Urinary Tract

Infection
Urinary Tract Infection

Upper urinary tract Infections:

Pyelonephritis
Lower urinary tract infections
Cystitis (traditional UTI)
Urethritis (often sexually-transmitted)
Prostatitis
Symptoms of Urinary Tract Infection

Lower urinary tract

Dysuria
Increased frequency (polakisuria)
Hematuria (upper UTI)
Fever
Upper urinary tract
Nausea/Vomiting (pyelonephritis)
Flank pain (pyelonephritis)
Findings on Exam in UTI

Physical Exam:
CVA tenderness (pyelonephritis)
Urethral discharge (urethritis)
Tender prostate on rectal toucher (prostatitis)
Labs: Urinalysis
+ leukocyte esterase
+ nitrites
More likely gram-negative rods
+ WBCs
+ RBCs
Culture in UTI

Positive Urine Culture = >105 CFU/mL

Most common pathogen for cystitis, prostatitis, pyelonephritis:
Escherichia coli dari anus
Staphylococcus saprophyticus dari kulit perineum
Proteus mirabilis dari GI tract
Klebsiella dari GI tract
Enterococcus dari GI tract
Most common pathogen for urethritis
Chlamydia trachomatis (non spesifik)
Neisseria Gonorrhea (spesifik)
Lower Urinary Tract Infection -
Cystitis
Uncomplicated (Simple) cystitis
In healthy woman, with no signs of systemic disease
Complicated cystitis
In men, or woman with comorbid medical problems.
Recurrent cystitis
Uncomplicated (simple) Cystitis

Definition
Healthy adult woman (over age 12)
Non-pregnant
No fever, nausea, vomiting, flank pain
Diagnosis
Dipstick urinalysis (no culture or lab tests needed)
Treatment
Trimethroprim/Sulfamethoxazole for 3 days
May use fluoroquinolone (ciprofoxacin or levofloxacin) in patient with sulfa allergy,
areas with high rates of bactrim-resistance
Risk factors:
Sexual intercourse
May recommend post-coital voiding or prophylactic antibiotic use.
Complicated Cystitis

Definition
Females with comorbid medical conditions
All male patients
Indwelling foley catheters
Urosepsis/hospitalization
Diagnosis
Urinalysis, Urine culture
Further labs, if appropriate.
Treatment
Fluoroquinolone (or other broad spectrum antibiotic)
7-14 days of treatment (depending on severity)
May treat even longer (2-4 weeks) in males with UTI
Special cases of Complicated
cystitis
Indwelling foley catheter (Catheter-associated UTI)
Try to get rid of foley if possible!
Only treat patient when symptomatic (fever, dysuria)
Leukocytes on urinalysis
Patients with indwelling catheters are frequently colonized with great deal of
bacteria.
Should change foley before obtaining culture, if possible
Candiduria
Frequently occurs in patients with indwelling foley.
If grows in urine, try to get rid of foley!
Treat only if symptomatic.
If need to treat, give fluconazole (amphotericin if resistance)
Recurrent Cystitis

Want to make sure urine culture and sensitivity obtained.

(pembentuk ammonia, sulfur, Proteus)
May consider urologic work-up to evaluate for anatomical
abnormality.
Treat for 7-14 days.
Pyelonephritis

Infection of the kidney

Associated with constitutional symptoms fever, nausea, vomiting, headache
Diagnosis:
Urinalysis, urine culture, Complete Blood Count, Chemistry

Treatment:
2-weeks of Trimethroprim/sulfamethoxazole or fluoroquinolone
Hospitalization and IV antibiotics if patient unable to take po.

Complications:
Perinephric/Renal abscess:
Suspect in patient who is not improving on antibiotic therapy.
Diagnosis: CT with contrast, renal ultrasound
May need surgical drainage.

Nephrolithiasis with UTI

Suspect in patient with severe flank pain
Need urology consult for treatment of kidney stone
Prostatitis

Symptoms:
Pain in the perineum, lower abdomen, testicles, penis, and with ejaculation, bladder irritation,
bladder outlet obstruction, and sometimes blood in the semen
Diagnosis:
Typical clinical history (fevers, chills, dysuria, malaise, myalgias, pelvic/perineal pain, cloudy urine)
The finding of an edematous and tender prostate on physical examination
Will have an increased PSA
Urinalysis, urine culture
Treatment:
Trimethoprim/sulfamethoxazole, fluroquinolone or other broad spectrum antibiotic
4-6 weeks of treatment
Risk Factors:
Trauma
Sexual abstinence
Dehydration
Urethritis

Chlamydia trachomatis Neisseria gonorrhoeae

Frequently asymptomatic in females, May present with dysuria, discharge,
but can present with dysuria, PID
discharge or pelvic inflammatory
disease. Send UA, urine culture
Send Urine Analysis, Urine culture (if Pelvic exam send discharge
pyuria seen, but no bacteria, suspect samples for gram stain, culture, PCR
Chlamydia) Treatment:
Pelvic exam send discharge from Ceftriaxone 125 mg IM x 1
cervical or urethral os for chlamydia
PCR Cipro 500 mg po x 1

Chlamydia screening is now Levofloxacin 250 mg po x 1

recommended for all females 25 Ofloxacin 400 mg po x 1
years
Spectinomycin 2 g IM x 1
Treatment:
You should always also treat for
Azithromycin 1 g po x 1 chlamydia when treating for
Doxycycline 100 mg po BID x 7 days gonnorhea!
Question #1

An 18-year old woman presents with urinary frequency, dysuria, and

low-grade fever. Urinalysis shows pyuria and bacilli. She has never
had similar symptoms or treatment for urinary tract infection.
Question # 1

What category of UTI does this patient have?

Does this patient require further testing?
Would you treat this patient, and if so, with what and how long?
Question # 2

An 18-year old woman present with her third episode of urinary

frequency, dysuria, and pyuria in the past 4 months.
Question # 2

What further questions do you have for this patient?

What type of UTI does this patient have?
What testing might you perform in this patient?
How would you treat her, and for how long?
Question #3

A 24-year old woman presents with fever, chills, nausea, vomiting,

flank pain and tenderness. Her temperature is 40C, pulse rate is
120/min., and blood pressure is 100/60 mm Hg.
Question # 3

What further studies do you want in this patient?

How would you treat this patient?
What might you do if she does not improve after 3-4 days?
Question # 4

A 78-year old female presents with an indwelling foley catheter and

pyuria.
Question # 4

What would you do for this patient at this time?

How might your work-up/management change if she was having
fevers and confusion?
Question # 5

58-year old man presents with his first episode of urinary frequency
and dysuria. Urinalysis shows pyuria and bacilli.
Question # 5

What type of UTI does this patient likely have?

How would you treat this man, and for how long?
What activities would put this patient at risk for UTI?
Question # 6

A 28-year old male had a sexual encounter with a prostitute while

on a business trip in Seattle 1 week ago. After returning home, he
noted a burning sensation on urination and a yellow discharge in his
underwear. Microscopic examination of the discharge reveals 4+
leukocyte esterase, and the following gram stain.
Question # 6
Question # 6

Which of the following is the best course of action for this patient?

Give the patient a prescription for doxycycline, 100 mg po BID for 7

days
Give the patient two prescriptions for ofloxacin 300 mg po QDay for 7
days, one for him, and one for his wife.
Administer ceftriaxone 125 mg IV x 1 and Azithromycin 1 g po x 1,
draw blood for a VDRL and HIV antibody arrange for his wife to be
examined and treated.
Administer a single dose of Ceftriaxone 125 mg IV x 1, and
ciprofloxacin 500 mg po x 1 draw blood for a VDRL and HIV-antibody,
and arrange for his wife to be examined and treated.
Administer a single dose of cefixime 400 mg, draw blood for a VDRL
and arrange for his wife to be examined and treated.
Final thoughts!

Antibiotic choice and duration are determined by classification of

UTI.
Biggest bugs for UTI are E. Coli, Staph. Saprophyticus, Proteus
mirabilis, Enterococci and gram-negatives
Dont use moxifloxacin for UTI!
Chlamydia screening is now recommended for all women 25 years
and under since infection is frequently asymptomatic, and risk for
PID/infertility is high!