Urinary Tract Infection

1. Urinary Tract Infection
Michele Ritter, M.D.
Argy Resident – Feb. 2007

2. Urinary Tract Infection
Upper urinary tract Infections:
Pyelonephritis
Lower urinary tract infections
Cystitis (“traditional” UTI)
Urethritis (often sexually-transmitted)
Prostatitis

3. Symptoms of Urinary Tract Infection
Dysuria
Increased frequency
Hematuria
Fever
Nausea/Vomiting (pyelonephritis)
Flank pain (pyelonephritis)

4. 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

5. 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

6. 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

7. 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.

8. 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

9. 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)

10. 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.

11. 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

12. 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

13. 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!

14. 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.

15. 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?

16. Question # 2
An 18-year old woman present with her
third episode of urinary frequency,
dysuria, and pyuria in the past 4 months.

17. 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?

18. 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.

19. 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?

20. Question # 4
A 78-year old female presents with an
indwelling foley catheter and pyuria.

21. 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?

22. Question # 5
58-year old man presents with his first
episode of urinary frequency and
dysuria. Urinalysis shows pyuria and
bacilli.

23. 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?

24. 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.

25. Question # 6

26. Question # 6
 Which of the following is the best course of action for
this patient?
a) Give the patient a prescription for doxycycline, 100 mg po BID
for 7 days
b) Give the patient two prescriptions for ofloxacin 300 mg po
QDay for 7 days, one for him, and one for his wife.
c) 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.
d) 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.
e) Administer a single dose of cefixime – 400 mg, draw blood for
a VDRL and arrange for his wife to be examined and treated.

27. 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!