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urinary tract infection (UTI)

An infection in the urinary tract caused by the invasion of pathogenic micro-organisms, which proceed to establish themselves, multiply, & produce various symptoms in their host. Classification: - uncomplicated: - cystitis or pyelonephritis in non-pregnant women without structural or neurologic disorder or comorbidities [15] - age alone does not define complicated vs uncomplicated UTI - complicated: - all orther cases - includes men, urinary calculi, urinary catheter, recent antibiotics, urinary obstruction or cause of urinary retention, immunosuppression, kidney disease [15] Etiology: 1) colonic bacteria ascend through the urethra 2) short length & positioning of urethra makes females more susceptible to UTIs & pyelonephritis than men 3) urinary obstruction, especially prostatic hypertrophy predisposes men to UTIs 4) etiologic agents a) Escherichia coli* (most common etiologic agent) b) Proteus mirabilis c) Klebsiella pneumoniae d) Pseudomonas aeruginosa e) Enterobacter species f) Staphylococcus saprophyticus g) Staphylococcus aureus h) Streptococcus viridans i) Enterococcus j) Candida albicans 5) risk factors a) female sex (especially if sexually active) b) diabetes c) pregnancy d) spermicide use in women e) urinary tract instrumentation f) neurogenic bladder [15] 6) risk factors for infection with multidrug-resistant organism a) current or recent hospitalization b) immunodeficiency c) underlying urinary tract structural anomaly d) previous urinary tract infection e) renal transplantation f) recent antimicrobial therapy [15] 7) 9 pathogens account for 90% of all urinary tract infections in nursing homes [62] - Escherichia coli (41%) - fluoroquinolone (50%) & extended-spectrum cephalosporin resistance [20%) - Proteus (14%),Klebsiella pneumoniae/oxytoca (13%) - Pseudomonas aeruginosa (11%) multidrug resistance most common - Staphylococcus aureus (67% MRSA) - Enterococcus faecium (60% vancomycin-resistant) [62] * inadequate data linking multidrug-resistant uropathogenic E coli to beef or other animal sources of food [9] Epidemiology: 1) in neonates the female/male ratio is < 1 2) in children, the female/male ratio is > 1 3) 30% of women will have a UTI by age 24 years [15] 4) in adults, UTIs are largely a disease of sexually-active women 5) the female/male ratio is 2:1 after age 60 6) UTIs are the most common bacterial infection in elderly - commonly overdiagnosed in the elderly & treated [14,29] 7) UTIs are a common source of sepsis Pathology: - toll like receptor 11 involved with clearance of uropathogenic bacteria in mice [8] Clinical manifestations: 1) lower urinary tract infection (also see cystitis & urethritis) a) dysuria b) urinary frequency c) nocturia d) suprapubic pain/tenderness e) hematuria f) malodorous & cloudy urine* [21] g) urinary urgency h) urinary incontinence i) dyspareunia (premenopausal women) [67] 2) upper urinary tract infection (also see pyelonephritis) a) fever/chills b) nausea/vomiting c) back or flank pain (costovertebral angle tenderness) d) symptoms of cystitis e) tachypnea f) tachycardia g) altered mental status (elderly) 3) in the elderly, atypical presentations are common - altered mental status, falls, anorexia, failure to thrive 4) in institutionalized elderly, dysuria alone or fever plus - urinary frequency, urinary urgency, flank pain, suprapubic pain, gross hematuria, rigors, or new onset urinary incontinence [25] 5) in patients with Parkinson's disease, multiple sclerosis or previous stroke, deterioration of preexisting neurological deficits may occur [30] * children Diagnostic criteria: - any 2 of: fever, urinary frequency, urinary urgency, acute dysuria, suprapubic pain/tenderness, costovertebral angle tenderness - a positive urine culture >= 100,000 CFU/mL confirms diagnosis [35] Laboratory: 1) biochemical screening tests (urine dipstick)* a) glucose oxidase b) catalase c) nitrite reductase d) leukocyte esterase e) presence of both nitrite & leukocyte esterase is highly predictive of urinary tract infection [15] 2) urinalysis a) clean-catch or in & out catheterization prior to antibiotic therapy b) for patient < 2 years of age, either urethral catheterization or suprapubic aspiration [18] - reserve urethral catheterization for children with a positive dipstick screen from bagged urine [44] c) > 10 WBC/mL in fresh unspun urine (pyuria) d) spun urine specimen with >5 WBC/high-power field e) gram stain: >1 bacteria/hpf (oil) in unspun urine, or >10 bacteria/hpf (oil) in centrifuged urine correlates with: >10E5 colony forming units per mL on culture f) RBC (non-specific) g) WBC casts suggest pyelonephritis 3) urine culture a) not needed for uncomplicated urinary tract infection because results rarely affect management [15] b) pyuria with asymptomatic bacteriuria is not an indication for urine culture [15] c) indications - elderly, men - an unusual or antimicrobial-resistant organism is suspected (in a patient recently infected with a non E coli organism or who recently received antimicrobial therapy) - pregnancy (obtain after empiric treatment) - relapse or treatment failure [15] - children [45]; 13% without pyruria or leukocyte esterase + d) > 10E6 colonies/mL indicates significant infection e) pyuria with negative culture suggests infection by: - Chlamydia - Neisseria gonorrhoeae - tuberculosis - send urine for acid-fast bacilli stain & culture [13] f) presence of multiple organisms suggests contamination 4) blood cultures in toxic or elderly patients with signs of pyelonephritis 5) neither urine dipstick testing for leukocyte esterase nor urine culture enhances diagnostic sensitivity [34] 6) complete blood count 7) basic chemistry panel * consideration of clinical hydration status, withholding diuretics &/or psychotropics, & a period of observation is recommended prior to urine dipstick testing in institutionalized elderly women with altered perception, disorganized speech, & lethargy [35] Special laboratory: - voiding cystourethrogram (VCUG) a) not routinely indicated after 1st febrile UTI b) indicated if renal & bladder ultrasonography reveals hydronephrosis, scarring, or other findings that would suggest either high-grade vesicoureteral reflux or obstructive uropathy [22] c) indicated for recurrent UTI in children [18] Radiology: 1) routine imaging not indicated [15] 2) renal & bladder ultrasound* 3) abdominal radiograph* (KUB) 4) intravenous pyelogram * initial tests in men [6] Differential diagnosis: 1) lower urinary tract infection (cystitis) a) urethritis s) vaginitis c) genital Herpes d) chemical irritation from: 1] feminine hygiene products 2] contraceptive agents e) prostatitis - most likely cause of urosepsis in men [15] f) epididymitis g) torsion of testes 2) see pyelonephritis 3) asymptomatic bacteriuria & asymptomatic candiduria (generally do not need treatment) 4) antibiotic stewardship considerations in nursing home residents [61] Management: 1) pyuria with asymptomatic bacteriuria is not considered an infection & is not an indication for antibiotic treatment [15] === acute uncomplicated bacterial lower UTI === 1) acute uncomplicated bacterial lower UTI in women* a) does not always require culture (see above) b) 3-5 days of oral antibiotics as outpatient* - 3 days adequate treatment for women > 65 years* [7] - 3 days for Bactrim, 5 days for nitrofurantoin [13,34] - fluoroquinolone & fosfomycin are alternatives [15,34] - ciprofloxacin clearly superior to cefpodoxime [20] - gepotidacin 1500 mg PO BID for 5 days - fosfomycin (single dose) if compliance an issue c) if pregnant - empiric treatment for 3-7 days with amoxicillin clavulanate or cephalosporin - nitrofurantoin associated with birth defects [15] - fluoroquinolones are toxic to developing cartilage - single dose of fosfomycin is acceptable [15] - obtain follow-up urine cultures after completion of treatment [15] d) may be diagnosed & treated without office visit [34] - no known anatomic urinary tract abnormalities - no recent urinary tract instrumentation - no recent systemic illness - absence of vaginal discharge - 2 of 3 symptoms: dysuria, urgency, or frequency e) NSAIDs inferior to antibiotics for treatment of UTI - diclofenac significantly lowers antibiotic use but is inferior to norfloxacin for symptom resolution in women with uncomplicated UTI [51] - ibuprofen is inferior to pivmecillinam for treating uncomplicated UTIs in women [53] 2) acute uncomplicated bacterial lower UTI in men - 7-14 days of oral antibiotics [24,34] - no clinical benefit for treatment > 7 days [60] 3) children: a) early antibiotic treatment may prevent renal scars [31,48] b) 3 days of IV antibiotics appears adequate in infants < 60 days of age [50] === complicated bacterial UTI === 1) 14 days of antibiotic therapy 2) factors designating UTI as complicated - age > 65 years* (may NOT indicate complicated UTI) [7] - indwelling catheter - replacing indwelling catheter does not improve outcomes [55] - recent genitourinary instrumentation - diabetes mellitus - renal transplantation - neutropenia - recent antibiotic therapy - recurrent UTI - pregnancy - glucocorticoid therapy - immunocompromised host - structural or functional urinary tract impairment === empiric oral antibiotics === - trimethoprim-sulfamethoxazole 160/800 mg (Bactrim DS, Septra DS) every 12 hours for 3 days (1st line) [11,19] - trimethoprim 200 mg every 12 hours - nitrofurantoin; first line all women [11] - contraindicated in 3rd trimester of pregnancy near term (38-42 weeks gestation) [15] - does not achieve tissue levels sufficent for treatment of pyelonephritis [15] - may be less effective in patients with renal insufficiency - less effective than ciprofloxacin for treatment of cystitis in elderly women regardless of renal function [42] - despite this, MKSAP17 recommends nitrofurantoin to treat cystitis in elderly women [15,42] - may not be a good choice for the elderly - Macrodantin (Pediatrics): 5-7 mg/kg/day every 6 hours (1st line) [11] - sustained-release nitrofurantoin (MacroBid) - 100 mg BID for 5 days - pregnant women (except near term) [15] - 3-7 days of therapy - 5 days of nitrofurantoin results in greater likelihood of clinical & microbiological cure of uncomplicated UTI in women > 18 years of age than single dose fosfomycin [52] - doxycycline 100 mg every 12 hours day 1, then 100-200 mg QD - fluoroquinolone - agent of choice in complicated UTIs - norfloxacin (Noroxin) 400 mg every 12 hours - ciprofloxacin* (Cipro) 500-750 mg every 12 hours - levofloxacin - risk factors for fluoroquinolone resistance - fluoroquinolone use during the preceding 6 months - use of a urinary catheter - recent hospitalization [16] - sulfisoxazole 120-150 mg/kg/day every 6 hours - amoxicillin clavulanate (Augmentin) 250-500 mg PO every 6 hours - cephalexin (Keflex) 250-500 mg PO every 6 hours - ampicillin 250-500 mg PO every 6 hours - fosfomycin: single dose for uncomplicated UTI due to multidrug-resistant gram negative bacteria [40] * superior to Bactrim for empiric treatment of urinary tract infection in elderly women [5] & superior to Augmentin in younger women [10] * serious side effects generally outweigh the benefits [43] === empiric intravenous antibiotics === - cefepime for urosepsis in men [15] - ticarcillin clavulanate (Timentin) 3.1 g every 4-6 hours - piperacillin tazobactam vs meropenem vaborbactam for complicated urinary tract infection - carbapenem for extended-spectrum beta-lactamase producing organism (even if antibiotic susceptibility shows sensitivity to Zosyn) - amoxicillin clavulanate 1.5-3.0 g every 6 hours - cefazolin (Ancef, Kefzol) 0.25-1.5 g every 6 hours - cephalothin (Keflin) 0.5 g every 6 hours - 2.0 g every 4 hours - ceftazidime (Fortaz) 1-2 g every 6-12 hours - ceftriaxone (Rocephin) 1-2 g every 12-24 hours - gentamicin 3-5 mg/kg/day divided every 8 hours === UTI during pregnancy === - quinolones cannot be used during pregnancy - sulfonamides & nitrofurantion cannot be used close to delivery [15] - amoxicillin in 3rd trimester [15] - cephalosporin such as cephalexin (Keflex) 250-500 mg every 6 hours - 3-7 days of therapy === UTI during lactation === - cephalosporin such as cephalexin (Keflex) 250-500 mg every 6 hours - if infant is > 1 month, nitrofurantoin may be used - continue breast feeding === UTI in elderly === - 3-5 days of therapy for women (cystitis) - 7-14 days of therapy for men (cystitis) - no clinical benefit for treatment > 7 days, unless immunocompromised, prostatitis, pyelonephritis, nephrolithiasis, or benign prostatic hyperplasia [60] - treatment for 7 days noninferior to 14 days of treatment [63] - a delay in antibiotic therapy for elderly with UTI may put them at increased risk for urosepsis & death [58] - men > 85 years of age particularly at risk [58] === recurrent UTI === - also see recurrent UTI - presents > 2 weeks after completion of therapy for index UTI - caused by a different organism than the index UTI [15] - a different antibiotic may be prudent [15] - indications for prophylactic antibiotics - >= UTI in past 12 months or >=2 UTI in past 6 months - vesicoureteral reflux (maybe not) [18] - Bactrim QD - single dose of antibiotic after intercourse [15] === patient education === - patients should improve after 2-3 days of therapy - patients should complete full course of antibiotics - voiding after sexual intercourse can decrease frequency of UTIs in some women - consider alternate form of contraception if UTI is associated with use of diaphragm e) adequate hydration is important === follow-up, prevention === - no indication for routine urinalysis or culture for non-pregnant women with acute uncomplicated cystitis after treatment - UTI in men - follow-up culture after completion of therapy - genitourinary exam: especially prostate exam - see radiology (above) - recurrent UTI in women: - IVP of little value - low dose antibiotics for 4-6 months - Septra DS 1 tab QD - macrodantin 50-100 mg QD - genitourinary exam - cranberry juice: - conflicting reports suggest little or no benefit [3] - perhaps some benefit but less so than Bactrim [17] - 30% risk reduction [23] - cranberry may limit ability of bacteria to attach to uroepithelial cells [23] - not effective for preventing bacteriuria plus pyuria in elderly women residing in nursing home [49] - switch from spermicide-based contraception to non-spermicide based contraception - post-coital antibiotic prophylaxis, particularly ifUTIs are temporally associated with coitus - continuous antibiotic prophylaxis, particularly if UTIs are not associated with coitus or use of spermicide-based contraception - self-initiated therapy for frequent recurrent episodes not associated with coitus - urinary antiseptic methenamine hippurate may be useful alternative to low-dose antibiotics [64] - hydrolyzed to formaldehyde (bactericidal) in the distal renal tubule [64] - UTI in children - follow-up culture 3-7 days after completion of therapy - children under 5 - renal ultrasound - voiding cystourethrogram (VCUG) - fluoroscopic VCUG in males - radionuclide cystogram (RCG) === surgical indications === - vesicoureteral reflux

Related

bacteriuria candiduria cystitis pyelonephritis urethritis

Specific

catheter-associated urinary tract infection (CAUTI) kidney infection recurrent urinary tract infection urosepsis

General

urologic disease urogenital infection

References

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