Urinary tract infection: Difference between revisions

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== Definition ==
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==Background==
   
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* Bacterial infection of the urinary tract, either lower (cystitis) or upper (pyelonephritis)
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*Bacterial infection of the urinary tract, either lower (cystitis) or upper (pyelonephritis)
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* When UTI causes sepsis syndrome, often referred to as urosepsis
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*When UTI causes sepsis syndrome, often referred to as urosepsis
⚫
* Diagnostic criteria include clinical and laboratory symptoms:
  
⚫
** Two or more clinical symptoms:
  
⚫
*** Fever > 38ºC
  
⚫
*** Urinary urgency or frequency
  
⚫
*** Acute dysuria
  
⚫
*** Hypogastric pain
  
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*** Costovertebral angle tenderness
  
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** One or more laboratory finding:
  
⚫
*** Bacteriuria (> 100,000 CFUs/mL)
  
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*** Pyuria (>10 WBCs/HPF)
  
   
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== Etiology ==
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===Microbiology===
   
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*Gram-negative bacteria
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* Typical organisms include:
  
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** ''[[E. coli]]''
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**[[Escherichia coli]], most common cause overall
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**[[Proteus]], [[Klebsiella]], [[Enterobacter]]
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** ''[[S. saprophicitus]]''
  
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**[[Pseudomonas]], [[Acinetobacter]]
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* Gram-positive bacteria
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**[[Staphylococcus saprophyticus]], more common in young women
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**[[Enterococcus faecalis]]
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**[[Staphylococcus aureus]], as a complication of [[Staphylococcus aureus bacteremia]]
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**[[Corynebacterium urealyticum]]
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*Viruses
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**[[Adenovirus]], which can cause [[hemorrhagic cystitis]] in [[hematopoietic stem cell transplantation]] recipients
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**[[BK virus]], in renal transplant recipients
   
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=== Risk Factors ===
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== Investigations ==
  
   
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* '''Premenopausal women:''' sexual intercourse, new partner, no postcoital voiding, spermicide use, prior UTI, [[diabetes mellitus]]
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* Labs
  
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* '''Postmenopausal women:''' genitourinary atrophy/estrogen deficiency, urethral diverticulum, vaginal prolapse beyond the hymen, incontinence, postvoid residual, catheterization
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** Urinalysis has high NPV (~100%) if negative for leukocyst esterase and nitrites is negative
  
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* '''Men:''' reduced prostatic secretions (older men), postvoid residual, incontinence, catheterization
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  +
==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
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*Urine microscopy
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**Pyuria indicated by 5-10 cells per HPF
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  +
== Management ==
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  +
* Acute afebrile UTI in men: 7 days [[ciprofloxacin]] or [[cotrimoxazole]][[CiteRef::drekonja2021ef]]
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* Acute afebrile UTI in women:
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** First-line antibiotics
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*** [[Nitrofurantoin]] monohydrate/macrocrystals (Macrobid) 100 mg p.o. twice daily for 5 days
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*** [[Co-trimoxazole]] DS p.o. twice daily for 3 days
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*** [[Fosfomycin]] 3 g p.o. once
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*** [[Trimethoprim]] 100 mg p.o. twice daily for 3 days
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*** [[Pivmecillinam]] 400 mg p.o. three times daily for 3 to 5 days
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** Second-line is a β-lactam
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*** [[Amoxicillin-clavulanic acid]] 500 mg/125 mg p.o. twice daily for 5 to 7 days
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*** [[Cefadroxil]] 500 mg p.o. twice daily for 5 to 7 days
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*** [[Cephalexin]] 250 to 500 mg p.o. every 6 hours for 5 to 7 days
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** Last-line is a fluoroquinolone
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*** [[Ciprofloxacin]] 250 mg p.o. twice daily for 3 days
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*** [[Ciprofloxacin]] XR 500 mg p.o. daily for 3 days
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*** [[Levofloxacin]] 250 mg p.o. daily for 3 days
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=== ESBLs ===
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* Uncomplicated UTIs:
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** Preferred: [[nitrofurantoin]] or [[co-trimoxazole]]
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** Alternatives: [[amoxicillin-clavulanate]] (if in vitro susceptibility), single-dose [[aminoglycosides]], and oral [[fosfomycin]] (for [[Escherichia coli|E. coli]])
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* Complicated UTIs and pyelonephritis:
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** Preferred: [[ertapenem]], [[meropenem]], [[imipenem-cilastatin]], [[ciprofloxacin]], [[levofloxacin]], or [[trimethoprim-sulfamethoxazole]]
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** Alternatives: once-daily [[aminoglycosides]]
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  +
=== CREs ===
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* Uncomplicated UTIs:
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** Preferred: [[ciprofloxacin]], [[levofloxacin]], [[trimethoprim-sulfamethoxazole]], [[nitrofurantoin]], or a single-dose of an [[Aminoglycosides|aminoglycoside]]
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** Alternative: [[meropenem]] (if susceptible), [[ceftazidime-avibactam]], [[meropenem-vaborbactam]], [[imipenem-cilastatin-relebactam]], [[cefiderocol]]
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** Also: single-dose [[aminoglycosides]]
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** For CRE [[Escherichia coli|E. coli]]: [[fosfomycin]]
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** If necessary: [[colistin]]
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* Complicated UTIs and pyelonephritis:
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** 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 08:55, 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.

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