Urinary tract infection resident survival guide

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

Introduction

A urinary tract infection 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

• Escherichia coli
• Klebsiella pneumonia
• Neisseria gonorrhea
• Proteus mirabilis
• Pseudomonas aeruginosa
• Staphylococcus saprophyticus
• Urinary catheterization

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 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 spermicices

Examine the patient: ❑ Suprapubic tenderness ❑ Flank pain or costovertebral angle tenderness ❑ Tender prostate

Consider alternative diagnosis: ❑ Urethritis ❑ Prostatitis ❑ Renal abscess

Order tests: ❑ Urine culture ❑ Urinalysis ❑ Blood culture ❑ Abdominal CT ❑ Renal ultrasound scan ❑ Voiding cystourethrogram ❑ Intravenous pyelogram

Diagnosis and Treatment

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

UTI confirmed (≥ 105 CFU/mL) + Pyuria

Is there suprapubic pain?

Yes

No

Consider Cystitis

Is there flank or back pain?

Acute uncomplicated cystitis Preferred regimen Trimethoprim/Sulfamethoxazole 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

Acute Cystitis in Pregnancy

Yes

No

Consider pyelonephritis

Consider alternative diagnosis such as; Prostatitis Urethritis Renal abscess

Acute uncomplicated pyelonephritis (Outpatient) Preferred regimen 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 Trimethoprim/Sulfamethoxazole 160/800mg bid x 14 days Alternative regimen: Template:See main

Complicated pyelonephritis (Inpatient)

Acute pyelonephritis in Pregnancy

Is there urethral discharge?

Yes

No

Consider Urethritis

Weak stream or hesitancy?

Yes

No

Consider Prostatitis

Renal USS to rule out 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

• Do not give fluoroquinolones in pregnancy.
• Don't give TMP-SMX in first trimester or near term.