|
|
(37 intermediate revisions by 3 users not shown) |
Line 1: |
Line 1: |
| ==Background== | | ==Background== |
| ===Definitions===
| | [[File:2605 The Bladder.jpg|thumb|Anatomy of the bladder (male)]] |
| *UTI = significant bacteriuria in presence of symptoms
| | [[File:Prostatelead.jpg|thumb|Prostate anatomy]] |
| **Described by location: urethritis, cystitis, or pyelonephritis
| | {{UTI types}} |
| *Relapse
| |
| **Recurrence of symptoms w/in month despite tx
| |
| ***Caused by same organism and represents treatment failure
| |
| *Reinfection
| |
| **Development of symptoms 1-6mo after tx
| |
| **Usually due to a different organism
| |
| **If pt has >3 recurrences in 1 yr consider tumor, calculi, DM
| |
| *Men <50 yr: symptoms of dysuria or urinary frequency usually due to STI
| |
| *Men >50 yr: incidence of UTI rises dramatically d/t prostatic obstruction
| |
| *Uncomplicated UTI:
| |
| **No structural or functional abnormalities w/in urinary tract or kidney
| |
| **No relevant comorbidities that place pt at risk for more serious adverse outcome
| |
| **Not associated with GU tract instrumentation
| |
| ===Risk factors for complicated UTI===
| |
| #Male sex
| |
| ##In young males dysuria is more commonly d/t STI
| |
| ##Suspect underlying anatomic abnormality in men with culture-proven UTI
| |
| #Anatomic abnormality of urinary tract or external drainage system
| |
| ##Indwelling urinary catheter, stent
| |
| ##Nephrolithiasis, neurogenic bladder, polycystic renal disease, recent instrumentation
| |
| #Recurrent UTI (three or more per year)
| |
| #Advanced age in men (BPH, recent instrumentation, recent prostatic biopsy)
| |
| #Nursing home residency (w/ or w/o indwelling bladder catheter)
| |
| #Neonatal state
| |
| #Comorbidities (DM, sickle cell disease)
| |
| #Pregnancy
| |
| #Immunosuppression (AIDS, immunosuppressive drugs)
| |
| #Advanced neurologic disease (CVA w/ disability, spinal cord injuries)
| |
| #Known or suspected atypical pathogens (Non–E. coli infection)
| |
| #Known or suspected abx resistance (resistance to cipro predicts multidrug resistance)
| |
| ===Bacteriology===
| |
| *Most common pathogen is E. coli
| |
| *Anaerobic organisms are rarely pathogenic (do not grow well in urine)
| |
| *Complicated UTIs more likely to be caused by pseudomonas or enterococcus
| |
|
| |
|
| ==Diagnosis== | | ==Evaluation== |
| ===Clinical Features===
| | {{Perinephric vs Renal Abscess}} |
| *UTI dx requires both bacteriuria and clinical symptoms
| |
| **Cystitis = Dysuria, hematuria, frequency, urgency, suprapubic pain, CVAT
| |
| **Pyelo = Cystitis sx AND fever/chills/nausea/vomiting
| |
| ***CVAT alone may be referred pain from cystitis
| |
| ***CVAT is only physical examination finding that increases likelihood of a UTI
| |
| *Urethritis
| |
| **In males more likely due to chlam/GC
| |
| **In females more likely due to chlam/GC if:
| |
| ***Stuttering urination symptoms
| |
| ***New sex partner or partner w/ urethritis
| |
| ***Signs/symptoms cervicitis
| |
| ***Sterile pyuria
| |
| *Complicated UTI
| |
| **Pts may not have classic symptoms; may only have weakness, fever, abd pain, AMS
| |
| ===Labs===
| |
| ====UA====
| |
| =====WBC count=====
| |
| *WBC >5 in pt w/ appropriate symptoms is diagnostic
| |
| **Lower degrees of pyuria may still be clinically significant in presence of UTI sx
| |
| ***False negative may be due to: dilute urine, systemic leukopenia, obstruction
| |
| **WBC 1-2 w/ bacteriuria can be significant in men
| |
| ***More likely represents urethritis or prostatitis from STI
| |
| =====Nitrite=====
| |
| *Very high specificity (>90%) in confirming diagnosis of UTI
| |
| *Low sensitivity (enterococcus, pseudomonas, acinetobacter are not detected)
| |
| ====Urine Culture====
| |
| *Indicated for:
| |
| **Complicated UTI
| |
| **Pyelonephritis
| |
| **Pregnant women
| |
| **Children
| |
| **Adult males
| |
| **Relapse/reinfection
| |
| ====Blood Culture====
| |
| *Not indicated
| |
| **Organisms in blood cx matched those in urine cx 97% of time
| |
| | |
| ===Imaging===
| |
| *Consider if pyelonephritis and any of the following:
| |
| #History of renal stone
| |
| #Poor response to abx
| |
| #Male
| |
| #Elderly
| |
| #Diabetic
| |
| #Severely ill
| |
| | |
| ==Treatment==
| |
| *Consider local resistance patterns (if >10-20% use a different agent)
| |
| *Avoid use of fluoroquinolones for uncomplicated cystitis if possible
| |
| *Consider longer course of tx for uncomplicated cystitis if:
| |
| **Symptoms >7d
| |
| **DM
| |
| **UTI in previous 4wk
| |
| **Men
| |
| **Age 65 yr
| |
| **Women who use spermicides or diaphragm
| |
| **Relapse
| |
| ===Women, uncomplicated cystitis===
| |
| *Nonpregnant, few prior UTI episodes, symptoms <7d, no flank pain or fever
| |
| #Nitrofurantoin ER 100mg BID x 5d OR
| |
| #TMP-SMX DS (160/800mg) 1 tab BID x 3d OR
| |
| #Cephalexin 250mg QID x 5d OR
| |
| #Ciprofloxacin 250mg BID x3d
| |
| ===Women, complicated cystitis/pyelo===
| |
| *Risks for complicated UTI or symptoms of pyelo
| |
| #Ciprofloxacin 500mg BID x10-14d OR
| |
| #Cefpodoxime 200 mg BID x10-14d
| |
| ===Women, uncomplicated cystitis AND urethritis===
| |
| #CTX 250mg IM x1 AND azithromycin 1gm PO x1 AND nitrofurantoin ER 100mg BID x5d OR
| |
| #Levofloxacin 500mg QD x 14d (covers UTI pathogens, GC, and chlam)
| |
| ##GC resistance to fluoroquinolones is increasing
| |
| ===Men, cystitis/pyelo===
| |
| *Consider urethritis and prostatitis
| |
| #Ciprofloxacin 500mg BID x10-14d OR
| |
| #Cefpodoxime 200 mg BID x10-14d
| |
| ===Inpatient===
| |
| *Ciprofloxacin 400mg IV q12hr OR
| |
| *Ceftriaxone 1gm IV QD OR
| |
| *Cefotaxime 1-2gm IV q8hr OR
| |
| *Gentamicin 3mg/kg/day divided q8hr +/- ampicillin 1–2 gm q4hr OR
| |
| *Piperacillin-tazobactam 3.375 gm IV q6hr OR
| |
| *Cefepime 2gm IV q8hr OR
| |
| *Imipenem 500mg IV q8hr
| |
| | |
| ==Disposition==
| |
| ===Uncomplicated UTI===
| |
| *Admit
| |
| **Unable to tolerate PO
| |
| *Discharge
| |
| **Consider phenazopyridine 100-200mg TID after meals x2d only (bladder analgesic)
| |
| ===Pyelonephritis===
| |
| *Discharge
| |
| **Consider if young, otherwise healthy, tolerating PO
| |
| *Admission
| |
| **Consider if elderly, calculi, obstruction, recent hospitalization/instrumentation, DM
| |
| | |
| ==Complications==
| |
| *Suspect in pts who have inadequate or atypical response to tx for presumed pyelo
| |
| #Acute bacterial nephritis
| |
| ##CT shows ill-defined focal areas of decreased density
| |
| #Renal/Perinephric abscesses
| |
| ##Sign/symptoms similar to pyelo (fever, CVAT, dysuria)
| |
| ##Occurs in setting of ascending infection w/ obstructed pyelo
| |
| ##Associated w/ DM and renal stones
| |
| ##Also occurs due to bacteremia w/ hematogenous seeding (Staph)
| |
| #Emphysematous pyelonephritis
| |
| ##Rare gas-forming infection nearly always occurring in pts w/ DM and obstruction
| |
| ###Pts appear toxic and septic; nephrectomy may be required
| |
| | |
| ==Special Populations==
| |
| ===AIDS===
| |
| *TMP-SMX resistance is increased due to its use in PCP PNA prophylaxis
| |
| **Fluoroquinolones should be initial antibiotic of choice
| |
| *Most UTIs are caused by typical pathogens or common STI organisms
| |
| ===Pregnant Women===
| |
| *Treat all cases of asymptomatic bacteriuria
| |
|
| |
|
| ==See Also== | | ==See Also== |
| | *[[Dysuria]] |
| | *[[Hematuria]] |
| | *[[Flank pain]] |
| *[[UTI (Peds)]] | | *[[UTI (Peds)]] |
| *[[Dysuria (DDX)]]
| |
|
| |
| ==Source ==
| |
| Tintinalli
| |
|
| |
|
| [[Category:Nephro]] | | [[Category:Renal]] |
| [[Category:ID]] | | [[Category:ID]] |
| | [[Category:Urology]] |