|
|
| Line 1: |
Line 1: |
| | ==Background== | | ==Background== |
| − | *Also known as acute cystitis; abbreviation = UTI
| + | May refer to: |
| − | ===Definitions===
| + | *[[Acute cystitis]] |
| − | *UTI = significant bacteriuria in presence of symptoms
| |
| − | **Described by location: urethritis, cystitis, or pyelonephritis
| |
| − | *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, [[diabetes]]
| |
| − | *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)
| |
| − | | |
| − | ===[[Microbiology]]===
| |
| − | *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==
| |
| − | ===Clinical Features===
| |
| − | *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 [[chlamydia]]/[[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 [[antibiotics]]
| |
| − | #Male
| |
| − | #Elderly
| |
| − | #[[Diabetic]]
| |
| − | #Severely ill
| |
| − | | |
| − | ==Differential Diagnosis==
| |
| − | ===Major===
| |
| | *[[Pyelonephritis]] | | *[[Pyelonephritis]] |
| − | *Infected [[kidney stone]] | + | *[[Urethritis]] |
| − | | |
| − | ===Pelvic Pain===
| |
| − | {{Pelvic pain DDX}}
| |
| − | | |
| − | ===Dysuria===
| |
| − | {{Dysuria DDX}}
| |
| − | | |
| − | ==Management==
| |
| − | *Consider local resistance patterns (if >10-20% use a different agent)
| |
| − | *Avoid use of fluoroquinolones for uncomplicated cystitis if possible
| |
| − | | |
| − | ;Consider longer course of complicated cystitis if:
| |
| − | *Symptoms >7d
| |
| − | *[[DM]]
| |
| − | *UTI in previous 4wk
| |
| − | *Men
| |
| − | *Age 65 yr
| |
| − | *Women who use spermicides or diaphragm
| |
| − | *Relapse
| |
| − | *Pregnancy
| |
| − | | |
| − | {{UTI Antibiotics}}
| |
| − | | |
| − | ==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, [[Renal Calculi]], obstruction, recent hospitalization/instrumentation, [[DM]]
| |
| − | | |
| − | ==Complications==
| |
| − | *Suspect in pts who have inadequate or atypical response to tx for presumed [[pyelonephritis]]
| |
| − | #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== |
| | *[[UTI (Peds)]] | | *[[UTI (Peds)]] |
| − | *[[Dysuria]]
| |
| − |
| |
| − | ==Source ==
| |
| − | Tintinalli
| |
| | | | |
| | [[Category:Nephro]] | | [[Category:Nephro]] |
| | [[Category:ID]] | | [[Category:ID]] |
| | [[Category:GU]] | | [[Category:GU]] |
