Urinary tract infection resident survival guide: Difference between revisions

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! style="padding: 0 5px; font-size: 80%; background: #A8A8A8;" align="center" | {{fontcolor|#2B3B44|Urinary tract infection<BR>Resident Survival Guide}}
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align="left" | [[{{PAGENAME}}#Overview|Overview]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align="left" | [[{{PAGENAME}}#Causes|Causes]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align="left" | [[{{PAGENAME}}#Complete Diagnostic Approach|Diagnosis]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align="left" | [[{{PAGENAME}}#Treatment|Treatment]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align="left" | [[{{PAGENAME}}#Do's|Do's]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align="left" | [[{{PAGENAME}}#Don'ts|Don'ts]]
|}
__NOTOC__
__NOTOC__
{{CMG}}; {{AE}} {{Ochuko}}


==Introduction==
{{CMG}}; {{AE}} {{Ochuko}} {{IQ}}
A urinary tract infection is a bacterial [[infection]] that affects any part of the [[urinary tract]].
 
==Overview==
A urinary tract infection ([[UTI]]) is a bacterial [[infection]] that affects any part of the [[urinary tract]].


==Causes==
==Causes==
===Life Threatening Causes===
===Life Threatening Causes===
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.  
* Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.  


Urinary tract infection does not have life threatening causes.
* Urinary tract infection does not have life threatening causes.


===Common Causes===
===Common Causes===
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{{familytree/start}}
{{familytree/start}}
{{familytree | | | | A01 | | | | | | | | | | | | A01=<div style="float: left; text-align: left; line-height: 150% ">'''Characterize the symptoms:''' <br> ❑ [[Fever]] <br> ❑ [[Dysuria]] <br> ❑ [[Frequent urination]] <br> ❑ Suprapubic pain <br> ❑ [[Hematuria]] <br> ❑ [[Vomiting]] <br> ❑ [[Diarrhea]] <br> ❑ [[Nausea]] <br> ❑ [[Flank pain]] or [[back pain]] <br> ❑ Weak stream <br> ❑ Hesistancy <br> ❑ [[Nocturia]] <br> ❑ Chills <br> ❑ [[Urethral discharge]]
{{familytree | | | | A01 | | | | | | | | | | | | A01=<div style="float: left; text-align: left; line-height: 150% ">'''Characterize the symptoms:''' <br> ❑ [[Fever]] <br> ❑ [[Dysuria]] <br> ❑ [[Frequent urination]] <br> ❑ [[abdominal pain|Suprapubic pain]] <br> ❑ [[Hematuria]] <br> ❑ [[Vomiting]] <br> ❑ [[Diarrhea]] <br> ❑ [[Nausea]] <br> ❑ [[Flank pain]] or [[back pain]] <br> ❑ [[Weak urine stream]] <br> ❑ [[Hesistancy]] <br> ❑ [[Nocturia]] <br> ❑ [[Chills]] <br> ❑ [[Urethral discharge]]
----
----
'''Obtain a detailed history:''' <br> ❑ [[urinary catheterization|Use of urinary catheters]] <br> ❑ [[Pregnancy]] <br> ❑ [[Diabetes]] <br> ❑ Female and sexually active <br> ❑ Renal problems <br> ❑ Menopausal <br> ❑ [[Sickle cell disease]] <br> ❑ [[Elderly]] <br> ❑ Antibiotic use <br> ❑ Urogynecologic surgery <br> ❑ [[Urinary retention]] <br> ❑ [[Urinary incontinence]] <br> ❑ Anatomic malformations of the urinary tract <br> ❑ Increased susceptibility to UTIs <br> ❑ Allergies to latex condoms or spermicices</div>|}}
'''Obtain a detailed history:''' <br> ❑ [[urinary catheterization|Use of urinary catheters]] <br> ❑ [[Pregnancy]] <br> ❑ [[Diabetes]] <br> ❑ Female and sexually active <br> ❑ Renal problems <br> ❑ Menopausal <br> ❑ [[Sickle cell disease]] <br> ❑ [[Elderly]] <br> ❑ [[antibiotic|Antibiotic use]] <br> ❑ Urogynecologic surgery <br> ❑ [[Urinary retention]] <br> ❑ [[Urinary incontinence]] <br> ❑ Anatomic malformations of the urinary tract <br> ❑ Increased susceptibility to UTIs <br> ❑ Allergies to latex condoms or spermicides</div>|}}
{{familytree | | | | |!| | | | | | | | | | | | | | |}}
{{familytree | | | | |!| | | | | | | | | | | | | | |}}
{{familytree | | | | B01 | | | | | | | | | | | | B01=<div style="float: left; text-align: left; line-height: 150% ">'''Examine the patient:''' <br> ❑ Suprapubic tenderness <br> ❑ Flank pain or costovertebral angle tenderness <br> ❑ Tender prostate</div>}}
{{familytree | | | | B01 | | | | | | | | | | | | B01=<div style="float: left; text-align: left; line-height: 150% ">'''Examine the patient:''' <br> ❑ Suprapubic tenderness <br> ❑ Flank pain or costovertebral angle tenderness <br> ❑ Tender prostate</div>}}
{{familytree | | | | |!| | | | | | | | | | | | | | | |}}
{{familytree | | | | |!| | | | | | | | | | | | | | | |}}
{{familytree | | | | C01 | | | | | | | | | | | | C01=<div style="float: left; text-align: left; line-height: 150% ">'''Consider alternative diagnosis:''' <br> ❑ [[Urethritis]] <br> ❑ [[Prostatitis]] <br> ❑ Renal abscess</div>}}
{{familytree | | | | C01 | | | | | | | | | | | | C01=<div style="float: left; text-align: left; line-height: 150% ">'''Consider alternative diagnosis:''' <br> ❑ [[Urethritis]] <br> ❑ [[Prostatitis]] <br> ❑ [[Renal abscess]]</div>}}
{{familytree | | | | |!| | | | | | | | | | | | | | | |}}
{{familytree | | | | |!| | | | | | | | | | | | | | | |}}
{{familytree | | | | D01 | | | | | | | | | | | | D01=<div style="float: left; text-align: left; line-height: 150% "> '''Order tests:'''<br> ❑ [[Urine culture]] <br> ❑ [[Urinalysis]] <br> ❑ [[Blood culture]] <br> ❑ Abdominal CT <br> ❑ Renal ultrasound scan <br> ❑ [[Voiding cystourethrogram]] <br> ❑ [[Intravenous pyelogram]]</div>}}
{{familytree | | | | D01 | | | | | | | | | | | | D01=<div style="float: left; text-align: left; line-height: 150% "> '''Order tests:'''<br> ❑ [[Urine culture]] <br> ❑ [[Urinalysis]] <br> ❑ [[Blood culture]] <br> ❑ [[CT|Abdominal CT]] <br> ❑ [[ultrasound|Renal ultrasound scan]] <br> ❑ [[Voiding cystourethrogram]] <br> ❑ [[Intravenous pyelogram]]</div>}}
{{familytree/end}}
{{familytree/end}}




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{{familytree/start}}
{{familytree/start}}
{{familytree | | | | | | | | | A01 | |A01=[[UTI]] confirmed <br> (≥ 10<sup>5</sup> CFU/mL) + Pyuria}}
{{familytree | | | | | | | | | A01 | |A01=[[UTI]] confirmed with [[urine culture]] <br> (≥ 10<sup>5</sup> CFU/mL) + [[Pyuria]]}}
{{familytree | | | | | | | | | |!| |}}
{{familytree | | | | | | | | | |!| |}}
{{familytree | | | | | | | | | B01 | |B01=Is there suprapubic pain?}}
{{familytree | | | | | | | | | B01 | |B01=Is there [[abdominal pain|suprapubic pain]]?}}
{{familytree | | | | | | |,|-|-|^|-|-|.| |}}
{{familytree | | | | | | |,|-|-|^|-|-|.| |}}
{{familytree | | | | | | C01 | | | | C02 | |C01=Yes|C02=No}}
{{familytree | | | | | | C01 | | | | C02 | |C01=Yes|C02=No}}
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{{familytree | | | | | | D01 | | | | D02 | |D01=Consider [[Cystitis]]|D02=Is there flank or back pain?}}
{{familytree | | | | | | D01 | | | | D02 | |D01=Consider [[Cystitis]]|D02=Is there flank or back pain?}}
{{familytree | |,|-|-|-|v|^|-|-|.| | |!| |}}
{{familytree | |,|-|-|-|v|^|-|-|.| | |!| |}}
{{familytree | E01 | | E02 | | E03 | |!| | |E01=Acute uncomplicated cystitis <br> '''''Preferred regimen'''''<ref name="pmid24570249">{{cite journal| author=| title=Drugs for urinary tract infections. | journal=JAMA | year= 2014 | volume= 311 | issue= 8 | pages= 855-6 | pmid=24570249 | doi=10.1001/jama.2014.972 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24570249  }} </ref><ref name="pmid21292654">{{cite journal| author=Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG et al.| title=International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. | journal=Clin Infect Dis | year= 2011 | volume= 52 | issue= 5 | pages= e103-20 | pmid=21292654 | doi=10.1093/cid/ciq257 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21292654  }} </ref> <br> [[TMP-SMX]] 160/800mg bid x 3 days <br> OR <br> Nitrofurantoin monohydrate/macrocrystals 100mg bid x 5-7 days <br> OR <br> Fosfomycin trometamol 3g once (single dose) <br> OR <br> Pivmecillinam 400mg bid x 5 days <br> '''''Alternative regimen''''': {{See main|Cystitis medical therapy}}|E02=Complicated/Catheter-Associated Cystitis <br> '''''Preferred regimen''''' <br> For those who can tolerate '''ORALLY''' <br> [[Ciprofloxacin]] 500mg PO bid x 5-14 days <br> OR <br> Ciprofloxacin Extended Release 1000mg daily x 5-14 days <br> OR <br> '''PARENTERALLY''' <br> IV [[Levofloxacin]] 500mg <br> OR <br> IV [[Ceftriaxone]] 1g <br> OR <br> IV Ertapenem 1g <br> '''''Catheter-Associated UTI''''' <br> Remove catheter or intermittent catheterization <br> Use same antibiotic therapy as above for CA-Cystitis <br> '''''Alternative regimen''''': {{See main|Cystitis medical therapy}}|E03= Acute Cystitis in Pregnancy <br> '''''Preferred regimen''''' <br> [[Nitrofurantoin]] 100mg PO q12h x 5 days <br> OR <br> [[Amoxicillin-clavulanate]] 500mg PO q12h 3-7 days <br> OR <br> [[Fosfomycin]] 3g PO single dose <br> '''''Alternative regimen''''': <br> [[TMP-SMX]] DS PO bid x 3 days only in 2nd trimester <br> {{See main|Cystitis medical therapy}}}}
{{familytree | E01 | | E02 | | E03 | |!| | |E01=Acute uncomplicated cystitis <br> '''''Preferred regimen'''''<ref name="pmid24570249">{{cite journal| author=| title=Drugs for urinary tract infections. | journal=JAMA | year= 2014 | volume= 311 | issue= 8 | pages= 855-6 | pmid=24570249 | doi=10.1001/jama.2014.972 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24570249  }} </ref><ref name="pmid21292654">{{cite journal| author=Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG et al.| title=International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. | journal=Clin Infect Dis | year= 2011 | volume= 52 | issue= 5 | pages= e103-20 | pmid=21292654 | doi=10.1093/cid/ciq257 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21292654  }} </ref> <br> [[TMP-SMX]] 160/800mg bid x 3 days <br> OR <br> [[nitrofurantoin|Nitrofurantoin monohydrate/macrocrystals]] 100mg bid x 5-7 days <br> OR <br> [[fosfomycin|Fosfomycin trometamol]] 3g once (single dose) <br> OR <br> [[Pivmecillinam]] 400mg bid x 5 days <br> '''''Alternative regimen''''': {{See main|Cystitis medical therapy}}|E02=Complicated/Catheter-Associated Cystitis <br> '''''Preferred regimen''''' <br> For those who can tolerate '''ORALLY''' <br> [[Ciprofloxacin]] 500mg PO bid x 5-14 days <br> OR <br> [[Ciprofloxacin]] Extended Release 1000mg daily x 5-14 days <br> OR <br> '''PARENTERALLY''' <br> IV [[Levofloxacin]] 500mg <br> OR <br> IV [[Ceftriaxone]] 1g <br> OR <br> IV [[Ertapenem]] 1g <br> '''''Catheter-Associated UTI''''' <br> Remove catheter or intermittent catheterization <br> Use same antibiotic therapy as above for CA-Cystitis <br> '''''Alternative regimen''''': {{See main|Cystitis medical therapy}}|E03= Acute Cystitis in Pregnancy <br> '''''Preferred regimen''''' <br> [[Nitrofurantoin]] 100mg PO q12h x 5 days <br> OR <br> [[Amoxicillin-clavulanate]] 500mg PO q12h 3-7 days <br> OR <br> [[Fosfomycin]] 3g PO single dose <br> '''''Alternative regimen''''': <br> [[TMP-SMX]] DS PO bid x 3 days only in 2nd trimester <br> {{See main|Cystitis medical therapy}}}}
{{familytree | | | | | | | | | | |,|-|^|-|-|.| |}}
{{familytree | | | | | | | | | | |,|-|^|-|-|.| |}}
{{familytree | | | | | | | | | | F01 | | | F02 | |F01=Yes|F02=No}}
{{familytree | | | | | | | | | | F01 | | | F02 | |F01=Yes|F02=No}}
{{familytree | | | | | | | | | | |!| | | | |!| |}}
{{familytree | | | | | | | | | | |!| | | | |!| |}}
{{familytree | | | | | | | | | | G01 | | | G02 | |G01=Consider pyelonephritis|G02=Consider alternative diagnosis such as; <br> Prostatitis <br> Urethritis <br> Renal abscess}}
{{familytree | | | | | | | | | | G01 | | | G02 | |G01=Consider [[pyelonephritis]]|G02=Consider alternative diagnosis such as; <br> [[Prostatitis]] <br> [[Urethritis]] <br> [[Renal abscess]]}}
{{familytree | | | |,|-|-|-|v|-|-|^|.| | | |!| |}}
{{familytree | | | |,|-|-|-|v|-|-|^|.| | | |!| |}}
{{familytree | | | H01 | | H02 | | H03 | | H04 | |H01=Acute uncomplicated pyelonephritis (Outpatient) <br> '''''Preferred regimen'''''<ref name="pmid24570249">{{cite journal| author=| title=Drugs for urinary tract infections. | journal=JAMA | year= 2014 | volume= 311 | issue= 8 | pages= 855-6 | pmid=24570249 | doi=10.1001/jama.2014.972 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24570249  }} </ref><ref name="pmid21292654">{{cite journal| author=Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG et al.| title=International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. | journal=Clin Infect Dis | year= 2011 | volume= 52 | issue= 5 | pages= e103-20 | pmid=21292654 | doi=10.1093/cid/ciq257 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21292654  }} </ref> <br> Ciprofloxacin (immediate release) 500mg bid x 7 days <br> Ciprofloxacin (extended release) 1000mg once daily x 7 days <br> OR <br> Levofloxacin 750mg once daily x 5 days OR <br> Trimethoprim/Sulfamethoxazole 160/800mg bid x 14 days <br> '''''Alternative regimen''''': {{See main|Pyelonephritis medical therapy}}|H02=Complicated pyelonephritis (Inpatient) <br> '''''Preferred regimen''''' <br> IV Ceftriaxone 1g q24h <br> OR <br> IV Ciprofloxacin 400mg q12h <br> OR <br> IV Levofloxacin 750mg q24h <br> OR <br> IV Cefepime q12h <br> '''''Alternative regimen''''': {{See main|Pyelonephritis medical therapy}}|H03=Acute pyelonephritis in Pregnancy <br> '''''Preferred regimen''''' <br> IV Ceftriaxone 1g q24h <br> OR <br> IV Ampicillin 1-2g q6h <br> OR <br> IV Cefepime 1g q12h <br> '''''Alternative regimen''''': {{See main|Pyelonephritis medical therapy}}|H04=Is there urethral discharge?}}
{{familytree | | | H01 | | H02 | | H03 | | H04 | |H01=Acute uncomplicated pyelonephritis (Outpatient) <br> '''''Preferred regimen'''''<ref name="pmid24570249">{{cite journal| author=| title=Drugs for urinary tract infections. | journal=JAMA | year= 2014 | volume= 311 | issue= 8 | pages= 855-6 | pmid=24570249 | doi=10.1001/jama.2014.972 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24570249  }} </ref><ref name="pmid21292654">{{cite journal| author=Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG et al.| title=International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. | journal=Clin Infect Dis | year= 2011 | volume= 52 | issue= 5 | pages= e103-20 | pmid=21292654 | doi=10.1093/cid/ciq257 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21292654  }} </ref> <br> [[Ciprofloxacin]] (immediate release) 500mg bid x 7 days <br> [[Ciprofloxacin]] (extended release) 1000mg once daily x 7 days <br> OR <br> [[Levofloxacin]] 750mg once daily x 5 days OR <br> [[TMP-SMX]] 160/800mg bid x 14 days <br> '''''Alternative regimen''''': {{See main|Pyelonephritis medical therapy}}|H02=Complicated [[pyelonephritis]] (Inpatient) <br> '''''Preferred regimen''''' <br> IV [[Ceftriaxone]] 1g q24h <br> OR <br> IV [[Ciprofloxacin]] 400mg q12h <br> OR <br> IV [[Levofloxacin]] 750mg q24h <br> OR <br> IV [[Cefepime]] q12h <br> '''''Alternative regimen''''': {{See main|Pyelonephritis medical therapy}}|H03=Acute [[pyelonephritis]] in Pregnancy <br> '''''Preferred regimen''''' <br> IV [[Ceftriaxone]] 1g q24h <br> OR <br> IV [[Ampicillin]] 1-2g q6h <br> OR <br> IV [[Cefepime]] 1g q12h <br> '''''Alternative regimen''''': {{See main|Pyelonephritis medical therapy}}|H04=Is there [[urethral discharge]]?}}
{{familytree | | | | | | | | | | | | | |,|-|^|-|.| | |}}
{{familytree | | | | | | | | | | | | | |,|-|^|-|.| | |}}
{{familytree | | | | | | | | | | | | | I01 | | I02 | |I01=Yes|I02=No}}
{{familytree | | | | | | | | | | | | | I01 | | I02 | |I01=Yes|I02=No}}
{{familytree | | | | | | | | | | | | | |!| | | |!| |}}
{{familytree | | | | | | | | | | | | | |!| | | |!| |}}
{{familytree | | | | | | | | | | | | | J01 | | J02 | |J01=Consider [[Urethritis]] <br> For treatment of urethritis: <br> {{See main|Urethritis medical therapy}}|J02=Weak stream or hesitancy?}}
{{familytree | | | | | | | | | | | | | J01 | | J02 | |J01=Consider [[Urethritis]] <br> For treatment of [[urethritis]]: <br> {{See main|Urethritis medical therapy}}|J02=[[Weak urine stream]] or [[hesitancy]]?}}
{{familytree | | | | | | | | | | | | | | | |,|-|^|-|.| |}}
{{familytree | | | | | | | | | | | | | | | |,|-|^|-|.| |}}
{{familytree | | | | | | | | | | | | | | | K01 | | K02 | |K01=Yes|K02=No}}
{{familytree | | | | | | | | | | | | | | | K01 | | K02 | |K01=Yes|K02=No}}
{{familytree | | | | | | | | | | | | | | | |!| | | |!| | |}}
{{familytree | | | | | | | | | | | | | | | |!| | | |!| | |}}
{{familytree | | | | | | | | | | | | | | | L01 | | L02 | |L01=Consider [[Prostatitis]]|L02=Renal USS to rule out renal abscess (drainage + antibiotics for renal abscess) <br> Other investigations (Abdominal CT, VSUG, for anatomic abnormality or obstructions}}
{{familytree | | | | | | | | | | | | | | | L01 | | L02 | |L01=Consider [[Prostatitis]]|L02=Renal USS to rule out [[renal abscess]] (drainage + antibiotics for renal abscess) <br> Other investigations (Abdominal CT, VSUG, for anatomic abnormality or obstructions}}
{{familytree/end}}
{{familytree/end}}


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==Dont's==
==Dont's==
*Don't use fluoroquinolones empirically for treatment of acute uncomplicated cystitis.<ref name="pmid24570249">{{cite journal| author=| title=Drugs for urinary tract infections. | journal=JAMA | year= 2014 | volume= 311 | issue= 8 | pages= 855-6 | pmid=24570249 | doi=10.1001/jama.2014.972 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24570249  }} </ref>
*Do not give [[fluoroquinolones]] in pregnancy.
*Do not give [[fluoroquinolones]] in pregnancy.
*Don't give [[TMP-SMX]] in first trimester or near term of pregnancy.
*Don't give [[TMP-SMX]] in first trimester or near term of pregnancy.
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[[Category:Resident survival guide]]
[[Category:Resident survival guide]]
[[Category:Infectious disease]]
 
[[Category:Urology]]
[[Category:Urology]]
[[Category:Nephrology]]
[[Category:Nephrology]]

Latest revision as of 20:44, 5 March 2021

Urinary tract infection
Resident Survival Guide
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ogheneochuko Ajari, MB.BS, MS [2] Iqra Qamar M.D.[3]

Overview

A urinary tract infection (UTI) is a bacterial infection that affects any part of the urinary tract.

Causes

Life Threatening Causes

  • Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
  • Urinary tract infection does not have life threatening causes.

Common Causes

Management

Shown below is an algorithm depicting the initial approach to UTI.

 
 
 
Characterize the symptoms:
Fever
Dysuria
Frequent urination
Suprapubic pain
Hematuria
Vomiting
Diarrhea
Nausea
Flank pain or back pain
Weak urine stream
Hesistancy
Nocturia
Chills
Urethral discharge
Obtain a detailed history:
Use of urinary catheters
Pregnancy
Diabetes
❑ Female and sexually active
❑ Renal problems
❑ Menopausal
Sickle cell disease
Elderly
Antibiotic use
❑ Urogynecologic surgery
Urinary retention
Urinary incontinence
❑ Anatomic malformations of the urinary tract
❑ Increased susceptibility to UTIs
❑ Allergies to latex condoms or spermicides
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:
❑ Suprapubic tenderness
❑ Flank pain or costovertebral angle tenderness
❑ Tender prostate
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider alternative diagnosis:
Urethritis
Prostatitis
Renal abscess
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Diagnosis and Treatment

An algorithm using symptoms/physical finding in diagnosis and treatment of UTIs.


 
 
 
 
 
 
 
 
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[1][2]
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[1][2]
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
 

Do's

  • TMP-SMX should only be used in the second trimester of pregnancy.

Dont's

  • Don't use fluoroquinolones empirically for treatment of acute uncomplicated cystitis.[1]
  • Do not give fluoroquinolones in pregnancy.
  • Don't give TMP-SMX in first trimester or near term of pregnancy.

References

  1. 1.0 1.1 1.2 "Drugs for urinary tract infections". JAMA. 311 (8): 855–6. 2014. doi:10.1001/jama.2014.972. PMID 24570249.
  2. 2.0 2.1 Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG; et al. (2011). "International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases". Clin Infect Dis. 52 (5): e103–20. doi:10.1093/cid/ciq257. PMID 21292654.