Urinary tract infection: Difference between revisions

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==Background==
* Bacterial infection of the urinary tract, either lower (cystitis) or upper (pyelonephritis)
* When UTI causes sepsis syndrome, often referred to as urosepsis


*Bacterial infection of the urinary tract, either lower (cystitis) or upper (pyelonephritis)
== Criteria ==
*When UTI causes sepsis syndrome, often referred to as urosepsis


===Microbiology===
* Diagnostic criteria include clinical and laboratory symptoms:
** Two or more clinical symptoms:
*** Fever > 38ºC
*** Urinary urgency or frequency
*** Acute dysuria
*** Hypogastric pain
*** Costovertebral angle tenderness
** One or more laboratory finding:
*** Bacteriuria (> 100,000 CFUs/mL)
*** Pyuria (>10 WBCs/HPF)


*Gram-negative bacteria
== Etiology ==
**[[Escherichia coli]], most common cause overall
**[[Proteus]], [[Klebsiella]], [[Enterobacter]]
**[[Pseudomonas]], [[Acinetobacter]]
* Gram-positive bacteria
**[[Staphylococcus saprophyticus]], more common in young women
**[[Enterococcus faecalis]]
**[[Staphylococcus aureus]], as a complication of [[Staphylococcus aureus bacteremia]]
**[[Corynebacterium urealyticum]]
*Viruses
**[[Adenovirus]], which can cause [[hemorrhagic cystitis]] in [[hematopoietic stem cell transplantation]] recipients
**[[BK virus]], in renal transplant recipients


=== Risk Factors ===
* Typical organisms include:
** ''[[E. coli]]''
** ''[[S. saprophicitus]]''


* '''Premenopausal women:''' sexual intercourse, new partner, no postcoital voiding, spermicide use, prior UTI, [[diabetes mellitus]]
== Investigations ==
* '''Postmenopausal women:''' genitourinary atrophy/estrogen deficiency, urethral diverticulum, vaginal prolapse beyond the hymen, incontinence, postvoid residual, catheterization
* '''Men:''' reduced prostatic secretions (older men), postvoid residual, incontinence, catheterization


==Clinical Manifestations==
* Labs

** Urinalysis has high NPV (~100%) if negative for leukocyst esterase and nitrites is negative
*Acute simple cystitis: acute UTI without signs of upper tract infection or systemic symptoms
*Acute complicate UTI: acute UTI with fever, chills, malaise, flank pain, CVA tenderness, or (in men) pelvic/perineal pain
*Diagnostic criteria include clinical and laboratory symptoms:
**Two or more clinical symptoms:
***Fever > 38ºC
***Urinary urgency or frequency
***Acute dysuria
***Hypogastric pain
***Costovertebral angle tenderness
**One or more laboratory finding:
***Bacteriuria (> 100,000 CFUs/mL)
***Pyuria (>10 WBCs/HPF)

==Investigations==

*Urinalysis
**Leukocyte esterase
**Nitrite, positive for organisms that convert nitrate to nitrite such as the Gram-negative bacteria
**High negative predictive value if both LE and nitrite are negative
*Urine microscopy
**Pyuria indicated by 5-10 cells per HPF

== Management ==

* Acute afebrile UTI in men: 7 days [[ciprofloxacin]] or [[cotrimoxazole]][[CiteRef::drekonja2021ef]]
* Acute afebrile UTI in women:
** First-line antibiotics
*** [[Nitrofurantoin]] monohydrate/macrocrystals (Macrobid) 100 mg p.o. twice daily for 5 days
*** [[Co-trimoxazole]] DS p.o. twice daily for 3 days
*** [[Fosfomycin]] 3 g p.o. once
*** [[Trimethoprim]] 100 mg p.o. twice daily for 3 days
*** [[Pivmecillinam]] 400 mg p.o. three times daily for 3 to 5 days
** Second-line is a β-lactam
*** [[Amoxicillin-clavulanic acid]] 500 mg/125 mg p.o. twice daily for 5 to 7 days
*** [[Cefadroxil]] 500 mg p.o. twice daily for 5 to 7 days
*** [[Cephalexin]] 250 to 500 mg p.o. every 6 hours for 5 to 7 days
** Last-line is a fluoroquinolone
*** [[Ciprofloxacin]] 250 mg p.o. twice daily for 3 days
*** [[Ciprofloxacin]] XR 500 mg p.o. daily for 3 days
*** [[Levofloxacin]] 250 mg p.o. daily for 3 days

=== ESBLs ===

* Uncomplicated UTIs:
** Preferred: [[nitrofurantoin]] or [[co-trimoxazole]]
** Alternatives: [[amoxicillin-clavulanate]] (if in vitro susceptibility), single-dose [[aminoglycosides]], and oral [[fosfomycin]] (for [[Escherichia coli|E. coli]])
* Complicated UTIs and pyelonephritis:
** Preferred: [[ertapenem]], [[meropenem]], [[imipenem-cilastatin]], [[ciprofloxacin]], [[levofloxacin]], or [[trimethoprim-sulfamethoxazole]]
** Alternatives: once-daily [[aminoglycosides]]

=== CREs ===

* Uncomplicated UTIs:
** Preferred: [[ciprofloxacin]], [[levofloxacin]], [[trimethoprim-sulfamethoxazole]], [[nitrofurantoin]], or a single-dose of an [[Aminoglycosides|aminoglycoside]]
** Alternative: [[meropenem]] (if susceptible), [[ceftazidime-avibactam]], [[meropenem-vaborbactam]], [[imipenem-cilastatin-relebactam]], [[cefiderocol]]
** Also: single-dose [[aminoglycosides]]
** For CRE [[Escherichia coli|E. coli]]: [[fosfomycin]]
** If necessary: [[colistin]]
* Complicated UTIs and pyelonephritis:
** Preferred: [[ciprofloxacin]], [[levofloxacin]], and [[trimethoprim-sulfamethoxazole]]
** Alternative: extended-infusion [[meropenem]] (if susceptible), [[ceftazidime-avibactam]], [[meropenem-vaborbactam]], [[imipenem-cilastatin-relebactam]], [[cefiderocol]]
** Also: once-daily [[aminoglycosides]]


[[Category:Genitourinary infections]]
[[Category:Genitourinary infections]]

Latest revision as of 12:55, 30 August 2022

Background

  • Bacterial infection of the urinary tract, either lower (cystitis) or upper (pyelonephritis)
  • When UTI causes sepsis syndrome, often referred to as urosepsis

Microbiology

Risk Factors

  • Premenopausal women: sexual intercourse, new partner, no postcoital voiding, spermicide use, prior UTI, diabetes mellitus
  • Postmenopausal women: genitourinary atrophy/estrogen deficiency, urethral diverticulum, vaginal prolapse beyond the hymen, incontinence, postvoid residual, catheterization
  • Men: reduced prostatic secretions (older men), postvoid residual, incontinence, catheterization

Clinical Manifestations

  • Acute simple cystitis: acute UTI without signs of upper tract infection or systemic symptoms
  • Acute complicate UTI: acute UTI with fever, chills, malaise, flank pain, CVA tenderness, or (in men) pelvic/perineal pain
  • Diagnostic criteria include clinical and laboratory symptoms:
    • Two or more clinical symptoms:
      • Fever > 38ºC
      • Urinary urgency or frequency
      • Acute dysuria
      • Hypogastric pain
      • Costovertebral angle tenderness
    • One or more laboratory finding:
      • Bacteriuria (> 100,000 CFUs/mL)
      • Pyuria (>10 WBCs/HPF)

Investigations

  • Urinalysis
    • Leukocyte esterase
    • Nitrite, positive for organisms that convert nitrate to nitrite such as the Gram-negative bacteria
    • High negative predictive value if both LE and nitrite are negative
  • Urine microscopy
    • Pyuria indicated by 5-10 cells per HPF

Management

ESBLs

CREs

References

  1. ^  Dimitri M. Drekonja, Barbara Trautner, Carla Amundson, Michael Kuskowski, James R. Johnson. Effect of 7 vs 14 Days of Antibiotic Therapy on Resolution of Symptoms Among Afebrile Men With Urinary Tract Infection. JAMA. 2021;326(4):324. doi:10.1001/jama.2021.9899.