the urine - these can be streptococci, intestinal and pseudomonas aeruginosa, staphylococci or bacteria from the genus proteus - protea. Any kind of bacteria entering the genitourinary sphere causes inflammation of the urinary system or kidneys, but also infection with microorganisms is possible in some parts of the colon, provoking proctitis. Bacteriuria is observed in people who suffer from chronic constipation, hemorrhoids, much less often in patients with brucellosis, typhoid fever, paratyphoid and leptospirosis due to the low prevalence of these diseases.

[23], [24], [25], [26], [27], [28], [29], [30]

Pathogenesis

What is bacteriuria?

Bacteriuria is the presence of microorganisms (bacteria) in the urine, which are detected by microscopic examination of urine, usually in connection with inflammatory diseases of the urinary tract, kidneys and genitals in men.

Urine in healthy people in principle should not contain bacteria, in a bacterial sense, the sterility of urine is an indicator of kidney and urinary tract health. However, when they become infected, microorganisms enter urine, bacteriuria develop, leukocyturia and pyuria are possible. Not every contamination of urine can be considered bacteriuria, in microscopic identification there are clear boundaries - an excess of 105 per 1 millilitre of urine is a sign of an inflammatory bacteriological process. The longer a bacterial infection of urine is in the bladder, the more pronounced the degree of bacteriuria.

[31], [32], [33], [34], [35], [36], [37], [38], [39], [40]

Symptoms of the bacteriuria

Bacteriuria symptoms demonstrate in accordance with the underlying disease. Bacteriuria occurs (is diagnosed) most often with pyelonephritis, urethritis and cystitis.

Also, bacteriuria can be a symptom of the following pathologies: 

• Prostate adenoma.
• Prostatitis, both chronic and in the stage of exacerbation.
• Diabetes.
• Bacterial sepsis.
• Urethritis.

Bacteriuria symptoms are characteristic of pyelonephritis, urethritis and cystitis, the rest of the disease does not have a specific symptomatology, which makes it possible to differentiate nosology only from laboratory analysis of urine.

Bacteriuria, symptoms similar to those of pyelonephritis: 

• Dysuria - rapid or slow urination, burning, pain.
• Spontaneous allocation of urine.
• Transient nausea, sudden urge to vomit.
• Sharply rising body temperature, chills.
• Subfebrile temperature for 1-2 weeks.
• Pain in the lumbar region.
• Pain in the lower abdomen, in the region of the bladder.
• Muddy urine, often with inclusions of pus, with an unpleasant odor that is uncharacteristic of urine.

Bacteriuria, symptoms similar to those of urethritis: 

• Isolation of the urethra, often with pus.
• Painful urination, dysuria.
• Hyperemic edges of the urethra, irritation, burning.
• Pain in the perineum.
• Increased body temperature, chills.
• General deterioration, weakness.

Bacteriuria, symptoms identical to those of cystitis: 

• Dysuria - frequent, painful urination. 
• Burning during urination. 
• Frequent urge to urinate with a small discharge of urine. 
• Uncharacteristic smell of urine. 
• The cloudy urine changes its color.
• Chronic aching pain in the lower abdomen. 
• A fever may occur. 
• Discharge from the urethra, often with pus.

[41], [42], [43], [44], [45]

Forms

True bacteriuria and false bacteriuria

True bacteriuria are bacteria that do not just enter the urinary tract, but also multiply there, provoking severe inflammation. False bacteriuria - bacteria enter the bladder, urinary tract, but they do not have time to spread and multiply due to the fact that a person has either active immunity or he is taking antibacterial therapy for an inflammatory disease.

If bacteria take urine as a nutrient medium, where there are necessary weakly alkaline and neutral conditions for them, they begin to multiply, sometimes their number exceeds 100,000 in one milliliter of urine. True bacteriuria or significant bacteriuria, as it was called in the middle of the last century by microbiologists Cass and his colleague Finland, is an undeniable proof for the diagnosis of urinary tract infection. Despite the fact that signs of inflammation in the bladder may appear earlier at much lower rates, the Cassa and Finnland parameter is the only statistically confirmed and is used in laboratory practice nowadays as the main criterion. 

[46], [47], [48], [49], [50], [51], [52], [53]

Hidden bacteriuria, asymptomatic bacteriuria

Hidden bacteriuria is most often determined by routine prophylactic medical examination in people who are not bothered by the bladder, kidneys, or impaired urination. Especially often in this sense, asymptomatic bacteriuria is detected in pregnant women.

In addition to the fact that a chronic asymptomatic inflammatory process poses a threat to human health, latent bacteriuria carries the threat of infection and transmission of bacteria to surrounding people, provided that the causative agent is a representative of the family Enterobacteriaceae - that is, a causative agent of typhus. We can speak about the fact that the patient has asymptomatic bacteriuria after a positive two-stage study of urine. The collection of the material should occur at intervals of 24 hours, and the bacterial index should be twice confirmed within the range of 100,000 per milliliter of urine.

Most often, asymptomatic bacteriuria is detected in women and girls. In men with a screening examination, the detected asymptomatic bacteriuria is an excuse for further diagnostic searches for hidden prostatitis. Also, often latent bacteriuria is often detected in patients over 65 years of age, when bacterial colonization is found to be chronic, lasting for many years. Most often, asymptomatic bacteriuria occurs in men who have prostatic hyperplasia and a violation of the outflow of urine, in which bacteria multiply. In most cases, in the elderly, such an indicator is not threatening, since the isolated microorganisms are not identified as pathogenic in the study.

Diagnostics of the bacteriuria

Bacteriuria in the urine is determined with the help of a fresh urine intake, as a rule, the average portion is collected. Urine analysis for bacteriuria is performed after compliance with all hygiene procedures in order to avoid distortion of the results, especially it is important for female patients. Also important is the speed of research, that is, from the moment of collecting the material to getting it directly to the laboratory, this is necessary to reduce the risk of reproduction of flora in warm conditions with access to air. Of course, the most "clean" in this sense are the analyzes collected by catheterization or aspiration, but these methods can also provoke bacteriuria, therefore they are used only in exceptional cases, according to strict indications, for example, when the patient is immobile or atony of the bladder.

Urine analysis for bacteriuria can be carried out in several ways.

Bacteriuria in the urine is revealed either with routine clinical examinations, or with an already developed inflammatory process. Depending on the purpose and urgency of the diagnosis, high-sensitivity methods such as urine culture for bacteriuria, time-consuming treatment of results, or rapid but not entirely accurate methods by which bacteriuria in the urine is determined can be used. 

As an express method, approximate-chemical methods are used:

• TTX test or a procedure for the recovery of triphenyltetrazolium chloride, which uses the property of bacteria to convert the color of colorless tetrazolium salts to blue (formazan derivative). 
• The Griss test is a nitrite method, when nitrates, when interacting with the bacteria present, are transformed into nitrites. Nitrite, in turn, is detected with the help of special Griss reagents. The test is suitable for the material (urine) of adults, since in children, urine usually does not contain nitrates. 
• Glucose reduction test, when the ability of microorganisms to reduce glucose in small amounts is used. In the morning portion of urine dip a reagent (paper strip), which shows the presence or absence of glucose. If a certain amount of glucose is not present, this means that it has been "absorbed" by the bacteria. The test is not 100% accurate, but as an express method it is considered acceptable at the initial diagnostic stage. 

Urine culture for bacteriuria

The most informative is the culture of urine for bacteriuria, when the number of breeding bacteria is counted within certain limits of norms. This method is considered to be the most sensitive, especially to determine the degree of colonization of bacteria, but it requires 24 to 48 hours to perform. Gould's method is less durable and more simplified. Sowing urine for bacteriuria by Gould is a method where the material is sown on agar, in a special Petri dish, in 4 sectors. Each time the next sector of the urine is transferred through a sterile platinum loop. To determine the degree of bacteriuria it takes only 24 hours, this time is enough for incubation of bacteria at a comfortable temperature for them - 37 degrees. Next, the number of bacteria is calculated from a special table. Also to the faster crops is the method in which the plates coated with the nutrient medium are immersed in urine. After immersion in the urine, the plates are quickly transferred to special containers, where the bacteria are incubated in a warm temperature of 12-16 hours. The degree of bacteriuria is determined by comparing the results with the normal scale. This is the most accurate test, the reliability of which is within 95%.

Any analysis on bacteriuria should be carried out twice, because even with false bacteriuria, the second crop can show a significant increase in the number of bacteria. This is explained by the fact that the first study, possibly, was carried out with the material that was collected with a plentiful drink or dysuria, distortion is also possible with the administration of antibiotics or antiseptic drugs. In addition, bacteriuria in the urine with a properly selected method of investigation allows to identify the true pathogen, determine its sensitivity to medicines and choose the appropriate treatment.

[54], [55], [56], [57], [58], [59], [60]

Treatment of the bacteriuria

Any kind of bacteria in urine is a signal about possible inflammation in the genitourinary sphere, therapeutic measures and choice of drugs depends on how much the degree of bacteriuria is expressed, on the age of the patient and his physiological state.

Acute infectious inflammation is treated with the latest generation of antibiotics with a wide spectrum of action and minimal side effects. For the treatment of chronic infections, a second culture for bacteriuria and an antibioticogram are needed to determine the sensitivity of the pathogen to a particular group of drugs. 

Treatment of bacteriuria in pregnant women

Bacteriuria in pregnancy is a fairly common phenomenon, not always associated with inflammation. Often, bacteria in the urine appear due to elementary stagnation of urine, and the growing uterus can press on the kidneys and bladder, causing weakness of kidney activity and physiological changes in the structure of urine, in addition, the composition of urine affects the hormonal system, which has been in an unstable all nine months condition. Therefore, bacteriuria in pregnant women requires re-examination and confirmation or refutation of primary results. If the number of microorganisms really exceeds the norm, treatment of bacteriuria in pregnant women is carried out as sparing, but at the same time, an effective method.

The first thing you need to do is activate urinary excretion (passage) and lower urine pH with diuretic aseptic drinks, for example, cranberry mors. Further, as a rule, preparations of group cephalosporins, less often penicillins, are prescribed in tableted form for a course not exceeding 3-5 days. It is this term that is considered in clinical practice sufficient for a single attack on bacteria and sparing the mother and fetus for the body. The first months of pregnancy allow the appointment of semi-synthetic drugs - amoxicillin, ampicillin, the second trimester allows the use of macrolides. The effectiveness of antibiotic treatment is controlled by repeated crops for bacteriuria. It is necessary to avoid the appointment of the entire group of tetracyclines, fluoroquinolones, antifungal agents. As supportive therapy, the administration of the nitrofuran group is indicated, usually taken at night.

Asymptomatic bacteriuria in pregnancy is treated more sparing, rather preventive methods, including phytotherapy, homeopathic remedies such as Kanefron, Cyston. Bacteriuria during pregnancy treatment also involves using very powerful active drugs that are taken once. These funds include Monural - an effective uroantispetics, which is prescribed 2-3 times a day for 3 grams per day. If a massive single dose of the drug does not give a result, it is necessary to treat cephalosporins for one week, and possibly for a longer time. It is also important to monitor the entire period of treatment for the timely emptying of the bladder and not to allow stagnation of urine, for this, the cranberry and dog rose must be included in the pregnant menu, diuretic infusions.

Asymptomatic bacteriuria during pregnancy is not dangerous in itself, but in that it can provoke infection of the urinary canal and formation of conditions for the development of pyelonephritis. In addition, asymptomatic bacteriuria is a risk factor for the birth of a child with a deficiency of weight, premature water leakage, anemia, gestosis, placental insufficiency. That is why treatment of bacteriuria in pregnant women should be as effective as possible in order to prevent possible complications in a timely manner.

In general, treatment of bacteriuria in pregnant women should adhere to the following principles: 

• Appointed only those drugs that are guaranteed to be safe and meet the bioavailability criteria. 
• When choosing drugs, it is necessary to take into account the trimester of pregnancy, especially the term up to 5 months. 
• The entire treatment process should be performed under regular and strict medical supervision, including blood and urine screening.

Treatment of bacteriuria in children

Bacteriuria in children, especially in asymptomatic form, does not require independent separate therapy. It is enough to eliminate the main source of infection, and this is actually achieved by antibiotic therapy and activation of immunity. In addition, the treatment of bacteriuria in children is often associated with adherence to basic rules of hygiene, followed by the parents of the sick child. Also, often bacteria in the urine are able to multiply because of a rare urination: the child "forgets" to urinate, playing. These moments seem not so important, but according to statistics, about 25-30% of cases of detection of microorganisms in urine in children are associated with such reasons, which practically do not require treatment. Adjust the diet, watch for the timely urination, eliminate constipation and take regular baths, shower - sometimes this is enough to ensure that asymptomatic bacteriuria has left without a trace. If bacteriuria in children is a consequence of cystitis or pyelonephritis, treatment should be adequate to the underlying disease.

Therapeutic actions to eliminate bacterial infection in cystitis are aimed at improving urination and neutralizing the infectious agent. Of medicines, preference is given to urine and anti-spasmolytic drugs, antibacterial drugs are prescribed only in cases where a high degree of bacteriuria is confirmed. As preparations relatively safe in terms of side effects, inhibitor-protected penicillins-amoxicillin are chosen, alternatively, third-generation cephalosporins are chosen. Antimycotic agents and macrolides are prescribed only in situations where the atypical flora in the urine is determined. Like any other antibiotic therapy, antibiotics take at least 7 days. From phyto-drugs it is good to take decoctions of a leaf of a cowberry, a calendula or a plantain. In addition, diet therapy, which is an integral part of the treatment of bacteriuria in children, should be long and should be adhered to at least three months after the end of the course of treatment.