Urinary tract infection

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Urinary Tract Infection Microchapters

Patient Information

Overview

Classification

Pyelonephritis
Cystitis
Prostatitis
Urethritis
Asymptomatic bacteriuria

Causes

Differential Diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Usama Talib, BSc, MD [2]

Synonyms and Keywords: UTI

Overview

A urinary tract infection is an infection that involves any part of the urinary tract. It can result due to the invasion by a bacteria, virus, fungus or any other pathogen. The most common cause of a urinary tract infection is a bacterial infection. Depending on the site of the infection, a urinary tract infection can be classified as either upper or lower UTI. Lower UTI includes urethritis, prostatitis, asymptomatic bacteriuria, and cystitis (bladder infection), where as upper UTI may include pyelonephritis (infection of the kidneys) and rarely urethritis (infection of the ureters). Each subtype of urinary tract infection can also be subclassified on the basis of duration, etiology or therapeutic approach as acute, chronic, or recurrent and as uncomplicated or complicated infections.

The urine is normally sterile, a urinary tract infection occurs when the normally sterile urinary tract is infected by bacteria, which leads to irritation and inflammation. Pyelonephritis and cystitis result mostly from ascending infections from the urethra (urethritis) but can also result from descending infections such as hematogenous spread, or by the lymphatic system. The condition more often affects women, but can affect either gender and all age groups. The pathogenesis of a complicated UTI may include obstruction and stasis of urine flow.[1] Various factors are associated with the risk of developing a urinary tract infection. A common cause of the urinary tract infection in hospital settings is the urinary catheter placement. Diabetes, Crohn's disease, iatrogenic causes, endometriosis, pelvic inflammatory disease, urinary obstruction, and bladder incontinence are some risk factors for acquiring a urinary tract infection. A thorough physical exam is very helpful in differentiating upper from lower urinary tract infections. Patients with an uncomplicated urinary tract infections are usually well–appearing. The symptoms may include abnormal urine color (cloudy), blood in the urine, frequent urination or urgent need to urinate, dysuria, pressure in the lower pelvis or back, suprapubic pain, flank pain, back pain, fever, nausea, vomiting, and chills.[2] Urinalysis and urine culture are very helpful laboratory tests in diagnosing a urinary tract infection. Pyuria and either white blood cells (WBCs) or red blood cells (RBCs) may be seen on urinalysis. Escherichia coli ("E. coli"), a bacterium found in the lower gastrointestinal tract is one of the most common culprits. The individual infection must be differentiated from various causes of dysuria such as cystitis, acute pyelonephritis, urethritis, prostatitis, vulvovaginitis, urethral strictures or diverticula, benign prostatic hyperplasia and neoplasms such as renal cell carcinoma and cancers of the bladder, prostate, and penis. Antimicrobial therapy is indicated in case of a symptomatic UTI.[3][4] A large proportion of patients with acute uncomplicated urinary infections will recover without treatment within a few days or weeks. If left untreated, some patients may progress to develop recurrent infection, involve and infect other parts of the urinary tract, hematuria, and rarely renal failure. Prognosis is generally good for lower UTIs.[5] The treatment of a UTI depends on the type of the disease, the disease course (acute uncomplicated versus complicated), history of the individual, and the rates of drug resistance in the community. Preventative measures to avoid a UTI include abstinence, being faithful, using a condom, using barrier contraception during sexual intercourse, urinating after intercourse, increasing fluid intake and frequency of urination, and use of estrogen among postmenopausal women.

Classification

Urinary tract infections can be classified as follows:

Anatomical Classification

 
 
 
 
 
 
 
 
 
 
 
 
Urinary tract infections
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Upper UTI
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Lower UTI
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pyelonephritis
 
 
Cystitis
 
 
 
 
 
 
 
Prostatitis
 
 
 
Urethritis
 
 
 
 
 
Asymptomatic bacteriuria
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
• Acute uncomplicated
• Acute complicated
• Chronic
• Emphysematous
• Xantho-granulomatous
 
 
• Acute uncomplicated
• Complicated
• Recurrent/chronic
 
 
 
 
 
 
 
• Acute bacterial
• Chronic bacterial
• Chronic inflammatory
• Chronic non-inflammatory
• Asymptomatic
 
 
 
 
 
 
 
 
 

Classification Based on Symptoms

This classification is primarily used to estimate duration of antibiotic treatment.[6]

 
 
 
UTI
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
*Fever > 99.9 F OR
*Flank pain or CVA tenderness with pyuria OR
*Fever with pyuria OR
*Sepsis OR
*Systemic signs such as chills, rigors, fatigue OR
*UTI in men OR
*Anatomical renal defects OR
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Present (anyone)
 
 
 
Absent
 
 
 
 
 
 
 
 
 
 
 
 
Treat as complicated UTI
*5-14 days based on choice of antibiotics
 
 
 
Treat as uncompliacred UTI
*5 days

Causes

The various causes of urinary tract infections include:

Common Pathogens Pyelonephritis Cystitis Urethritis Prostatitis Asymptomatic Bacteriuria
Ecoli*[7][8][9][10] + (70%) + (78.6%) + (58%) + (80%)
Klebsiella[11] + + + +
Proteus[12] + + + +
Neisseria gonorrhoeae[13] + (21.6%) +
Pseudomonas[14] + + + +
Staphylococcus + + + +
Chlamydia trachomatis[15][16][17] + + + (20–30%) +
Mycoplasma[18][19] + +
Trichomonas[20][21][22] + + + +

*Ecoli is the most common cause of all urinary tract infections[23]

Differential Diagnosis

Urinary tract infections should be differentiated from one another and from various other diseases:

Diseases Symptoms Physical Examination Diagnostic tests Past medical history Other Findings
Hematuria Pyuria Frequency Urgency Dysuria Fever Tenderness Discharge Inguinal Lymphadenopathy Urinalysis Urine Culture Gold Standard
Differentiating amongst different types of urinary tract infections:
Pyelonephritis + + + + Flank or costovertebral angle + + Identifies causative bacteria Urine culture
Cystitis + + + + + + Suprapubic + >100,000CFU/mL Urine culture
Urethritis + + + Urethral discharge + Gram stain & mucoid or purulent discharge
Prostatitis + + + + + Identifies causative bacteria (in bacterial subtypes) Urine culture
Diseases Symptoms Physical Examination Diagnostic tests Past medical history Other Findings
Hematuria Pyuria Frequency Urgency Dysuria Fever Tenderness Discharge Inguinal Lymphadenopathy Urinalysis Urine Culture Gold Standard
Differentiating UTIs from other diseases:
Vulvovagintis + + Vaginal discharge  + Gram stain & culture of discharge
  • Number and type of sexual partners (new, casual, or regular)
  • Prior STDs
  • Previous history of symptomatic BV in female partner (in homosexual women)
Cervicitis + + + Cervical Endocervical exudate Culture for gonococcal cervicitis
Epididymitis + + + + + Testicular & suprapubic +/– urethral discharge + + Culture
Syphilis

(STD)

+/– + Darkfield microscopy
BPH + + + + DRE

& Serum PSA

Neoplasms + + + +/– + Imaging and biopsy
Diseases Symptoms Physical Examination Diagnostic tests Past medical history Other Findings
Hematuria Pyuria Frequency Urgency Dysuria Fever Tenderness Discharge Inguinal Lymphadenopathy Urinalysis Urine Culture Gold Standard

References

  1. Hooton TM (2000). "Pathogenesis of urinary tract infections: an update". J Antimicrob Chemother. 46 Suppl A: 1–7. PMID 10969044.
  2. Colgan R, Williams M (2011). "Diagnosis and treatment of acute uncomplicated cystitis". Am Fam Physician. 84 (7): 771–6. PMID 22010614.
  3. Bremnor JD, Sadovsky R (2002). "Evaluation of dysuria in adults". Am Fam Physician. 65 (8): 1589–96. PMID 11989635.
  4. Kurowski K (1998). "The woman with dysuria". Am Fam Physician. 57 (9): 2155–64, 2169–70. PMID 9606306.
  5. Urinary Tract Infections in Adults. NIDDK 2016. http://www.niddk.nih.gov/health-information/health-topics/urologic-disease/urinary-tract-infections-in-adults/Pages/facts.aspx. Accessed on February 9, 2016
  6. Peterson J, Kaul S, Khashab M, Fisher AC, Kahn JB (2008). "A double-blind, randomized comparison of levofloxacin 750 mg once-daily for five days with ciprofloxacin 400/500 mg twice-daily for 10 days for the treatment of complicated urinary tract infections and acute pyelonephritis". Urology. 71 (1): 17–22. doi:10.1016/j.urology.2007.09.002. PMID 18242357.
  7. R. M. Echols, R. L. Tosiello, D. C. Haverstock & A. D. Tice (1999). "Demographic, clinical, and treatment parameters influencing the outcome of acute cystitis". Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 29 (1): 113–119. doi:10.1086/520138. PMID 10433573.
  8. Manuel Etienne, Pascal Chavanet, Louis Sibert, Frederic Michel, Herve Levesque, Bernard Lorcerie, Jean Doucet, Pierre Pfitzenmeyer & Francois Caron (2008). "Acute bacterial prostatitis: heterogeneity in diagnostic criteria and management. Retrospective multicentric analysis of 371 patients diagnosed with acute prostatitis". BMC infectious diseases. 8: 12. doi:10.1186/1471-2334-8-12. PMID 18234108.
  9. James B. Hill, Jeanne S. Sheffield, Donald D. McIntire & George D. Jr Wendel (2005). "Acute pyelonephritis in pregnancy". Obstetrics and gynecology. 105 (1): 18–23. doi:10.1097/01.AOG.0000149154.96285.a0. PMID 15625136.
  10. Rebecca E. Watts, Viktoria Hancock, Cheryl-Lynn Y. Ong, Rebecca Munk Vejborg, Amanda N. Mabbett, Makrina Totsika, David F. Looke, Graeme R. Nimmo, Per Klemm & Mark A. Schembri (2010). "Escherichia coli isolates causing asymptomatic bacteriuria in catheterized and noncatheterized individuals possess similar virulence properties". Journal of clinical microbiology. 48 (7): 2449–2458. doi:10.1128/JCM.01611-09. PMID 20444967.
  11. R. M. Echols, R. L. Tosiello, D. C. Haverstock & A. D. Tice (1999). "Demographic, clinical, and treatment parameters influencing the outcome of acute cystitis". Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 29 (1): 113–119. doi:10.1086/520138. PMID 10433573.
  12. R. M. Echols, R. L. Tosiello, D. C. Haverstock & A. D. Tice (1999). "Demographic, clinical, and treatment parameters influencing the outcome of acute cystitis". Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 29 (1): 113–119. doi:10.1086/520138. PMID 10433573.
  13. Stephanie N. Taylor, Oliver Liesenfeld, Rebecca A. Lillis, Barbara A. Body, Melinda Nye, James Williams, Carol Eisenhut, Edward W. 3rd Hook & Barbara Van Der Pol (2012). "Evaluation of the Roche cobas(R) CT/NG test for detection of Chlamydia trachomatis and Neisseria gonorrhoeae in male urine". Sexually transmitted diseases. 39 (7): 543–549. doi:10.1097/OLQ.0b013e31824e26ff. PMID 22706217.
  14. Allan Ronald (2002). "The etiology of urinary tract infection: traditional and emerging pathogens". The American journal of medicine. 113 Suppl 1A: 14S–19S. PMID 12113867.
  15. J. Dimitrakov, V. Ganev, T. Zlatanov, I. Detchev, A. Horvat, S. Kirov, I. Vatchkova & D. Dimitrakov (1998). "PCR studies on the presence of Chlamydia trachomatis in the upper urinary tract of patients with obstructive pyelonephritis". Folia medica. 40 (3): 24–28. PMID 10658351.
  16. J. Dimitrakov, V. Ganev, T. Zlatanov, I. Detchev, A. Horvat, S. Kirov, I. Vatchkova & D. Dimitrakov (1998). "PCR studies on the presence of Chlamydia trachomatis in the upper urinary tract of patients with obstructive pyelonephritis". Folia medica. 40 (3): 24–28. PMID 10658351.
  17. Matthew J. Perkins & Catherine F. Decker (2016). "Non-gonococcal urethritis". Disease-a-month : DM. 62 (8): 274–279. doi:10.1016/j.disamonth.2016.03.011. PMID 27107783.
  18. Iu L. Naboka, L. I. Vasil'eva, M. I. Kogan, I. A. Gudima & I. Iu Suchkov (2009). "[Microbial associations defecting in children with chronic pyelonephritis]". Zhurnal mikrobiologii, epidemiologii, i immunobiologii (5): 8–12. PMID 20063785.
  19. Iu L. Naboka, L. I. Vasil'eva, M. I. Kogan, I. A. Gudima & I. Iu Suchkov (2009). "[Microbial associations defecting in children with chronic pyelonephritis]". Zhurnal mikrobiologii, epidemiologii, i immunobiologii (5): 8–12. PMID 20063785.
  20. Template:Hoffman, David J., et al. "Urinary tract infection with Trichomonas vaginalis in a premature newborn infant and the development of chronic lung disease." Journal of perinatology 23.1 (2003): 59-61.
  21. L. SYLVESTRE, M. BELANGER & Z. GALLAI (1960). "Urogenital trichomoniasis in the male: review of the literature and report on treatment of 37 patients by a new nitroimidazole derivative (Flagyl)". Canadian Medical Association journal. 83: 1195–1199. PMID 13774369.
  22. Template:Kuberski, Tim. "Trichomonas vaginalis associated with nongonococcal urethritis and prostatitis." Sexually transmitted diseases 7.3 (1979): 135-136.
  23. Matthew J. Perkins & Catherine F. Decker (2016). "Non-gonococcal urethritis". Disease-a-month : DM. 62 (8): 274–279. doi:10.1016/j.disamonth.2016.03.011. PMID 27107783.

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