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Urinary Tract Infections

Definition of UTI

  • Pathologic bacteria in urine
    • Asymptomatic patients: growth of > 10^5 (100,000) CFU/mL
    • Symptomatic patients: 10^2 (100) CFU/mL

Classification of UTI

  • Lower tract infections: urethritis, cystitis
  • Upper tract infections: pyelonephritis, prostatitis
  • Community-acquired
  • Nosocomial: catheter-related

Etiology

  • E. coli - most common
  • Gram negative rods
  • Adenovirus - children

Pathophysiology

  • Colonization of external genetalia
  • Bacteria can ascend into the urinary tract 
  • Upper tract infection most common complication of lower tract infection
  • Hematogenous spread - S. aureus

Who gets UTIs?

  • Females > males
  • Increased incidence with sexual activity
  • Childhood: M > F

Female Patients

  • Vaginal introitus and distal urethra normally colonized by gram positive organisms
  • Female urethra more prone to gram negative infection 
    • Close to anus
    • Short length 
  • Risk factors
    • Hygiene issues
    • Sexual activity
      • Void after intercourse decreases this risk

Male Patients

  • Rare
  • > 50 years of age, BPH is main cause

Other Risk Factors

  • Pregnancy
  • Unsterile or prolonged catheterization
  • Obstruction
  • Vesicourethral reflux

Cystitis

  • Most common manifestation of UTI
  • Infection/inflammation of bladder
  • Most commonly E. coli, can be adenovirus
  • Clinical presentation
    • Irritative voiding 
    • Supraspubic discomfort
    • Other urinary complaints?
  • PE
    • Unremarkable
    • No CVA tenderness
  • Lab
    • Urinalysis
      • (+) LES
      • (+) Nitrites
    • Urine gram-staining
      • E. coli
      • Contamination possible
  • Acute urethral syndrome
    • “Painful voiding syndrome”
    • Dysuria with sterile culture
    • Irritants, trauma, etc.
  • Management
    • Antimicrobials
      • Short-term (< 7 days) for uncomplicated cases
      • Longer therapy (7-10 days) for DM, recurrent UTI, over 65, Men
    • Symptomatic treatment
  • Follow-up
    • Repeat urine C&S 3-5 days after antibiotics finished

Pyelonephritis

  • Infection/inflammation of renal parenchyma and pelvis
  • Most commonly E. coli or Proteus sp. 
  • Presentation
    • Flank pain
    • Fever
    • Chills
    • Toxic appearance
    • CVA tenderness
  • Lab
    • Urinalysis
      • (+) LES
      • (+) Nitrites
      • WBC casts
    • Urine gram stain
      • E. coli
      • Contamination possible
    • CBC
      • Leukocytosis with left shift
  • Imaging
    • Only done in complicated cases
  • Complications
    • Sepsis/shock
    • Scarring/fibrosis
      • Chronic pyelonephritis
  • Management
    • Usually treated as outpatient
    • Empiric therapy
      • Broad-spectrum antibiotics
        • IV 
        • PO quinolone
        • No nitrofurantoin
        • Watch resistance for Augmentin and Bactrim 
      • 14+ days
        • Inpatient: 24 hours after fever resolves
        • Outpatient: 14 days
  • Follow-up
    • Repeat urine C&S 1-2 weeks after treatment completed
    • Treatment failure
      • Imaging or referral

UTIs in Pregnancy

  • Asymptomatic bacteriuria very common - treat due to risk of complications to fetus
  • Cystitis
    • No fluoroquinolones
    • Recheck urine C&S
  • Pyelonephritis
    • Hospitalization
    • Empiric IV therapy, then PO
    • No fluoroquinolones
    • Recheck urine C&S

Nosocomial UTIs

  • Foley catheters 
  • Care for UTIs not reimbursed by Medicare/Medicaid 

Recurrent Infections: more than 2-3 per year

Vesicoureteral reflux (VUR)

  • Reflux of urine from bladder into ureters/renal pelvis
  • Common cause of UTI in children
  • Renal scarring due to volume and duration of reflux
  • Presentation
    • Weight loss
    • Nocturnal enuresis
    • Failure to thrive
  • Labs
    • Urinalysis
      • (+) LES
      • (+) Nitrites
    • Urine gram stain
      • E. coli
    • Cast formation
  • Imaging
    • Voiding cystourethrogram (VCUG)
    • Management of VUR
      • Mild
        • Spontaneous resolution usually
        • Antibiotics until puberty
      • Severe
        • Surgical intervention
        • Antibiotics into condition corrected