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]

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

• 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 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

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