Urinary Tract Infection

Michele Ritter, M.D.

Argy Resident Feb. 2007
Urinary Tract Infection

Upper urinary tract Infections:

Pyelonephritis
Lower urinary tract infections
Cystitis (traditional UTI)
Urethritis (often sexually-transmitted)

Prostatitis
Symptoms of Urinary Tract Infection

Dysuria
Increased frequency
Hematuria
Fever
Nausea/Vomiting (pyelonephritis)
Flank pain (pyelonephritis)
Findings on Exam in UTI
Physical Exam:
CVA tenderness (pyelonephritis)
Urethral discharge (urethritis)
Tender prostate on DRE (prostatitis)
Labs: Urinalysis
+ leukocyte esterase
+ nitrites
More likely gram-negative rods
+ WBCs
+ RBCs
Culture in UTI
Positive Urine Culture = >105 CFU/mL
Most common pathogen for cystitis,
prostatitis, pyelonephritis:
Escherichia coli
Staphylococcus saprophyticus
Proteus mirabilis
Klebsiella
Enterococcus
Most common pathogen for urethritis
Chlamydia trachomatis
Neisseria Gonorrhea
Lower Urinary Tract Infection -
Cystitis
Uncomplicated (Simple) cystitis
In healthy woman, with no signs of systemic
disease
Complicated cystitis
In men, or woman with comorbid medical
problems.
Recurrent cystitis
Uncomplicated (simple) Cystitis
Definition
Healthy adult woman (over age 12)
Non-pregnant
No fever, nausea, vomiting, flank pain
Diagnosis
Dipstick urinalysis (no culture or lab tests needed)
Treatment
Trimethroprim/Sulfamethoxazole for 3 days
May use fluoroquinolone (ciprofoxacin or levofloxacin) in
patient with sulfa allergy, areas with high rates of bactrim-
resistance
Risk factors:
Sexual intercourse
May recommend post-coital voiding or prophylactic antibiotic
use.
Complicated Cystitis
Definition
Females with comorbid medical conditions
All male patients
Indwelling foley catheters
Urosepsis/hospitalization
Diagnosis
Urinalysis, Urine culture
Further labs, if appropriate.
Treatment
Fluoroquinolone (or other broad spectrum antibiotic)
7-14 days of treatment (depending on severity)
May treat even longer (2-4 weeks) in males with UTI
Special cases of Complicated
cystitis
Indwelling foley catheter
Try to get rid of foley if possible!
Only treat patient when symptomatic (fever, dysuria)
Leukocytes on urinalysis
Patients with indwelling catheters are frequently colonized with
great deal of bacteria.
Should change foley before obtaining culture, if possible
Candiduria
Frequently occurs in patients with indwelling foley.
If grows in urine, try to get rid of foley!
Treat only if symptomatic.
If need to treat, give fluconazole (amphotericin if resistance)
Recurrent Cystitis

Want to make sure urine culture and

sensitivity obtained.
May consider urologic work-up to
evaluate for anatomical abnormality.
Treat for 7-14 days.
Pyelonephritis
Infection of the kidney
Associated with constitutional symptoms fever, nausea,
vomiting, headache
Diagnosis:
Urinalysis, urine culture, CBC, Chemistry
Treatment:
2-weeks of Trimethroprim/sulfamethoxazole or fluoroquinolone
Hospitalization and IV antibiotics if patient unable to take po.
Complications:
Perinephric/Renal abscess:
Suspect in patient who is not improving on antibiotic therapy.
Diagnosis: CT with contrast, renal ultrasound
May need surgical drainage.
Nephrolithiasis with UTI
Suspect in patient with severe flank pain
Need urology consult for treatment of kidney stone
Prostatitis
Symptoms:
Pain in the perineum, lower abdomen, testicles, penis, and with ejaculation,
bladder irritation, bladder outlet obstruction, and sometimes blood in the
semen
Diagnosis:
Typical clinical history (fevers, chills, dysuria, malaise, myalgias,
pelvic/perineal pain, cloudy urine)
The finding of an edematous and tender prostate on physical examination
Will have an increased PSA
Urinalysis, urine culture
Treatment:
Trimethoprim/sulfamethoxazole, fluroquinolone or other broad spectrum
antibiotic
4-6 weeks of treatment
Risk Factors:
Trauma
Sexual abstinence
Dehydration
Urethritis
Chlamydia trachomatis
Frequently asymptomatic in females, but can present with dysuria, discharge or
pelvic inflammatory disease.
Send UA, Urine culture (if pyuria seen, but no bacteria, suspect Chlamydia)
Pelvic exam send discharge from cervical or urethral os for chlamydia PCR
Chlamydia screening is now recommended for all females 25 years
Treatment:
Azithromycin 1 g po x 1
Doxycycline 100 mg po BID x 7 days
Neisseria gonorrhoeae
May present with dysuria, discharge, PID
Send UA, urine culture
Pelvic exam send discharge samples for gram stain, culture, PCR
Treatment:
Ceftriaxone 125 mg IM x 1
Cipro 500 mg po x 1
Levofloxacin 250 mg po x 1
Ofloxacin 400 mg po x 1
Spectinomycin 2 g IM x 1
You should always also treat for chlamydia when treating for gonnorhea!
Question #1

An 18-year old woman presents with

urinary frequency, dysuria, and low-
grade fever. Urinalysis shows pyuria and
bacilli. She has never had similar
symptoms or treatment for urinary tract
infection.
Question # 1

What category of UTI does this patient

have?
Does this patient require further testing?
Would you treat this patient, and if so,
with what and how long?
Question # 2

An 18-year old woman present with her

third episode of urinary frequency,
dysuria, and pyuria in the past 4 months.
Question # 2

What further questions do you have for

this patient?
What type of UTI does this patient have?
What testing might you perform in this
patient?
How would you treat her, and for how
long?
Question #3

A 24-year old woman presents with

fever, chills, nausea, vomiting, flank pain
and tenderness. Her temperature is
40C, pulse rate is 120/min., and blood
pressure is 100/60 mm Hg.
Question # 3

What further studies do you want in this

patient?
How would you treat this patient?
What might you do if she does not
improve after 3-4 days?
Question # 4

A 78-year old female presents with an

indwelling foley catheter and pyuria.
Question # 4

What would you do for this patient at this

time?
How might your work-up/management
change if she was having fevers and
confusion?
Question # 5

58-year old man presents with his first

episode of urinary frequency and
dysuria. Urinalysis shows pyuria and
bacilli.
Question # 5

What type of UTI does this patient likely

have?
How would you treat this man, and for
how long?
What activities would put this patient at
risk for UTI?
Question # 6

A 28-year old male had a sexual

encounter with a prostitute while on a
business trip in Seattle 1 week ago.
After returning home, he noted a burning
sensation on urination and a yellow
discharge in his underwear. Microscopic
examination of the discharge reveals 4+
leukocyte esterase, and the following
gram stain.
Question # 6
Question # 6
Which of the following is the best course of action for
this patient?

a) Give the patient a prescription for doxycycline, 100 mg po BID

for 7 days
b) Give the patient two prescriptions for ofloxacin 300 mg po
QDay for 7 days, one for him, and one for his wife.
c) Administer ceftriaxone 125 mg IV x 1 and Azithromycin 1 g
po x 1, draw blood for a VDRL and HIV antibody arrange for
his wife to be examined and treated.
d) Administer a single dose of Ceftriaxone 125 mg IV x 1, and
ciprofloxacin 500 mg po x 1 draw blood for a VDRL and HIV-
antibody, and arrange for his wife to be examined and treated.
e) Administer a single dose of cefixime 400 mg, draw blood for
a VDRL and arrange for his wife to be examined and treated.
Final thoughts!
Antibiotic choice and duration are determined
by classification of UTI.
Biggest bugs for UTI are E. Coli, Staph.
Saprophyticus, Proteus mirabilis, Enterococci
and gram-negatives
Dont use moxifloxacin for UTI!
Chlamydia screening is now recommended for
all women 25 years and under since infection
is frequently asymptomatic, and risk for
PID/infertility is high!