Urinary tract infection resident survival guide

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Urinary tract infection
Resident Survival Guide
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Iqra Qamar M.D.[2] Ogheneochuko Ajari, MB.BS, MS [3]

Overview

A urinary tract infection (UTI) is a bacterial infection that affects any part of the urinary tract.

Causes

Life Threatening Causes

  • Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
  • Urinary tract infection does not have life threatening causes.

Common Causes

Management

Shown below is an algorithm depicting the initial approach to UTI.

 
 
 
Characterize the symptoms:
Fever
Dysuria
Frequent urination
Suprapubic pain
Hematuria
Vomiting
Diarrhea
Nausea
Flank pain or back pain
Weak urine stream
Hesistancy
Nocturia
Chills
Urethral discharge
Obtain a detailed history:
Use of urinary catheters
Pregnancy
Diabetes
❑ Female and sexually active
❑ Renal problems
❑ Menopausal
Sickle cell disease
Elderly
Antibiotic use
❑ Urogynecologic surgery
Urinary retention
Urinary incontinence
❑ Anatomic malformations of the urinary tract
❑ Increased susceptibility to UTIs
❑ Allergies to latex condoms or spermicides
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:
❑ Suprapubic tenderness
❑ Flank pain or costovertebral angle tenderness
❑ Tender prostate
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider alternative diagnosis:
Urethritis
Prostatitis
Renal abscess
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Diagnosis and Treatment

An algorithm using symptoms/physical finding in diagnosis and treatment of UTIs.


 
 
 
 
 
 
 
 
UTI confirmed with urine culture
(≥ 105 CFU/mL) + Pyuria
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is there suprapubic pain?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider Cystitis
 
 
 
Is there flank or back pain?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acute uncomplicated cystitis
Preferred regimen[1][2]
TMP-SMX 160/800mg bid x 3 days
OR
Nitrofurantoin monohydrate/macrocrystals 100mg bid x 5-7 days
OR
Fosfomycin trometamol 3g once (single dose)
OR
Pivmecillinam 400mg bid x 5 days
Alternative regimen:
See main article: Cystitis medical therapy
 
Complicated/Catheter-Associated Cystitis
Preferred regimen
For those who can tolerate ORALLY
Ciprofloxacin 500mg PO bid x 5-14 days
OR
Ciprofloxacin Extended Release 1000mg daily x 5-14 days
OR
PARENTERALLY
IV Levofloxacin 500mg
OR
IV Ceftriaxone 1g
OR
IV Ertapenem 1g
Catheter-Associated UTI
Remove catheter or intermittent catheterization
Use same antibiotic therapy as above for CA-Cystitis
Alternative regimen:
See main article: Cystitis medical therapy
 
Acute Cystitis in Pregnancy
Preferred regimen
Nitrofurantoin 100mg PO q12h x 5 days
OR
Amoxicillin-clavulanate 500mg PO q12h 3-7 days
OR
Fosfomycin 3g PO single dose
Alternative regimen:
TMP-SMX DS PO bid x 3 days only in 2nd trimester
See main article: Cystitis medical therapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider pyelonephritis
 
 
Consider alternative diagnosis such as;
Prostatitis
Urethritis
Renal abscess
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acute uncomplicated pyelonephritis (Outpatient)
Preferred regimen[1][2]
Ciprofloxacin (immediate release) 500mg bid x 7 days
Ciprofloxacin (extended release) 1000mg once daily x 7 days
OR
Levofloxacin 750mg once daily x 5 days OR
TMP-SMX 160/800mg bid x 14 days
Alternative regimen:
See main article: Pyelonephritis medical therapy
 
Complicated pyelonephritis (Inpatient)
Preferred regimen
IV Ceftriaxone 1g q24h
OR
IV Ciprofloxacin 400mg q12h
OR
IV Levofloxacin 750mg q24h
OR
IV Cefepime q12h
Alternative regimen:
See main article: Pyelonephritis medical therapy
 
Acute pyelonephritis in Pregnancy
Preferred regimen
IV Ceftriaxone 1g q24h
OR
IV Ampicillin 1-2g q6h
OR
IV Cefepime 1g q12h
Alternative regimen:
See main article: Pyelonephritis medical therapy
 
Is there urethral discharge?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider Urethritis
For treatment of urethritis:
See main article: Urethritis medical therapy
 
Weak urine stream or hesitancy?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider Prostatitis
 
Renal USS to rule out renal abscess (drainage + antibiotics for renal abscess)
Other investigations (Abdominal CT, VSUG, for anatomic abnormality or obstructions
 

Do's

  • TMP-SMX should only be used in the second trimester of pregnancy.

Dont's

  • Don't use fluoroquinolones empirically for treatment of acute uncomplicated cystitis.[1]
  • Do not give fluoroquinolones in pregnancy.
  • Don't give TMP-SMX in first trimester or near term of pregnancy.

References

  1. 1.0 1.1 1.2 "Drugs for urinary tract infections". JAMA. 311 (8): 855–6. 2014. doi:10.1001/jama.2014.972. PMID 24570249.
  2. 2.0 2.1 Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG; et al. (2011). "International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases". Clin Infect Dis. 52 (5): e103–20. doi:10.1093/cid/ciq257. PMID 21292654.

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