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

Diagnosis

Dipstick urinalysis (no culture or lab tests needed)

Treatment

Healthy adult woman (over age 12)

Non-pregnant
No fever, nausea, vomiting, flank pain

Trimethroprim/Sulfamethoxazole for 3 days

May use fluoroquinolone (ciprofoxacin or levofloxacin) in
patient with sulfa allergy, areas with high rates of bactrimresistance

Risk factors:

Sexual intercourse

May recommend post-coital voiding or prophylactic antibiotic use.

Complicated Cystitis

Definition

Diagnosis

Females with comorbid medical conditions

All male patients
Indwelling foley catheters
Urosepsis/hospitalization
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:

Treatment:

Urinalysis, urine culture, CBC, Chemistry

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:

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:

Pain in the perineum, lower abdomen, testicles, penis, and with ejaculation,
bladder irritation, bladder outlet obstruction, and sometimes blood in the
semen

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 lowgrade 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
Give the patient two prescriptions for ofloxacin 300 mg po
QDay for 7 days, one for him, and one for his wife.
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.
Administer a single dose of Ceftriaxone 125 mg IV x 1, and
ciprofloxacin 500 mg po x 1 draw blood for a VDRL and HIVantibody, and arrange for his wife to be examined and treated.
Administer a single dose of cefixime 400 mg, draw blood for
a VDRL and arrange for his wife to be examined and treated.

b)
c)

d)

e)

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!