Urology: Urinary Tract Infection (UTI)

Urinary Tract Infection (UTI)

Definitions

  • Urinary Tract Infection: Infection of the Urinary Tract, Includes Cystitis & Pyelonephritis
    • Most Common Infection in Surgery Patients
  • Cystitis: Infection of the Bladder & Lower Urinary Tract
  • Pyelonephritis: Infection of the Kidney & Upper Urinary Tract

Complexity

  • Definitions:
    • Simple UTI: Infection Confined to Bladder
    • Complicated UTI: Infection Spread Beyond the Bladder
  • Signs Suggesting Complex Infection:
    • Fever
    • Flank Pain
    • Costovertebral Angle (CVA) Tenderness
    • Significant Fatigue
  • Risk Factors for Complicated UTI:
    • Poorly Controlled Diabetes
    • Immunocompromised
    • Nephrolithiasis
    • Strictures
    • Stents

Symptoms

  • Dysuria (Pain with Urination)
  • Pyuria (Burning with Urination)
  • Urinary Frequency
  • Urinary Urgency
  • Urinary Incontinence
  • Suprapubic Pain
  • Hematuria

Risk Factors

  • Urinary Catheters (Catheter-Associated UTI/CAUTI) – Largest Risk Factor
  • Female Sex
  • Previous UTI
  • Sexual Activity
  • Pregnancy
  • Elderly & Young Children
  • Structural Abnormality
  • Poor Hygiene (Potty-Training)

Organisms

  • Most Common Organism: Escherichia coli
  • Second Most Common:
    • Overall: Klebsiella
    • Young Adult Females: S saprophyticus
    • CAUTI (Catheter Associated): Enterococcus

Diagnosis

  • No Further Testing Required for Most Females with Suspected Simple UTI & Classic Symptoms
  • If Unsure of Diagnosis: Urinalysis (UA)
    • Indicators of UTI: Presence of Bacteria or Elevated WBC, Nitrites or Leukocyte Esterase
    • Presence of Squamous Epithelial Cells Indicates Contamination with Skin Flora, Making UA Unreliable
  • Urine Culture Should Also Be Obtained for All Patients at Risk for a Multi-Drug Resistant Organism, Including Patients with a Recent Inpatient Stay at a Health Care Facility
  • Consider Imaging (CT or US) for Complicated UTI if Severely Ill, Suspected Obstruction or Fails to Improve After 48-72 Hours

Indications for Treatment

  • Asymptomatic Bacteriuria: Nothing
  • Symptomatic or Complicated: Antibiotics

Antibiotic Selection

  • Uncomplicated: Oral Antibiotic Regimen
    • Nitrofurantoin (Macrobid) 100 mg BID x 5 Days – Most Common
    • Fosfomycin 3 g Single Dose
    • TMP-SMX Double Strength (DS) 160/800 mg BID x 3 Days
  • Complicated: IV Antibiotic Regimen for 5-10 Days
    • If Critically Ill or Suspected Obstruction: Meropenem or Imipenem & Vancomycin
    • If Concerned for a Multi-Drug Resistant Organism: Cefepime, Piperacillin-Tazobactam (Zosyn), Meropenem or Imipenem
    • If Not Concerned for a Multi-Drug Resistant Organism: Ceftriaxone, Piperacillin-Tazobactam (Zosyn), Ciprofloxacin or Levofloxacin
  • CAUTI Catheter Management:
    • Removal of Catheter is Preferred is Feasible
    • Intermittent Catheterization has Lower Risk of UTI
    • If Catheter is Required: Replace Catheter Upon Initiation of Antibiotics