Introduction

Background

Urinary tract infection (UTI) is defined as significant bacteriuria in the presence of symptoms.
This common clinical entity accounts for a significant number of emergency department (ED)
visits. It affects an estimated 20% of women at some time during their lifetimes.

Successful emergent management includes proper specimen collection, use of immediately

available laboratory testing for presumptive diagnosis, appreciation of epidemiological and host
factors that may identify patients with clinically inapparent upper UTI, and selection of
appropriate antimicrobial therapy with recommendations for follow-up care.

Pathophysiology

The urinary tract is normally sterile. Uncomplicated UTI involves the urinary bladder in a host
without underlying renal or neurologic disease. The clinical entity is termed cystitis and
represents bladder mucosal invasion, most often by enteric coliform bacteria (eg, Escherichia
coli) that inhabit the periurethral vaginal introitus and ascend into the bladder via the urethra.

Sexual intercourse may promote this migration, and cystitis is common in otherwise healthy
young women. Urine is generally a good culture medium; factors unfavorable to bacterial growth
include a low pH (5.5 or less), a high concentration of urea, and the presence of organic acids
derived from a diet that includes fruits and protein. Organic acids enhance acidification of the
urine.

Frequent and complete voiding has been associated with a reduction in the incidence of UTI.
Normally, a thin film of urine remains in the bladder after emptying, and any bacteria present are
removed by the mucosal cell production of organic acids. If the mechanisms of the lower urinary
tract fail, upper tract or kidney involvement occurs and is termed pyelonephritis. Host defenses at
this level include local leukocyte phagocytosis and renal production of antibodies that kill
bacteria in the presence of complement.

Complicated UTI occurs in the setting of underlying structural, medical, or neurologic disease.
Patients with a neurogenic bladder or bladder diverticulum and postmen opausal women with
bladder or uterine prolapse have an increased frequency of UTI due to incomplete bladder
emptying. This eventually allows residual bacteria to overwhelm local bladder mucosal defenses.
The high urine glucose content and the defective host immune factors in patients with diabetes
mellitus also predispose to infection.

Frequency

United States
UTI accounts for over 6 million patient visits to physicians per year in the United States.
Approximately one fifth of those visits are to EDs.

International

As 1 in 5 adult women experience UTI at some point, it is an exceedingly common, clinically

apparent, worldwide patient problem.

Mortality/Morbidity

 Although simple lower UTI (cystitis) may resolve spontaneously, effective treatment
lessens the duration of symptoms and reduces the incidence of progression to upper UTI.
 Pyelonephritis is associated with substantial morbidity, including systemic effects such as
fever, vomiting, dehydration, and loss of vasomotor tone resulting in hypotension.
Complications include acute papillary necrosis with possible development of ureteral
obstruction, septic shock, and perinephric abscess. Chronic pyelonephritis may lead to
scarring with diminished renal function.
 Younger patients have the lowest rates of morbidity and mortality. Unfortunately, despite
appropriate intervention, 1-3% of patients with acute pyelonephritis die. Factors
associated with unfavorable prognosis are general debility and old age, renal calculi or
obstruction, recent hospitalization or instrumentation, diabetes mellitus, sickle cell
anemia, underlying carcinoma, intercurrent chemotherapy, or chronic nephropathy.

Race

No racial predilection exists.

Sex

The natural history of UTI varies with sex and age.

 Of neonates, boys are slightly more likely than girls to present with UTI as part of a
gram-negative sepsis syndrome. The incidence in preschool children is approximately 2%
and is 10 times more common in girls. Five percent of school-aged girls experience UTI.
It is rare in school-aged boys.
 The largest group of patients with UTI is adult women. The incidence increases with age
and sexual activity. Rates of infection are high in postmenopausal women because of
bladder or uterine prolapse causing incomplete bladder emptying; loss of estrogen with
attendant changes in vaginal flora; loss of lactobacilli, which allows periurethral
colonization with gram-negative aerobes, such as E coli; and higher likelihood of
concomitant medical illness, such as diabetes.
 UTI is unusual in males younger than 50 years, and symptoms of dysuria and frequency
are usually due to urethral or prostatic infection. In older men, however, the incidence of
UTI rises because of prostatic obstruction or subsequent instrumentation.
Clinical
History

 The classical symptoms of UTI in the adult are primarily dysuria with accompanying
urinary urgency and frequency.
 A sensation of bladder fullness or lower abdominal discomfort is often present.
 Bloody urine is reported in as many as 10% of cases of UTI in otherwise healthy women;
this condition is called hemorrhagic cystitis.
 Fevers, chills, and malaise may be noted, though these are associated more frequently
with upper UTI (ie, pyelonephritis).
 Because of the referred pain pathways, even simple lower UTI may be accompanied by
flank pain and costovertebral angle tenderness. In the ED, assume that the presence of
these symptoms represents upper UTI.
 A history of vaginal discharge suggests that vaginitis, cervicitis, or pelvic inflammatory
disease is responsible for symptoms of dysuria; therefore, a pelvic examination must be
performed.
 Important additional information includes a history of prior sexually transmitted disease
(STD) and multiple current sexual partners.

Physical

 Most adult women with simple lower UTI have suprapubic tenderness with no evidence
of vaginitis, cervicitis, or pelvic tenderness (eg, cervical motion tenderness, which
suggests pelvic inflammatory disease).
 The patient appears uncomfortable but not toxic.
 The patient with pyelonephritis usually appears ill and, in addition to fever, sweating, and
prostration, is found to have costovertebral angle (flank) tenderness in the majority of
cases.
 The clinician may appreciate signs of dehydration, such as dry mucous membranes and
tachycardia, as well as poor vascular tone due to gram-negative bacteremia, which may
be manifested by clammy extremities and profound orthostatic hypotension.
A urinary tract infection (UTI) is a bacterial infection that affects any part of the urinary tract.
The main etiologic agent is Escherichia coli. Although urine contains a variety of fluids, salts,
and waste products, it does not usually have bacteria in it.[1] When bacteria get into the bladder or
kidney and multiply in the urine, they may cause a UTI.

The most common type of UTI is acute cystitis often referred to as a bladder infection. An
infection of the upper urinary tract or kidney is known as pyelonephritis, and is potentially more
serious. Although they cause discomfort, urinary tract infections can usually be easily treated
with a short course of antibiotics.[2] Symptoms include frequent feeling and/or need to urinate,
pain during urination, and cloudy urine.[3]

Contents
[hide]

 1 Signs and symptoms

 2 Risk factors
o 2.1 Sexual activity
o 2.2 Gender
o 2.3 Urinary catheters
o 2.4 Genetics
o 2.5 Others
 3 Pathogenesis
 4 Prevention
 5 Diagnosis
o 5.1 Differential
 6 Treatment
o 6.1 Uncomplicated
o 6.2 Pyelonephritis
o 6.3 Recurrent
 7 Epidemiology
 8 References
 9 External links

[edit] Signs and symptoms

The most common symptoms of a bladder infection are burning with urination (dysuria),
frequency of urination, an urge to urinate, without vaginal discharge or significant pain.[4] An
upper urinary tract infection or pyelonephritis may additionally present with flank pain and a
fever. Healthy women have an average of 5 days of symptoms.[4]
The symptoms of urinary tract infections may vary with age and the part of the urinary system
that was affected. In young children, urinary tract infection symptoms may include diarrhea, loss
of appetite, nausea and vomiting, fever and excessive crying that cannot be resolved by typical
measures. [5] Older children on the other hand may experience abdominal pain, or incontinence.
Lower urinary tract infections in adults may manifest with symptoms including hematuria (blood
in the urine), inability to urinate despite the urge and malaise. [6]

Other signs of urinary tract infections include foul smelling urine and urine that appears cloudy.
[7]

Depending on the site of infection, urinary tract infections may cause different symptoms.
Urethritis, meaning only the urethra has been affected, does not usually cause any other
symptoms besides dysuria. If the bladder is however affected (cystitis), the patient is likely to
experience more symptoms including lower abdomen discomfort, low-grade fever, pelvic
pressure and frequent urination all together with dysuria. [8] Infection of the kidneys (acute
pyelonephritis) typically causes more serious symptoms such as chills, nausea, vomiting and
high fever.

Whereas in newborns the condition may cause jaundice and hypothermia, in the elderly,
symptoms of urinary tract infections may even include lethargy and a change in the mental
status, signs that are otherwise nonspecific.

[edit] Risk factors

[edit] Sexual activity

In young sexually active women, sex is the cause of 75—90 % of bladder infections, with the
risk of infection related to the frequency of sex.[4] The term "honeymoon cystitis" has been
applied to this phenomenon of frequent UTIs during early marriage. In post menopausal women
sexual activity does not affect the risk of developing a UTI.[4] Spermicide use independent of
sexual frequency increase the risk of UTIs.[4]

[edit] Gender

Women are more prone to UTIs than men because in females, the urethra is much closer to the
anus than in males and they lack the bacteriostatic properties of prostatic secretions. UTI's more
commonly progress to bladder infections in females due to the much shorter length of the female
urethra.[9] Among the elderly, UTI frequency is roughly equal proportions in women and men.
This is due, in part, to an enlarged prostate in older men. As the gland grows, it obstructs the
urethra, leading to increased difficulty in micturition. Because there is less urine flushing the
urethra, there is a higher incidence of colonization.

[edit] Urinary catheters

Urinary catheters are a risk factor for urinary tract infections. The risk of an associated infection
can be decreased by only catheterizing when necessary, using aseptic technique for insertion, and
maintaining unobstructed closed drainage of the catheter.[10][11][12]

[edit] Genetics

A predisposition for bladder infections may run in families.[4]

[edit] Others

Other risk factors include diabetics[4] sickle-cell disease or anatomical malformations of the
urinary tract such as prostate enlargement.

While ascending infections are generally the rule for lower urinary tract infections and cystitis,
the same is not necessarily true for upper urinary tract infections like pyelonephritis which may
originate from a blood born infection.

[edit] Pathogenesis
The most common organism implicated in UTIs (80—85 %) is E. Coli,[4] while Staphylococcus
saprophyticus is the cause in 5—10 %.[4]

The bladder wall is coated with various mannosylated proteins, such as Tamm-Horsfall proteins
(THP), which interfere with the binding of bacteria to the uroepithelium. As binding is an
important factor in establishing pathogenicity for these organisms, its disruption results in
reduced capacity for invasion of the tissues.[clarification needed] Moreover, the unbound bacteria are
more easily removed when voiding. The use of urinary catheters (or other physical trauma) may
physically disturb this protective lining, thereby allowing bacteria to invade the exposed
epithelium.

During cystitis, uropathogenic Escherichia coli (UPEC) subvert innate defenses by invading
superficial umbrella cells and rapidly increasing in numbers to form intracellular bacterial
communities (IBCs).[13] By working together, bacteria in biofilms build themselves into
structures that are more firmly anchored in infected cells and are more resistant to immune
system assaults and antibiotic treatments [14] This is often the cause of chronic urinary tract
infections.

[edit] Prevention
The following are measures that studies suggest may reduce the incidence of urinary tract
infections.

 A prolonged course ( 6 months to a year ) of low-dose antibiotics (usually nitrofurantoin

or TMP/SMX) is effective in reducing the frequency of UTIs in those with recurrent
UTIs.[4]
  Cranberry (juice or capsules) may decrease the incidence of UTI in those with frequent
infections. Long term tolerance however is an issue.[15]
 For post-menopausal women intravaginal application of topical estrogen cream can
prevent recurrent cystitis.[16] This however is not as useful as low dose antibiotics.[4]
 Studies have shown that breastfeeding can reduce the risk of UTIs in infants.[17]

A number of measures have not been found to affect UTI frequency including: the use of birth
control pills or condoms, voiding after sex, the type of underwear used, personal hygiene
methods used after voiding or defecating, and whether one takes a bath or shower.[4]

[edit] Diagnosis

Multiple bacilli (rod-shaped bacteria, here shown as black and bean-shaped) shown between
white cells at urinary microscopy. This is called bacteriuria and pyuria, respectively. These
changes are indicative of a urinary tract infection.

In straight forward cases a diagnosis may be made and treatment given based on symptoms alone
without further laboratory confirmation.[4] In complicated or questionable cases confirmation via
urinalysis looking for the presence of nitrites, leukocytes or leukocyte esterase or via urine
microscopy looking for the presence of red blood cells, white blood cells, and bacteria maybe
useful.[4]

Urine culture showing a quantitative count of greater than or equal to 103 colony forming units
(CFU) per mL of a typical urinary tract organism along with antibiotic sensitives is useful to
guide antibiotic choice.[4] However women with negative cultures may still improve with
antibiotic treatment.[4]

Most cases of lower urinary tract infections in females are benign and do not need exhaustive
laboratory work-ups. However, UTI in young infants may receive some imaging study, typically
a retrograde urethrogram, to ascertain the presence/absence of congenital urinary tract anomalies.
All males with a confirmed UTI should be investigated further. Specific methods of investigation
include x-ray, nuclear medicine, MRI and CAT scans.

[edit] Differential

If the urine culture is negative:

  symptoms of urethritis may point at Chlamydia trachomatis or Neisseria gonorrheae
infection.
 symptoms of cystitis may point at interstitial cystitis.
 in men, prostatitis may present with dysuria.

The presence of bacteria in the urinary tract of older adults, without symptoms or signs of
infection, is a well recognized phenomenon which may not require antibiotics. This is usually
referred to as asymptomatic bacteriuria. The overuse of antibiotics in the context of bacteriuria
among the elderly is a concerning issue.

[edit] Treatment
[edit] Uncomplicated

Uncomplicated UTIs can be diagnosed and treated based on symptoms alone.[4] Oral antibiotics
such as trimethoprim, cephalosporins, nitrofurantoin, or a fluoroquinolone such as ciprofloxacin
substantially shorten the time to recovery. About 50% of people will recover without treatment
within a few days or weeks.[4] The Infectious Diseases Society of America recommends a
combination of trimethoprim and sulfamethoxazole as a first line agent in uncomplicated UTIs
rather than fluoroquinolones.[18] Resistance has developed in the community to all of these
medications due to their widespread use.[4]

A three-days treatment with trimethoprim, TMP/SMX, or a fluoroquinolone is usually sufficient

while nitrofurantoin requires 7 days.[4] Trimethoprim is often recommended to be taken at night
to ensure maximal urinary concentrations to increase its effectiveness. While trimethoprim /
sulfamethoxazole was previously internationally used (and continues to be used in the U.S. and
Canada); the addition of the sulfonamide gives little additional benefit compared to the
trimethoprim component alone. It is responsible however for a high incidence of mild allergic
reactions and rare but potentially serious complications. For simple UTIs children often respond
well to a three-day course of antibiotics.[19]

[edit] Pyelonephritis

Pyelonephritis is treated more aggressively than a simple bladder infection using either a longer
course of oral antibiotics or intravenous antibiotics. Regimens vary, and include SMX/TMP and
fluorquinolones. In the past, they have included aminoglycosides (such as gentamicin) used in
combination with a beta-lactam, such as ampicillin or ceftriaxone. These are continued for 48
hours after fever subsides.

If there is a poor response to IV antibiotics (marked by persistent fever, worsening renal

function), then imaging is indicated to rule out formation of an abscess either within or around
the kidney, or the presence of an obstructing lesion such as a stone or tumor.[20]

[edit] Recurrent
Women with recurrent simple UTIs may benefit from self-treatment upon occurrence of
symptoms with medical follow up only if the initial treatment fails.[4] Effective treatment can also
be delivered over the phone.[4]

[edit] Epidemiology
Bladder infections are most common in young women with 10% of women getting an infection
yearly and 60% having an infection at some point in their life.[4] Pyelonephritis occurs between
18—29 times less frequently.[4]

According to the 1997 National Ambulatory Medical Care Survey and National Hospital
Ambulatory Medical Care Survey, urinary tract infection accounted for nearly 7 million office
visits and 1 million emergency department visits, resulting in 100,000 hospitalizations. [21]

Nearly 1 in 3 women will have had at least 1 episode of urinary tract infections requiring
antimicrobial therapy by the age of 24 years. The risk of urinary tract infection increases with
increasing duration of catheterization. In non-institutionalized elderly populations, urinary tract
infections are the second most common form of infection, accounting for nearly 25% of all
infections. [22]

The condition rarely occurs in men who are younger than 50 years old and who did not undergo
any genitourinary procedure. However, the incidence of urinary tract infections in men tends to
rise after the age of 50.

According to statistics from 1990, the prevalence of urinary tract infections in pre-school and
school girls was 1% to 3%, nearly 30-fold higher than that in boys. [23] Also, the statistics from
the same year show that approximately 5% of girls will develop at least one urinary tract
infection in their school years.

In what concerns the symptoms of the condition, bacteriuria appears to increase in prevalence
with age in women, still being 50 times greater than the one in males. It is estimated that
bacteriuria will be experienced by 20 to 50% of older women and 5 to 20% of older men.