Genitourinary infection: Difference between revisions
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==Differential Diagnosis== | ==Differential Diagnosis== | ||
===Major=== | ===Major=== | ||
*Pyelonephritis | *[[Pyelonephritis]] | ||
*Infected kidney stone | *Infected [[kidney stone]] | ||
===Pelvic Pain=== | ===Pelvic Pain=== |
Revision as of 07:44, 27 January 2015
Background
Definitions
- UTI = significant bacteriuria in presence of symptoms
- Described by location: urethritis, cystitis, or pyelonephritis
- Relapse
- Recurrence of symptoms w/in month despite tx
- Caused by same organism and represents treatment failure
- Recurrence of symptoms w/in month despite tx
- Reinfection
- Development of symptoms 1-6mo after tx
- Usually due to a different organism
- If pt has >3 recurrences in 1 yr consider tumor, calculi, diabetes
- Men <50 yr: symptoms of dysuria or urinary frequency usually due to STI
- Men >50 yr: incidence of UTI rises dramatically d/t prostatic obstruction
- Uncomplicated UTI:
- No structural or functional abnormalities w/in urinary tract or kidney
- No relevant comorbidities that place pt at risk for more serious adverse outcome
- Not associated with GU tract instrumentation
Risk factors for complicated UTI
- Male sex
- In young males dysuria is more commonly d/t STI
- Suspect underlying anatomic abnormality in men with culture-proven UTI
- Anatomic abnormality of urinary tract or external drainage system
- Indwelling urinary catheter, stent
- Nephrolithiasis, neurogenic bladder, polycystic renal disease, recent instrumentation
- Recurrent UTI (three or more per year)
- Advanced age in men (BPH, recent instrumentation, recent prostatic biopsy)
- Nursing home residency (w/ or w/o indwelling bladder catheter)
- Neonatal state
- Comorbidities (DM, sickle cell disease)
- Pregnancy
- Immunosuppression (AIDS, immunosuppressive drugs)
- Advanced neurologic disease (CVA w/ disability, Spinal Cord Injuries)
- Known or suspected atypical pathogens (Non–E. coli infection)
- Known or suspected abx resistance (resistance to Cipro predicts multidrug resistance)
Microbiology
- Most common pathogen is E. coli
- Anaerobic organisms are rarely pathogenic (do not grow well in urine)
- Complicated UTIs more likely to be caused by pseudomonas or enterococcus
Diagnosis
Clinical Features
- UTI dx requires both bacteriuria and clinical symptoms
- Cystitis = Dysuria, hematuria, frequency, urgency, suprapubic pain, CVAT
- Pyelo = Cystitis sx AND fever/chills/nausea/vomiting
- CVAT alone may be referred pain from cystitis
- CVAT is only physical examination finding that increases likelihood of a UTI
- Urethritis
- Complicated UTI
Labs
UA
WBC count
- WBC >5 in pt w/ appropriate symptoms is diagnostic
- Lower degrees of pyuria may still be clinically significant in presence of UTI sx
- False negative may be due to: dilute urine, systemic leukopenia, obstruction
- WBC 1-2 w/ bacteriuria can be significant in men
- More likely represents urethritis or prostatitis from STI
- Lower degrees of pyuria may still be clinically significant in presence of UTI sx
Nitrite
- Very high specificity (>90%) in confirming diagnosis of UTI
- Low sensitivity (enterococcus, pseudomonas, acinetobacter are not detected)
Urine Culture
- Indicated for:
- Complicated UTI
- Pyelonephritis
- Pregnant women
- Children
- Adult males
- Relapse/reinfection
Blood Culture
- Not indicated
- Organisms in blood cx matched those in urine cx 97% of time
Imaging
- Consider if pyelonephritis and any of the following:
- History of Renal Stone
- Poor response to antibiotics
- Male
- Elderly
- Diabetic
- Severely ill
Differential Diagnosis
Major
- Pyelonephritis
- Infected kidney stone
Pelvic Pain
Acute Pelvic Pain
Gynecologic/Obstetric
- Pregnancy-related
- Ectopic Pregnancy
- Spontaneous abortion, threatened or incomplete
- Septic abortion
- Acute Infections
- Vulvovaginitis
- Adnexal Disorders
- Hemorrhage/rupture of ovarian cyst
- Ovarian torsion
- Twisted paraovarian cyst
- Other
- Myoma (degenerating)
- Genitourinary trauma
- Ovarian hyperstimulation syndrome
- Sexual assault
- Recurrent
- Mittelschmerz
- Primary/Secondary Dysmenorrhea
- Pelvic Congestion Syndrome
- Endometriosis
Genitourinary
Gastrointestinal
- Gastroenteritis
- Appendicitis
- Bowel obstruction
- Perirectal abscess
- Diverticulitis
- Inflammatory bowel disease
- Irritable bowel syndrome
- Mesenteric adenitis
Musculoskeletal
- Abdominal wall hematoma
- Psoas hematoma, psoas abscess
- Hernia
Vascular
- Pelvic thrombophlebitis
- Abdominal aortic aneurysm
- Ischemic bowel (Mesenteric Ischemia)
Dysuria
Dysuria
- Genitourinary infection
- Acute cystitis ("UTI")
- Pyelonephritis
- Urethritis
- Chronic cystitis
- Infected nephrolithiasis
- Prostatitis
- Epididymitis
- Renal abscess/perinephric abscess
- Emphysematous pyelonephritis
- Nephrolithiasis
- Urethral issue
- Urethritis
- Urolithiasis
- Urethral foreign body
- Urethral diverticulum
- Allergic reaction (contact dermatitis)
- Chemical irritation
- Urethral stricture or obstruction
- Trauma to vagina, urethra, or bladder
- Gynecologic
- Vaginitis/cervicitis
- PID
- Genital herpes
- Pelvic organ prolapse
- Fistula
- Cystocele
- Other
- Diverticulitis
- Interstitial cystitis
- Behavioral symptom without detectable pathology
Management
- Consider local resistance patterns (if >10-20% use a different agent)
- Avoid use of fluoroquinolones for uncomplicated cystitis if possible
- Consider longer course of complicated cystitis if
- Symptoms >7d
- DM
- UTI in previous 4wk
- Men
- Age 65 yr
- Women who use spermicides or diaphragm
- Relapse
- Pregnancy
Outpatient
Women, Uncomplicated
- Nitrofurantoin ER 100mg BID x 5d, OR
- TMP/SMX DS (160/800mg) 1 tab BID x 3d, OR
- Cephalexin 250mg QID x 5d, OR
- Ciprofloxacin 250mg BID x3d
- Avoid using fluoroquinolone for the first-line treatment of uncomplicated urinary tract infections (UTIs) in women.[2]
- Fosfomycin 3 g PO once
- Lower clinical and microbiologic success compared to nitrofurantoin TID for 5 days [3]
Women, Complicated
- Ciprofloxacin 500mg BID x10-14d, OR
- Cefpodoxime 200 mg BID x10-14d
Women, Concern for Urethritis
- Ceftriaxone 250mg IM x1 AND azithromycin 1gm PO x1 AND nitrofurantoin ER 100mg BID x5d, OR
- Levofloxacin 500mg QD x 14d (covers urinary pathogens, GC, and chlamydia)
- GC resistance to fluoroquinolones is increasing
Men
- Ciprofloxacin 500mg BID x10-14d, OR
- Cefpodoxime 200 mg BID x10-14d
Inpatient Options
- Ciprofloxacin 400mg IV q12hr, OR
- Ceftriaxone 1gm IV QD, OR
- Cefotaxime 1-2gm IV q8hr, OR
- Gentamicin 3mg/kg/day divided q8hr +/- ampicillin 1–2 gm q4hr, OR
- Piperacillin/Tazobactam 3.375 gm IV q6hr, OR
- Cefepime 2gm IV q8hr, OR
- Imipenem 500mg IV q8hr
Disposition
Uncomplicated UTI
- Admit
- Unable to tolerate PO
- Discharge
- Consider phenazopyridine 100-200mg TID after meals x2d only (bladder analgesic)
Pyelonephritis
- Discharge
- Consider if young, otherwise healthy, tolerating PO
- Admission
- Consider if elderly, Renal Calculi, obstruction, recent hospitalization/instrumentation, DM
Complications
- Suspect in pts who have inadequate or atypical response to tx for presumed pyelonephritis
- Acute bacterial nephritis
- CT shows ill-defined focal areas of decreased density
- Renal/Perinephric Abscesses
- Sign/symptoms similar to pyelo (fever, CVAT, dysuria)
- Occurs in setting of ascending infection w/ obstructed pyelo
- Associated w/ DM and Renal Stones
- Also occurs due to bacteremia w/ hematogenous seeding (Staph)
- Emphysematous pyelonephritis
Special Populations
AIDS
- TMP-SMX resistance is increased due to its use in PCP PNA prophylaxis
- Fluoroquinolones should be initial antibiotic of choice
- Most UTIs are caused by typical pathogens or common STI organisms
Pregnant Women
- Treat all cases of asymptomatic bacteriuria
See Also
Source
Tintinalli
- ↑ Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.
- ↑ Choosing Wisely. American Urogynecologic Society. http://www.choosingwisely.org/societies/american-urogynecologic-society
- ↑ Huttner, A., Kowalczyk, A., Turjeman, A., Babich, T., Brossier, C., Eliakim-Raz, N., … Harbarth, S. (2018). Effect of 5-Day Nitrofurantoin vs Single-Dose Fosfomycin on Clinical Resolution of Uncomplicated Lower Urinary Tract Infection in Women: A Randomized Clinical Trial. JAMA: The Journal of the American Medical Association, 319(17), 1781–1789.