Urinary tract infection

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Urinary Tract Infection Microchapters

Patient Information

Overview

Classification

Pyelonephritis
Cystitis
Prostatitis
Urethritis
Asymptomatic bacteriuria

Causes

Differential Diagnosis

Treatment

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Usama Talib, BSc, MD [2]

Synonyms and keywords: UTI

Overview

A urinary tract infection is an infection that involves any part of the urinary tract. It can result due to the invasion by a bacteria, virus, fungus or any other pathogen. The most common cause of a urinary tract infection is a bacterial infection. Depending on the site of the infection a UTI can be classified as either upper or lower UTI. Lower UTI includes urethritis, prostatitis, asymptomatic bacteriuria and cystitis (bladder infection) where as Upper UTI may include Pyelonephritis (infection of the kidney) and rarely uretritis (infection of the ureters). Each subtype of urinary tract infection can also be sub classified on the basis of duration, etiology or therapeutic approach as acute, chronic or recurrent and as uncomplicated or complicated infections.

The urine is normally sterile, a urinary tract infection occurs when the normally sterile urinary tract is infected by bacteria, which leads to irritation and inflammation. Pyelonephritis and Cystitis result mostly from ascending infections from the urethra (Urethritis) but can also result from descending infections i.e hematogenous spread, or by the lymphatic system. The condition more often affects women, but can affect either gender and all age groups. The pathogenesis of a complicated UTI may include obstruction and stasis of urine flow.[1] Various factors are associated with the risk of developing a urinary tract infection. A common cause of the urinary tract infection in hospital settings is the urinary catheter placement. Diabetes, Crohn's disease, iatrogenic causes, endometriosis, pelvic inflammatory disease, urinary obstruction, and bladder incontinence are some risk factors for acquiring a UTI. A thorough physical exam is very helpful in differentiating Upper from Lower UTI]s. Patients with an uncomplicated UTI are usually well-appearing. The symptoms may include abnormal urine color (cloudy), blood in the urine, frequent urination or urgent need to urinate, dysuria, pressure in the lower pelvis or back, suprapubic pain, flank pain, back pain, fever, nausea, vomiting, and chills.[2] Urinalysis and urine culture are very helpful laboratory tests in diagnosing a urinary tract infection. Pyuria and either white blood cells (WBCs) or red blood cells (RBCs) may be seen on urinalysis. Escherichia coli ("E. coli"), a bacterium found in the lower gastrointestinal tract is one of the most common culprits. The individual infection must be differentiated from various causes of dysuria such as cystitis, acute pyelonephritis, urethritis, prostatitis, vulvovaginitis, urethral strictures or diverticula, benign prostatic hyperplasia and neoplasms such as renal cell carcinoma and cancers of the bladder, prostate, and penis. Antimicrobial therapy is indicated in case of a symptomatic UTI.[3][4]A large proportion of patients with acute uncomplicated urinary infections will recover without treatment within a few days or weeks. If left untreated, some patients may progress to develop recurrent infection, involve and infect other parts of the urinary tract, hematuria, and rarely renal failure. Prognosis is generally good for lower UTIs.[5] The treatment of a UTI depends on the type of the disease, the disease course (acute uncomplicated vs. complicated), history of the individual and the rates of resistance in the community. Preventative measures to avoid a UTI include abstinence from sexual activity, use of barrier contraception during sexual intercourse, urinating after intercourse, increasing fluid intake and frequency of urination, and use of estrogen (among post-menopausal women).

Classification

 
 
 
 
 
 
 
 
 
 
 
 
Urinary Tract Infections
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Upper UTI
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Lower UTI
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pyelonephritis
 
 
Cystitis
 
 
 
 
 
 
 
Prostatitis
 
 
 
Urethritis
 
 
 
 
 
Asymptomatic bacteriuria
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑Acute Uncomplicated
❑Acute Complicated
❑Chronic
❑ Emphysematous
❑ Xanthogranulomatous
 
 
❑ Acute Uncomplicated
❑ Complicated
❑ Recurrent/Chronic
 
 
 
 
 
 
 
❑ Acute Bacterial
❑ Chronic bacterial
❑ Chronic Inflammatory
❑ Chronic non-inflammatory
❑ Asymptomatic
 
 
 
 
 
 
 
 
 

Causes

Common Pathogens Pyelonephritis Cystitis Urethritis Prostatitis Asymptomatic Bacteriuria
Ecoli*[6][7][8][9] ✔(70%) ✔(78.6%) - ✔(58%) ✔(80%)
Klebsiella[10] ✔(4.3%) -
Proteus[11] ✔(3.7%) -
Neisseria gonorrhoeae[12] - - ✔(21.6%) -
Pseudomonas[13] -
Staphylococcus -
Chlamydia trachomatis[14][15][16] ✔(20-30%) -
Mycoplasma[17][18] - - -
Trichomonas[19][20][21] -

*Ecoli is the most common cause of all urinary tract infections[22]

Differential Diagnosis

Diseases Diagnostic tests Physical Examination Symptoms Past medical history Other Findings
Urinalysis Urine Culture Gold Standard Fever Tenderness Discharge Inguinal Lymphadenopathy Hematuria Pyuria Frequency Urgency Dysuria
Differentiating amongst different types of Urinary Tract Infections:
Pyelonephritis
  • Leukocytes
  • Nitrite +ve
Identifies causative bacteria Imaging and culture Flank or costovertebral angle - -
  • History of Pyelonephritis
  • Recent history of Hospitalisation
  • Nephrolithiasis
  • Immunosupression
  • Costovertebral angle tenderness
  • Patient is in acute distress
  • Look for obstructive causes
Cystitis
  • Nitrite +ve
  • Leukocyte estrase+ve
  • WBCs
  • RBCs
>100,000CFU/mL Urinary culture Suprapubic -
  • Recent catheterisation
  • Pregnancy
  • recent intercourse
  • Diabetes
  • Personal or Family History of UTI
  • Known abnormality of the urinary tract
  • BPH or HIV
  • Imaging studies help differentiate the type
  • May company back pain, nausea, vomiting and chills
Urethritis
  • Positive leukocyte esterase test or >10 WBCs
  • Mucous threads in the morning urine
-

Gram stain & Mucoid or purulent discharge

- Urethral discharge - - -
  • Purulent discharge may suggest gonorrhoea
  • Exclusive dysuria suggest Chlamydia
  • Painful genital ulcers with dysuria suggest HSV
Prostatitis
  • 10-20 leukocytes for acute and chronic bacterial subtypes
Identifies causative bacteria (in bacterial subtypes)

Urine Culture

- - - -
  • Urogenital disorders
  • Recent catheterization or other genitourinary instrumentation
  • History of UTIs
  • In acute prostatitis, palpation reveals a tender and enlarged prostate[1][3]
  • In chronic prostatitis, palpation reveals a tender and soft (boggy) prostate[1]
  • A prostate massage should never be done in a patient with suspected acute prostatitis, since it may induce sepsis
Bacterial Vulvovagintis - -

Gram Stain & Culture of discharge

- Vaginal discharge  - - - -
  • Number and type of sexual partners (new, casual, or regular)
  • Prior STDs
  • Previous history of symptomatic BV in female partner (in homosexual women)
  • Fishy odor from the vagina (Whiff test)
  • Thin, white/gray homogeneous vaginal discharge
  • Microscopy (wet prep) and vaginal pH 
  • Clue cells
Cervicitis - - culture for gonococcal cervicitis Cervical

endocervical exudate

- - - -
  • Abnormal vaginal bleeding after intercourse or after menopause
  • Abnormal vaginal discharge
  • Painful sexual intercourse
  • Pressure or heaviness in the pelvis
  • Purulent or mucopurulent endocervical exudate
  • Sustained endocervical bleeding easily induced by a cotton swab
Epididymitis
  • Hematuria may be seen
Culture

Testicular & Suprapubic

+/- urethral discharge -
  • Scrotal pain: starts gradually, is usually unilateral and localized posterior to the testis
  • Scrotal swelling
  • Scrotal wall erythema
  • Constitutional symptoms: feeling of hotness, chills, nausea and vomiting
  • Ultrasound in patients with acute testicular pain to assess for testicular torsion
  • If equivocal do surgical exploration
Syphilis (STD) - - Darkfield Microscopy +/- - - - - - - -
  • History of STD
  • HIV
  • Immunosupression
  • Previous history of chancre
  • May be asymptomatic
  • Painless chancre in primary syphilis
  • Secondary syphilis may have generalised features and condylomata late
  • Tertiary syphilis can have neurosyphilis, cardiovascular syphilis and gummas
BPH
  • Hematuria may be seen
-

DRE & Serum PSA

- - - - -
Neoplasms
  • Hematuria may be seen
- Imaging and biopsy +- - - - -

Management

 
 
 
 
 
 
 
 
UTI confirmed with urine culture
(≥ 105 CFU/mL) + Pyuria
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is there suprapubic pain?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider Cystitis
 
 
 
Is there flank or back pain?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acute uncomplicated cystitis
Preferred regimen[23][24]
TMP-SMX 160/800mg bid x 3 days
OR
Nitrofurantoin monohydrate/macrocrystals 100mg bid x 5-7 days
OR
Fosfomycin trometamol 3g once (single dose)
OR
Pivmecillinam 400mg bid x 5 days
Alternative regimen: Template:See main
 
Complicated/Catheter-Associated Cystitis
Preferred regimen
For those who can tolerate ORALLY
Ciprofloxacin 500mg PO bid x 5-14 days
OR
Ciprofloxacin Extended Release 1000mg daily x 5-14 days
OR
PARENTERALLY
IV Levofloxacin 500mg
OR
IV Ceftriaxone 1g
OR
IV Ertapenem 1g
Catheter-Associated UTI
Remove catheter or intermittent catheterization
Use same antibiotic therapy as above for CA-Cystitis
Alternative regimen: Template:See main
 
Acute Cystitis in Pregnancy
Preferred regimen
Nitrofurantoin 100mg PO q12h x 5 days
OR
Amoxicillin-clavulanate 500mg PO q12h 3-7 days
OR
Fosfomycin 3g PO single dose
Alternative regimen:
TMP-SMX DS PO bid x 3 days only in 2nd trimester
Template:See main
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider pyelonephritis
 
 
Consider alternative diagnosis such as;
Prostatitis
Urethritis
Renal abscess
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acute uncomplicated pyelonephritis (Outpatient)
Preferred regimen[23][24]
Ciprofloxacin (immediate release) 500mg bid x 7 days
Ciprofloxacin (extended release) 1000mg once daily x 7 days
OR
Levofloxacin 750mg once daily x 5 days OR
TMP-SMX 160/800mg bid x 14 days
Alternative regimen: Template:See main
 
Complicated pyelonephritis (Inpatient)
Preferred regimen
IV Ceftriaxone 1g q24h
OR
IV Ciprofloxacin 400mg q12h
OR
IV Levofloxacin 750mg q24h
OR
IV Cefepime q12h
Alternative regimen: Template:See main
 
Acute pyelonephritis in Pregnancy
Preferred regimen
IV Ceftriaxone 1g q24h
OR
IV Ampicillin 1-2g q6h
OR
IV Cefepime 1g q12h
Alternative regimen: Template:See main
 
Is there urethral discharge?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider Urethritis
For treatment of urethritis:
Template:See main
 
Weak urine stream or hesitancy?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider Prostatitis
 
Renal USS to rule out renal abscess (drainage + antibiotics for renal abscess)
Other investigations (Abdominal CT, VSUG, for anatomic abnormality or obstructions
 

References

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  14. J. Dimitrakov, V. Ganev, T. Zlatanov, I. Detchev, A. Horvat, S. Kirov, I. Vatchkova & D. Dimitrakov (1998). "PCR studies on the presence of Chlamydia trachomatis in the upper urinary tract of patients with obstructive pyelonephritis". Folia medica. 40 (3): 24–28. PMID 10658351.
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  16. Matthew J. Perkins & Catherine F. Decker (2016). "Non-gonococcal urethritis". Disease-a-month : DM. 62 (8): 274–279. doi:10.1016/j.disamonth.2016.03.011. PMID 27107783. Unknown parameter |month= ignored (help)
  17. Iu L. Naboka, L. I. Vasil'eva, M. I. Kogan, I. A. Gudima & I. Iu Suchkov (2009). "[Microbial associations defecting in children with chronic pyelonephritis]". Zhurnal mikrobiologii, epidemiologii, i immunobiologii (5): 8–12. PMID 20063785. Unknown parameter |month= ignored (help)
  18. Iu L. Naboka, L. I. Vasil'eva, M. I. Kogan, I. A. Gudima & I. Iu Suchkov (2009). "[Microbial associations defecting in children with chronic pyelonephritis]". Zhurnal mikrobiologii, epidemiologii, i immunobiologii (5): 8–12. PMID 20063785. Unknown parameter |month= ignored (help)
  19. Template:Hoffman, David J., et al. "Urinary tract infection with Trichomonas vaginalis in a premature newborn infant and the development of chronic lung disease." Journal of perinatology 23.1 (2003): 59-61.
  20. L. SYLVESTRE, M. BELANGER & Z. GALLAI (1960). "Urogenital trichomoniasis in the male: review of the literature and report on treatment of 37 patients by a new nitroimidazole derivative (Flagyl)". Canadian Medical Association journal. 83: 1195–1199. PMID 13774369. Unknown parameter |month= ignored (help)
  21. Template:Kuberski, Tim. "Trichomonas vaginalis associated with nongonococcal urethritis and prostatitis." Sexually transmitted diseases 7.3 (1979): 135-136.
  22. Matthew J. Perkins & Catherine F. Decker (2016). "Non-gonococcal urethritis". Disease-a-month : DM. 62 (8): 274–279. doi:10.1016/j.disamonth.2016.03.011. PMID 27107783. Unknown parameter |month= ignored (help)
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