Genitourinary infection

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  • 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, 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

  1. Male sex
    1. In young males dysuria is more commonly d/t STI
    2. Suspect underlying anatomic abnormality in men with culture-proven UTI
  2. Anatomic abnormality of urinary tract or external drainage system
    1. Indwelling urinary catheter, stent
    2. Nephrolithiasis, neurogenic bladder, polycystic renal disease, recent instrumentation
  3. Recurrent UTI (three or more per year)
  4. Advanced age in men (BPH, recent instrumentation, recent prostatic biopsy)
  5. Nursing home residency (w/ or w/o indwelling bladder catheter)
  6. Neonatal state
  7. Comorbidities (DM, sickle cell disease)
  8. Pregnancy
  9. Immunosuppression (AIDS, immunosuppressive drugs)
  10. Advanced neurologic disease (CVA w/ disability, spinal cord injuries)
  11. Known or suspected atypical pathogens (Non–E. coli infection)
  12. Known or suspected abx resistance (resistance to cipro predicts multidrug resistance)


  • 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


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 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



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
  • 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


  • Consider if pyelonephritis and any of the following:
  1. History of renal stone
  2. Poor response to abx
  3. Male
  4. Elderly
  5. Diabetic
  6. Severely ill


  • 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
  1. Nitrofurantoin ER 100mg BID x 5d OR
  2. TMP-SMX DS (160/800mg) 1 tab BID x 3d OR
  3. Cephalexin 250mg QID x 5d OR
  4. Ciprofloxacin 250mg BID x3d

===Women, complicated cystitis/pyelo

  • Risks for complicated UTI or symptoms of pyelo
  1. Ciprofloxacin 500mg BID x10-14d OR
  2. Cefpodoxime 200 mg BID x10-14d

Women, uncomplicated cystitis AND urethritis

  1. CTX 250mg IM x1 AND azithromycin 1gm PO x1 AND nitrofurantoin ER 100mg BID x5d OR
  2. Levofloxacin 500mg QD x 14d (covers UTI pathogens, GC, and chlam)
    1. GC resistance to fluoroquinolones is increasing

===Men, cystitis/pyelo

  • Consider urethritis and prostatitis
  1. Ciprofloxacin 500mg BID x10-14d OR
  2. Cefpodoxime 200 mg BID x10-14d


  • 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 and Follow-Up DISPOSITION FOR PATIENTS WITH UNCOMPLICATED URINARY TRACT INFECTION OR CYSTITIS Patients who are unable to retain fluids and medication should be admitted and antibiotics chosen as listed in Table 94-6. Adjunctive therapies for patients in stable enough condition for discharge include ingestion of plenty of fluids to enhance diuresis and fruit juices containing vitamin C to acidify the urine, consumption of a proper diet, and frequent voiding (at least every 2 hours) to diminish tissue contact with bacteria. The offer of 1 to 2 days of treatment with an oral bladder analgesic, such as phenazopyridine, is considerate when urination is painful for the patient. Cranberry juice appears to be mildly effective in reducing the incidence of recurrent infection.37 There is no conclusive evidence that postcoital voiding prevents cystitis.38

DISPOSITION FOR PATIENTS WITH PYELONEPHRITIS Young, otherwise healthy females with uncomplicated acute pyelonephritis are candidates for outpatient management provided they are able to tolerate fluids and medication.28,29 Urine culture with sensitivity testing should be performed. Patients should be instructed to return if they experience increasing pain, fever, or vomiting. Prescriptions for systemic analgesics (e.g., hydrocodone plus acetaminophen) and antiemetics (i.e., promethazine) should be considered. Overall, 80% to 90% of selected patients with acute pyelonephritis respond well to outpatient oral therapy.

The decision to admit a patient with UTI is based on age, host factors, and response to initial ED interventions. Overall, approximately 1% to 3% of patients with acute pyelonephritis die from the infection, with younger patients experiencing the fewest complications. Factors associated with an unfavorable prognosis are advanced age and general debility, renal calculi or obstruction, a history of recent hospitalization or instrumentation, diabetes mellitus, evidence of chronic nephropathy, sickle cell anemia, underlying carcinoma, and immunocompromised state [e.g., chemotherapy, human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS)].

Dangerous complications of acute pyelonephritis include acute papillary necrosis with possible ureter obstruction, septic shock, perinephric abscesses, and emphysematous pyelonephritis (see Imaging above).

PATIENTS WITH HUMAN IMMUNODEFICIENCY VIRUS INFECTION/ACQUIRED IMMUNODEFICIENCY SYNDROME In HIV/AIDS patients, resistance to TMP-SMX is increased due largely to its use in Pneumocystis jiroveci prophylaxis. Fluoroquinolones should be the initial antibiotic used for UTI in these patients unless urine culture and sensitivity test results are available to guide therapy. Most UTIs in HIV/AIDS patients are caused by typical pathogens or common STD organisms. Mycobacterium tuberculosis is an infrequent cause of UTI in the HIV/AIDS population. Close outpatient follow-up (recheck in 1 week) and possible infectious disease consultation is warranted when treating UTI in this population

Special Populations PREGNANT WOMEN See Chapter 102, Comorbid Diseases in Pregnancy, for a detailed discussion.


  • Suspect in pts who have inadequate or atypical response to tx for presumed pyelo
  1. Acute bacterial nephritis
    1. CT shows ill-defined focal areas of decreased density
  2. Renal/Perinephric abscesses
    1. Sign/symptoms similar to pyelo (fever, CVAT, dysuria)
    2. Occurs in setting of ascending infection w/ obstructed pyelo
    3. Associated w/ DM and renal stones
    4. Also occurs due to bacteremia w/ hematogenous seeding (Staph)
  3. Emphysematous pyelonephritis
    1. Rare gas-forming infection nearly always occurring in pts w/ DM and obstruction
      1. Pts appear toxic and septic; nephrectomy may be required

See Also