Definition
A.Infection of the urinary tract in the absence of comorbidities such as diabetes, pregnancy, or physiologic and structural anomalies.
Incidence
A.Urinary tract infections (UTIs) account for about 7 million office visits annually, affecting men and women.
B.These infections are more common in young, sexually active women than men.
C.30% to 40% of women will experience one episode/year.
Pathogenesis
A.UTIs are more common in women because the female urethra:
1.Is shorter and in closer proximity to the rectum.
2.Allows bacteria to colonize more easily.
B.UTIs peak in two different age groups in women.
1.20 to 40 age group: Predisposed by intercourse.
2.55 to 60 age group: Related to declining estrogen levels.
Predisposing Factors
A.Conditions that reduce urine flow.
1.Outflow obstruction: Prostatic hyperplasia, prostatic carcinoma, urethral stricture, or foreign body (calculus).
2.Neurogenic bladder.
3.Inadequate fluid uptake.
B.Conditions that promote colonization.
1.Sexual activity: Increased inoculation.
2.Spermicide: Increased binding.
3.Estrogen depletion: Increased binding.
4.Antimicrobial agents: Decreased indigenous flora.
C.Conditions that facilitate ascent.
1.Catheterization.
2.Urinary incontinence.
3.Fecal incontinence.
D.Conditions in older women, who may be at higher risk for UTIs due to a combination of factors.
1.Atrophic changes.
2.Impaired urethral function.
3.Insufficient fluid intake.
4.Constipation.
5.Increased residual urine volume.
Subjective Data
A.Common complaints/symptoms.
1.Foul-smelling urine.
2.Dysuria, increased frequency, or urgency.
3.Suprapubic pain and discomfort.
4.Occasional hematuria.
B.Atypical symptoms in older patients.
1.Confusion.
2.Delirium.
3.Falls or adverse behaviors.
Physical Examination
A.Possible suprapubic tenderness on palpation.
B.Increasing discharge from vagina.
C.Urinary meatus that may be erythematous or edematous.
D.Negative costovertebral angle (CVA) tenderness.
E.Negative pelvic or prostate examination.
F.Urological evaluation is required for men with UTI.
Diagnostic Tests
A.Urinalysis.
1.Urine dipstick with clean catch urine necessary.
2.Positive for blood, leukocyte esterase, or nitrate.
3.Sensitivity of 75% to 96% and a specificity of 94% to 98%.
B.Urine gram stain.
1.10 white blood cells (WBC)/high power field (HPF; may not be present).
2.Bacteria greater than 15 bacteria/HPF.
C.Urine culture.
1.More than 10,000 bacteria/mL in fresh, midstream specimen.
Differential Diagnosis
A.Genital herpes (herpes simplex virus [HSV]).
B.Urethritis.
C.Chlamydia.
D.Trichomonas.
E.Vaginitis.
F.Prostatitis.
G.Nephrolithiasis.
H.Trauma.
I.Urinary tract tuberculosis.
J.Urinary tract neoplasm.
K.Intra-abdominal abscess.
Evaluation and Management Plan
A.General plan.
1.See Figure 5.3.
2.Advise patients on condition, timeline of treatment, and expected course of disease process.
3.Collect urine culture before starting antibiotics.
4.Complete all antibiotic regimens.
FIGURE 5.3 Urinary tract infection flipped in chronic kidney disease.
ESRD, end-stage renal disease; IV, intravenous; LE, leukocyte esterase; UTI, urinary tract infection.
B.Patient/family teaching points.
1.Counsel patients about appropriate use of medications (dose, frequency, side effects, need to complete entire course of medications).
2.Recommend increasing fluid intake to 8 to 10 glasses per day.
3.Suggest that sitting in a warm tub may relieve symptoms of dysuria.
4.For women, advise that they wipe front to back after a bowel movement.
5.For women, advise against using douches.
6.Tell patients to avoid bubble baths.
7.Advise that voiding after intercourse may be beneficial.
8.Use appropriate cleaning for sex toys and advise against sharing sex toys.
C.Pharmacotherapy.
1.First-line antibiotics.
a.Bactrim, double strength orally twice a day for 3 days.
b.Nitrofurantoin, 100 mg twice a day for 5 days.
c.Fosfomycin 3 g single dose.
2.Second-line antibiotics.
a.Ciprofloxacin 250 mg orally twice a day for 3 days.
b.Amoxicillin/clavulanate 500/125 mg orally twice a day for 5 days.
3.Treatment during pregnancy.
a.Ampicillin 500 mg orally every 8 hours for 3 to 7 days.
b.Amoxicillin/clavulanate 500 mg every 8 hours for 3 to 7 days.
c.Cephalexin 500 mg every 6 hours for 3 to 7 days.
d.Nitrofurantoin 100 mg twice a day for 5 to 7 days (avoid during first trimester and at term).
e.Bactrim DS twice a day for 5 days (avoid during first trimester and at term).
f.Fosfomycin 3 g orally as single dose.
D.Discharge instructions.
1.Return to clinic for fever or if symptoms do not improve/progress in 48 to 72 hours.
Follow-Up
A.Follow-up with primary care provider.
Consultation/Referral
A.Consult or refer to urology only if complications occur.
Special/Geriatric Considerations
A.Geriatric patients may present with atypical symptoms and require close monitoring of intake versus output during UTI.
B.Patients with chronic kidney disease or end-stage renal disease (ESRD) may require antibiotic dose adjustments.
Bibliography
Lane, D. R., & Takhar, S. S. (2011, August). Diagnosis and management of urinary tract infection and pyelonephritis. Emergency Medicine Clinics of North America, 29(3), 539–552. doi:10.1016/j.emc.2011.04.001
Wagenlehner, F. M., Schmiemann, G., Hoyme, U., Fünfstück, R., Hummers-Pradier, E., Kaase, M., & Naber, K. G. (2011, February). National S3 guideline on uncomplicated urinary tract infection: Recommendations for treatment and management of uncomplicated community-acquired bacterial urinary tract infections in adult patients. Urologe A, 50(2), 153–169. doi:10.1007/s00120-011-2512-z
Workowski, K. A., & Bolan, G. A. (2015, June 5). Sexually transmitted diseases treatment guidelines,