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