Definitions
Anatomic
- Lower: urethritis, cystitis
- Upper: pyelonephritis, renal or perinephric abscess, prostatitis
Clinical
- Complicated UTI – Functional or anatomic abnormality of the urinary tract
- polycystic kidney disease
- nephrolithiasis
- Neurogenic bladder
- DM, immunosuppression
- Pregnancy
- Indwelling urinary catheter
- Bacteria establish biofilm in/on catheter & enter bladder retrograde
- Risk factors: duration of catheterization, errors in catheter care, DM, female sex
- Recent urinary tract instrumentation
- Uncomplicated UTI – cystitis in immunocompetent nonpregnant women w/o underlying structural or neurologic dz
- Pyelonephritis – inflammatory process of the renal parenchyma
- Fever
- CVA tenderness
- Blood & Urinary Cx indicated
Microbioogy – KEEPS
- Klebsiella pneumonia
- E Coli – most common in women
- Enterococci – most common in LTC facilities
- Proteus mirabilis – most common in men
- Staph. saprophyticus
- Yeast – most common in catheter associated UTI
- Chlamydia, Gonorrhoease, trichomonas vaginalis, HSV, ureaplasma, mycoplasma genitalium – Urethritis
- Staph Aureus – uncommon 1o in absence of catheter / instrumentation –> consider hematogenous seeding
Risk Factors for UTI
- Young women – frequent or recent sexual activity
- Elderly women – age, estrogen deficiency, incontinence, DM, cystoceles, previous GU surgery
Risk Factors for UTI in LTC facilities
- Age, female
- Indwelling catheter
- urinary incontinence, neurogenic bladder (due to stroke, Alzheimer’s, Parkinsons’s)
- DM, chronic comorbidities, gyne disorders (prolapse), BPH
Risk Factors for antimicrobial resistance
- Repeated exposure to antibiotics for recurrent UTI
- Increased use of antibiotics & transmission opportunities in LTC facilities
Dx (4 symptoms and 1 sign)
- Cystitis: Dysuria, frequency, urgency, hematuria, back pain, suprapubic pain, usually no fever
- Pyelonephritis: fever, chills, flank/back pain, n/v/d, CVA tenderness
- Urethritis: may be identical to cystitis except urethral discharge may be present
- Prostatitis
- Chronic: Similar to cystitis except obstruction symptoms – hesitancy, weak stream
- Acute: perineal pain, fever, tenderness on prostate exam
- Renal Abscess (intrarenal/perinephric) – identical to pyelonephritis except persistent fever despite appropriate Abx
No combination reliably r/o UTI
- U/A powerful – if the dipstick leuk or nitrite positive, UTI % is high, when combined with other Hx + O/E findings
- If dipstick is negative, but % is still high, a urine Cx should be considered to r/o infection
Dx UTI in LTC setting – Both 1 & 2 must be present
No Indwelling catheter
- ≥ 1 of the following:
- Acute dysuria OR acute pain, swelling or tenderness of the testes, epididymis or prostate
- Fever OR leukocytosis and at least 1 localized urinary tract symptom
- Two or more localized urinary tract symptoms
- Acute costovertebral angle pain or tenderness
- Suprapubic pain
- Gross hematuria
- New or marked increase in incontinence
- New or marked increase in urgency
- New or marked increase in frequency
- One of the following microb criteria:
- ≥10-5 of no more than 2 species OR
- ≥ 10² of any organisms collected by in&out catheter
With Chronic indwelling catheter
- ≥ 1 of the following
- F/C OR new-onset HoTN with no alt site of infxn
- Leukocytosis with no alt Dx AND acute mental status change / functional decline
- New-onset suprapubic pain OR CVA pain/tenderness
- Purulent d/x from around the catheter OR acute pain, swelling or tenderness of the testes, epididymis, or prostate
- Catheter specimen Cx with ≥ 10-5 cfu/ml – collected following replacement if catheter in place >14 days
Investigations
- UA if unclear symptoms: pyuria + bacteriuria +/- hematuria +/- nitrite
- a negative dipstick indicates the absence of UTI
- UCx clean catch urine if unclear UA, pyelonephritis, or complicated UTI:
- ≥ 10Λ5 CFU/ml in asx women, 10³ in men, 10² in sx or catheterized pts (hydration may dilute counts)
- not always needed if sx & + UA
- a negative urine culture excludes symptomatic UTI
- Repeat C&S after abx is not indicated unless UTI s/sx persist
- don’t collect urine in the absence of UTI symptoms
- CrCl – req for dosing of abx
- Sterile Pyuria: Pyuria + negative Cx
- –> urethritis, nephritis, renal tuberculosis, FB
- DNA detection / Cx for C. trachomatis/N. Gonorrhoeae
- in high risk pt or sterile pyuria
- Screen for asx bacteuria in pregnant women and pt undergoing urologic Sx
- 1st void & midstream, prostatic expressage, post-prostatic massage urine specimens if suspect prostatitis
- Blood Cx in febrile + possibly complicated UTI
- CT to r/o abscess in pts with pyelo who fail to defervesce after 72 hr
- Urologic workup – renal u/s w/ PVR, CT, voiding cystography, VCUG
- First UTI in male
- First UTI in female <3yo
- Second UTI in female
- Complicated pyelonephritis
- Fam Hx of renal anomalies or recurrent UTI
Prevention of UTI
- Proper hydration and nutrition
- Good perineal hygiene
- healthy voiding habits – address contipation / fecal impaction
- Prompted voiding program in LTC facilities
Prevention of Catheter-associated UTI
- Insert urinary catheters using aseptic technique
- if intermittent catheterization used, ensure it is done at regular intervals to prevent overdistention and using portable
bladder ultrasound devices to assess urine volume and reduce unnecessary catheter insertion - Maintain catheters based on recommended guidelines
- bag below bladder at all times to prevent reflux
- Empty bag regularly & prior to transporting pt
- Maintain an unobstructed urine flow: prevent kinks, vertical loops & blockages in the tubing
- Maintain a sterile, continuously closed drainage system
- Don’t replace catheters routinely if there is no evidence of infection / obstruction
- Don’t disconect the catheter from the drainage tubing
- Don’t routinely use silver/abx coated catheters
- Don’t use abx routinely as prophylaxis
- Review short-term catheter necessity daily & remove promptly
- Avoid unnecessary urinary catheters
- Appropriate:
- Acute urinary Retention or bladder outlet obstruction
- U/O monitoring in critically ill individuals or perioperative use
- Assistance in healing of open sacral or perineal wounds in incontinent individuals
- Prolonged immobilization (e.g. potentially unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fractures)
- To improve comfort for end of life care situations
- Inappropriate:
- Convenience or for u culture when pt can void voluntarily
- Appropriate:
- Alt to indwelling cathers
- External condom catheters for male pt w/o retention / obstruction
- bedside commode
- Intermittent cath for pt with spinal cord injury or bladder emptying dysfunction
Tx
Symptoms control
Phenazopyridine (Pyridium) 100-200mg po tid x 2 days
Empiric abx
- Uncomplicated UTI (cystitis), asx bacteruira prior to urologic sx
- Septra DS bid x 3 days
- asx bacteuria in pregnancy (U/A at 16GA)
- Amoxicillin or macrobid x 3-7 days
- Catheterized Pt
- Exchange catheter and Abx
- Urethritis
- Ceftriaxone 125mgIM x1 – Neisseria
- doxy 100mg po bid x 7 days or zeithromycin 1g po – Chlamydia
- Prostatitis
- Septra DS 14-28 days (acute) or 6-12 weeks (chronic)
- Pyelonephritis
- Outpt: FQ(Cirpofloxacin 500mg po bid or ceph po x 7-14d
- In-pt: Ceftriaxone IV or FQ po or aminoglycoside or clavulin x 14 days
- Renal Abscess
- Drainage & Abx as for pyelo
Reference:
- David Hui 2nd edition
- Pocket Medicine 4th edition
- Saskatchewan 2013 guideline
- UpToDate
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