UTI – Saskatchewan 2013 guideline

Definitions

Anatomic

• Lower: urethritis, cystitis
• Upper: pyelonephritis, renal or perinephric abscess, prostatitis

Clinical

• Complicated UTI – Functional or anatomic abnormality of the urinary tract
  1. polycystic kidney disease
  2. nephrolithiasis
  3. Neurogenic bladder
  4. DM, immunosuppression
  5. Pregnancy
  6. Indwelling urinary catheter
     • Bacteria establish biofilm in/on catheter & enter bladder retrograde
     • Risk factors: duration of catheterization, errors in catheter care, DM, female sex
  7. 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
  1. Fever
  2. CVA tenderness
  3. Blood & Urinary Cx indicated

---

Microbioogy – KEEPS

1. Klebsiella pneumonia
2. E Coli – most common in women
3. Enterococci – most common in LTC facilities
4. Proteus mirabilis – most common in men
5. Staph. saprophyticus
6. Yeast – most common in catheter associated UTI
7. Chlamydia, Gonorrhoease, trichomonas vaginalis, HSV, ureaplasma, mycoplasma genitalium – Urethritis
8. 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)

1. Cystitis: Dysuria, frequency, urgency, hematuria, back pain, suprapubic pain, usually no fever
2. Pyelonephritis: fever, chills, flank/back pain, n/v/d, CVA tenderness
3. Urethritis: may be identical to cystitis except urethral discharge may be present
4. Prostatitis
   • Chronic: Similar to cystitis except obstruction symptoms – hesitancy, weak stream
   • Acute: perineal pain, fever, tenderness on prostate exam
5. 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. ≥ 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
     1. Acute costovertebral angle pain or tenderness
     2. Suprapubic pain
     3. Gross hematuria
     4. New or marked increase in incontinence
     5. New or marked increase in urgency
     6. New or marked increase in frequency
2. 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. ≥ 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
2. 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

1. Proper hydration and nutrition
2. Good perineal hygiene
3. healthy voiding habits – address contipation / fecal impaction
4. Prompted voiding program in LTC facilities

Prevention of Catheter-associated UTI

1. Insert urinary catheters using aseptic technique
2. 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
3. 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
4. Review short-term catheter necessity daily & remove promptly
5. Avoid unnecessary urinary catheters
   • Appropriate:
     1. Acute urinary Retention or bladder outlet obstruction
     2. U/O monitoring in critically ill individuals or perioperative use
     3. Assistance in healing of open sacral or perineal wounds in incontinent individuals
     4. Prolonged immobilization (e.g. potentially unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fractures)
     5. To improve comfort for end of life care situations
   • Inappropriate:
     • Convenience or for u culture when pt can void voluntarily
6. Alt to indwelling cathers
   1. External condom catheters for male pt w/o retention / obstruction
   2. bedside commode
   3. 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

1. Uncomplicated UTI (cystitis), asx bacteruira prior to urologic sx
   • Septra DS bid x 3 days
2. asx bacteuria in pregnancy (U/A at 16GA)
   • Amoxicillin or macrobid x 3-7 days
3. Catheterized Pt
   • Exchange catheter and Abx
4. Urethritis
   • Ceftriaxone 125mgIM x1 – Neisseria
   • doxy 100mg po bid x 7 days or zeithromycin 1g po – Chlamydia
5. Prostatitis
   • Septra DS 14-28 days (acute) or 6-12 weeks (chronic)
6. 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
7. Renal Abscess
   • Drainage & Abx as for pyelo

---

Reference:

• David Hui 2nd edition
• Pocket Medicine 4th edition
• Saskatchewan 2013 guideline
• UpToDate