Urinary tract infection resident survival guide
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Urinary tract infection Resident Survival Guide |
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Overview |
Causes |
Diagnosis |
Treatment |
Do's |
Don'ts |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ogheneochuko Ajari, MB.BS, MS [2] Iqra Qamar M.D.[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
- Escherichia coli
- Klebsiella pneumonia
- Neisseria gonorrhea
- Proteus mirabilis
- Pseudomonas aeruginosa
- Staphylococcus saprophyticus
- Urinary catheterization
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 | |||||||||||||||||||||||||||||||||||||||||
Order tests: ❑ Urine culture ❑ Urinalysis ❑ Blood culture ❑ Abdominal CT ❑ Renal ultrasound scan ❑ Voiding cystourethrogram ❑ Intravenous pyelogram | |||||||||||||||||||||||||||||||||||||||||
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: Template:See main | 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: Template:See main | 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 Template:See main | |||||||||||||||||||||||||||||||||||||||||||
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: Template:See main | 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: Template:See main | Acute pyelonephritis in Pregnancy Preferred regimen IV Ceftriaxone 1g q24h OR IV Ampicillin 1-2g q6h OR IV Cefepime 1g q12h Alternative regimen: Template:See main | Is there urethral discharge? | ||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||
Consider Urethritis For treatment of urethritis: Template:See main | 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
- ↑ 1.0 1.1 1.2 "Drugs for urinary tract infections". JAMA. 311 (8): 855–6. 2014. doi:10.1001/jama.2014.972. PMID 24570249.
- ↑ 2.0 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.