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Urinary Tract Infection . Michele Ritter, M.D. Argy Resident – Feb. 2007. Urinary Tract Infection. Upper urinary tract Infections: Pyelonephritis Lower urinary tract infections Cystitis (“traditional” UTI) Urethritis (often sexually-transmitted) Prostatitis.

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urinary tract infection

Urinary Tract Infection

Michele Ritter, M.D.

Argy Resident – Feb. 2007

urinary tract infection2
Urinary Tract Infection
  • Upper urinary tract Infections:
    • Pyelonephritis
  • Lower urinary tract infections
    • Cystitis(“traditional” UTI)
    • Urethritis (often sexually-transmitted)
    • Prostatitis
symptoms of urinary tract infection
Symptoms of Urinary Tract Infection
  • Dysuria
  • Increased frequency
  • Hematuria
  • Fever
  • Nausea/Vomiting (pyelonephritis)
  • Flank pain (pyelonephritis)
findings on exam in uti
Findings on Exam in UTI
  • Physical Exam:
    • CVA tenderness (pyelonephritis)
    • Urethral discharge (urethritis)
    • Tender prostate on DRE (prostatitis)
  • Labs: Urinalysis
    • + leukocyte esterase
    • + nitrites
      • More likely gram-negative rods
    • + WBCs
    • + RBCs
culture in uti
Culture in UTI
  • Positive Urine Culture = >105 CFU/mL
  • Most common pathogen for cystitis, prostatitis, pyelonephritis:
    • Escherichia coli
    • Staphylococcus saprophyticus
    • Proteus mirabilis
    • Klebsiella
    • Enterococcus
  • Most common pathogen for urethritis
      • Chlamydia trachomatis
      • Neisseria Gonorrhea
lower urinary tract infection cystitis
Lower Urinary Tract Infection - Cystitis
  • Uncomplicated (Simple) cystitis
    • In healthy woman, with no signs of systemic disease
  • Complicated cystitis
    • In men, or woman with comorbid medical problems.
  • Recurrent cystitis
uncomplicated simple cystitis
Uncomplicated (simple) Cystitis
  • Definition
    • Healthy adult woman (over age 12)
    • Non-pregnant
    • No fever, nausea, vomiting, flank pain
  • Diagnosis
    • Dipstick urinalysis (no culture or lab tests needed)
  • Treatment
    • Trimethroprim/Sulfamethoxazole for 3 days
    • May use fluoroquinolone (ciprofoxacin or levofloxacin) in patient with sulfa allergy, areas with high rates of bactrim-resistance
  • Risk factors:
    • Sexual intercourse
      • May recommend post-coital voiding or prophylactic antibiotic use.
complicated cystitis
Complicated Cystitis
  • Definition
    • Females with comorbid medical conditions
    • All male patients
    • Indwelling foley catheters
    • Urosepsis/hospitalization
  • Diagnosis
    • Urinalysis, Urine culture
    • Further labs, if appropriate.
  • Treatment
    • Fluoroquinolone (or other broad spectrum antibiotic)
    • 7-14 days of treatment (depending on severity)
    • May treat even longer (2-4 weeks) in males with UTI
special cases of complicated cystitis
Special cases of Complicated cystitis
  • Indwelling foley catheter
    • Try to get rid of foley if possible!
    • Only treat patient when symptomatic (fever, dysuria)
      • Leukocytes on urinalysis
      • Patient’s with indwelling catheters are frequently colonized with great deal of bacteria.
    • Should change foley before obtaining culture, if possible
  • Candiduria
    • Frequently occurs in patients with indwelling foley.
    • If grows in urine, try to get rid of foley!
    • Treat only if symptomatic.
    • If need to treat, give fluconazole (amphotericin if resistance)
recurrent cystitis
Recurrent Cystitis
  • Want to make sure urine culture and sensitivity obtained.
  • May consider urologic work-up to evaluate for anatomical abnormality.
  • Treat for 7-14 days.
pyelonephritis
Pyelonephritis
  • Infection of the kidney
  • Associated with constitutional symptoms – fever, nausea, vomiting, headache
  • Diagnosis:
      • Urinalysis, urine culture, CBC, Chemistry
  • Treatment:
      • 2-weeks of Trimethroprim/sulfamethoxazole or fluoroquinolone
      • Hospitalization and IV antibiotics if patient unable to take po.
  • Complications:
    • Perinephric/Renal abscess:
      • Suspect in patient who is not improving on antibiotic therapy.
      • Diagnosis: CT with contrast, renal ultrasound
      • May need surgical drainage.
    • Nephrolithiasis with UTI
      • Suspect in patient with severe flank pain
      • Need urology consult for treatment of kidney stone
prostatitis
Prostatitis
  • Symptoms:
    • Pain in the perineum, lower abdomen, testicles, penis, and with ejaculation, bladder irritation, bladder outlet obstruction, and sometimes blood in the semen
  • Diagnosis:
    • Typical clinical history (fevers, chills, dysuria, malaise, myalgias, pelvic/perineal pain, cloudy urine)
    • The finding of an edematous and tender prostate on physical examination
    • Will have an increased PSA
    • Urinalysis, urine culture
  • Treatment:
    • Trimethoprim/sulfamethoxazole, fluroquinolone or other broad spectrum antibiotic
    • 4-6 weeks of treatment
  • Risk Factors:
    • Trauma
    • Sexual abstinence
    • Dehydration
urethritis
Urethritis
  • Chlamydia trachomatis
    • Frequently asymptomatic in females, but can present with dysuria, discharge or pelvic inflammatory disease.
    • Send UA, Urine culture (if pyuria seen, but no bacteria, suspect Chlamydia)
    • Pelvic exam – send discharge from cervical or urethral os for chlamydia PCR
    • Chlamydia screening is now recommended for all females ≤ 25 years
    • Treatment:
      • Azithromycin – 1 g po x 1
      • Doxycycline – 100 mg po BID x 7 days
  • Neisseria gonorrhoeae
    • May present with dysuria, discharge, PID
    • Send UA, urine culture
    • Pelvic exam – send discharge samples for gram stain, culture, PCR
    • Treatment:
      • Ceftriaxone – 125 mg IM x 1
      • Cipro – 500 mg po x 1
      • Levofloxacin – 250 mg po x 1
      • Ofloxacin – 400 mg po x 1
      • Spectinomycin – 2 g IM x 1
    • You should always also treat for chlamydia when treating for gonnorhea!
question 1
Question #1
  • An 18-year old woman presents with urinary frequency, dysuria, and low-grade fever. Urinalysis shows pyuria and bacilli. She has never had similar symptoms or treatment for urinary tract infection.
question 115
Question # 1
  • What category of UTI does this patient have?
  • Does this patient require further testing?
  • Would you treat this patient, and if so, with what and how long?
question 2
Question # 2
  • An 18-year old woman present with her third episode of urinary frequency, dysuria, and pyuria in the past 4 months.
question 217
Question # 2
  • What further questions do you have for this patient?
  • What type of UTI does this patient have?
  • What testing might you perform in this patient?
  • How would you treat her, and for how long?
question 3
Question #3
  • A 24-year old woman presents with fever, chills, nausea, vomiting, flank pain and tenderness. Her temperature is 40°C, pulse rate is 120/min., and blood pressure is 100/60 mm Hg.
question 319
Question # 3
  • What further studies do you want in this patient?
  • How would you treat this patient?
  • What might you do if she does not improve after 3-4 days?
question 4
Question # 4
  • A 78-year old female presents with an indwelling foley catheter and pyuria.
question 421
Question # 4
  • What would you do for this patient at this time?
  • How might your work-up/management change if she was having fevers and confusion?
question 5
Question # 5
  • 58-year old man presents with his first episode of urinary frequency and dysuria. Urinalysis shows pyuria and bacilli.
question 523
Question # 5
  • What type of UTI does this patient likely have?
  • How would you treat this man, and for how long?
  • What activities would put this patient at risk for UTI?
question 6
Question # 6
  • A 28-year old male had a sexual encounter with a prostitute while on a business trip in Seattle 1 week ago. After returning home, he noted a burning sensation on urination and a yellow discharge in his underwear. Microscopic examination of the discharge reveals 4+ leukocyte esterase, and the following gram stain.
question 626
Question # 6
  • Which of the following is the best course of action for this patient?
  • Give the patient a prescription for doxycycline, 100 mg po BID for 7 days
  • Give the patient two prescriptions for ofloxacin 300 mg po QDay for 7 days, one for him, and one for his wife.
  • Administer ceftriaxone – 125 mg IV x 1 and Azithromycin – 1 g po x 1, draw blood for a VDRL and HIV – antibody arrange for his wife to be examined and treated.
  • Administer a single dose of Ceftriaxone – 125 mg IV x 1, and ciprofloxacin – 500 mg po x 1 draw blood for a VDRL and HIV-antibody, and arrange for his wife to be examined and treated.
  • Administer a single dose of cefixime – 400 mg, draw blood for a VDRL and arrange for his wife to be examined and treated.
final thoughts
Final thoughts!
  • Antibiotic choice and duration are determined by classification of UTI.
  • Biggest bugs for UTI are E. Coli, Staph. Saprophyticus, Proteus mirabilis, Enterococci and gram-negatives
  • Don’t use moxifloxacin for UTI!
  • Chlamydia screening is now recommended for all women 25 years and under since infection is frequently asymptomatic, and risk for PID/infertility is high!