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| ==Background== | | ==Background== |
| *Also known as acute cystitis; abbreviation = UTI
| | May refer to: |
| ===Definitions===
| | *[[Acute cystitis]] |
| *UTI = significant bacteriuria in presence of symptoms
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| **Described by location: urethritis, cystitis, or pyelonephritis
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| *Relapse
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| **Recurrence of symptoms w/in month despite tx
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| ***Caused by same organism and represents treatment failure
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| *Reinfection
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| **Development of symptoms 1-6mo after tx
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| **Usually due to a different organism
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| **If pt has >3 recurrences in 1 yr consider tumor, calculi, [[diabetes]]
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| *Men <50 yr: symptoms of dysuria or urinary frequency usually due to [[STI]]
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| *Men >50 yr: incidence of UTI rises dramatically d/t prostatic obstruction
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| *Uncomplicated UTI: | |
| **No structural or functional abnormalities w/in urinary tract or kidney
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| **No relevant comorbidities that place pt at risk for more serious adverse outcome
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| **Not associated with GU tract instrumentation
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| ===Risk factors for complicated UTI===
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| #Male sex
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| ##In young males dysuria is more commonly d/t STI
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| ##Suspect underlying anatomic abnormality in men with culture-proven UTI
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| #Anatomic abnormality of urinary tract or external drainage system
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| ##Indwelling urinary catheter, stent
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| ##Nephrolithiasis, neurogenic bladder, polycystic renal disease, recent instrumentation
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| #Recurrent UTI (three or more per year)
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| #Advanced age in men (BPH, recent instrumentation, recent prostatic biopsy)
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| #Nursing home residency (w/ or w/o indwelling bladder catheter)
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| #Neonatal state
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| #Comorbidities ([[DM]], sickle cell disease)
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| #Pregnancy
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| #Immunosuppression ([[AIDS]], immunosuppressive drugs)
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| #Advanced neurologic disease ([[CVA]] w/ disability, [[Spinal Cord Injuries]])
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| #Known or suspected atypical pathogens (Non–E. coli infection)
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| #Known or suspected abx resistance (resistance to Cipro predicts multidrug resistance)
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| | |
| ===[[Microbiology]]===
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| *Most common pathogen is [[E. coli]]
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| *[[Anaerobic]] organisms are rarely pathogenic (do not grow well in urine)
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| *Complicated UTIs more likely to be caused by [[pseudomonas]] or [[enterococcus]]
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| | |
| ==Diagnosis==
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| ===Clinical Features===
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| *UTI dx requires both bacteriuria and clinical symptoms
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| **Cystitis = Dysuria, [[hematuria]], frequency, urgency, suprapubic pain, CVAT
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| **Pyelo = Cystitis sx AND fever/chills/nausea/vomiting
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| ***CVAT alone may be referred pain from cystitis
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| ***CVAT is only physical examination finding that increases likelihood of a UTI
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| *Urethritis
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| **In males more likely due to [[chlamydia]]/[[GC]]
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| **In females more likely due to [[chlam]]/[[GC]] if:
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| ***Stuttering urination symptoms
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| ***New sex partner or partner w/ urethritis
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| ***Signs/symptoms cervicitis
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| ***Sterile pyuria
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| *Complicated UTI
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| **Pts may not have classic symptoms; may only have [[weakness]], [[fever]], [[abd pain]], [[AMS]]
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| ===Labs===
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| ====UA====
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| =====WBC count=====
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| *WBC >5 in pt w/ appropriate symptoms is diagnostic
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| **Lower degrees of pyuria may still be clinically significant in presence of UTI sx
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| ***False negative may be due to: dilute urine, systemic leukopenia, obstruction
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| **WBC 1-2 w/ bacteriuria can be significant in men
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| ***More likely represents urethritis or [[prostatitis]] from [[STI]]
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| | |
| =====Nitrite=====
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| *Very high specificity (>90%) in confirming diagnosis of UTI
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| *Low sensitivity (enterococcus, pseudomonas, acinetobacter are not detected)
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| ====[[Urine Culture]]====
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| *Indicated for:
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| **Complicated UTI
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| **Pyelonephritis
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| **Pregnant women
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| **Children
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| **Adult males
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| **Relapse/reinfection
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| ====[[Blood Culture]]====
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| *Not indicated
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| **Organisms in blood cx matched those in urine cx 97% of time
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| ===Imaging===
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| *Consider if [[pyelonephritis]] and any of the following:
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| #History of [[Renal Stone]]
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| #Poor response to [[antibiotics]]
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| #Male
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| #Elderly
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| #[[Diabetic]]
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| #Severely ill
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| ==Differential Diagnosis==
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| ===Major===
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| *[[Pyelonephritis]] | | *[[Pyelonephritis]] |
| *Infected [[kidney stone]] | | *[[Urethritis]] |
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| ===Pelvic Pain===
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| {{Pelvic pain DDX}}
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| ===Dysuria===
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| {{Dysuria DDX}}
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| ==Management==
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| *Consider local resistance patterns (if >10-20% use a different agent)
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| *Avoid use of fluoroquinolones for uncomplicated cystitis if possible
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| | |
| ;Consider longer course of complicated cystitis if:
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| *Symptoms >7d
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| *[[DM]]
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| *UTI in previous 4wk
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| *Men
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| *Age 65 yr
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| *Women who use spermicides or diaphragm
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| *Relapse
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| *Pregnancy
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| {{UTI Antibiotics}}
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| ==Disposition==
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| ===Uncomplicated UTI===
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| *Admit
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| **Unable to tolerate PO
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| *Discharge
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| **Consider phenazopyridine 100-200mg TID after meals x2d only (bladder analgesic)
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| ===[[Pyelonephritis]]===
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| *Discharge
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| **Consider if young, otherwise healthy, tolerating PO
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| *Admission
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| **Consider if elderly, [[Renal Calculi]], obstruction, recent hospitalization/instrumentation, [[DM]]
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| ==Complications==
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| *Suspect in pts who have inadequate or atypical response to tx for presumed [[pyelonephritis]]
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| #Acute bacterial nephritis
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| ##CT shows ill-defined focal areas of decreased density
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| #Renal/Perinephric Abscesses
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| ##Sign/symptoms similar to [[pyelo]] ([[fever]], CVAT, dysuria)
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| ##Occurs in setting of ascending infection w/ obstructed pyelo
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| ##Associated w/ [[DM]] and [[Renal Stones]]
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| ##Also occurs due to bacteremia w/ hematogenous seeding (Staph)
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| #Emphysematous pyelonephritis
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| ##Rare gas-forming infection nearly always occurring in pts w/ [[DM]] and obstruction
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| ###Pts appear toxic and [[septic]]; nephrectomy may be required
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| ==Special Populations==
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| ===[[AIDS]]===
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| *[[TMP-SMX]] resistance is increased due to its use in [[PCP PNA]] prophylaxis
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| **[[Fluoroquinolones]] should be initial antibiotic of choice
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| *Most UTIs are caused by typical pathogens or common STI organisms
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| ===Pregnant Women===
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| *Treat all cases of asymptomatic bacteriuria
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| ==See Also== | | ==See Also== |
| *[[UTI (Peds)]] | | *[[UTI (Peds)]] |
| *[[Dysuria]]
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| ==Source ==
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| Tintinalli
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| [[Category:Nephro]] | | [[Category:Nephro]] |
| [[Category:ID]] | | [[Category:ID]] |
| [[Category:GU]] | | [[Category:GU]] |
