Urinary tract infection resident survival guide

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

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.